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Vafaei N, Mohebbi A, Rezaei Z, Heidari M, Hosseinpour S, Dehnavi AZ, Ghamari A, Salehipour M, Rabbani A, Mahdieh N, Ashrafi MR. TPP1 Variants in Iranian patients: A Novel Pathogenic Homozygous Variant Causing Neuronal Ceroid Lipofuscinosis 2. Mol Syndromol 2024; 15:30-36. [PMID: 38357261 PMCID: PMC10862320 DOI: 10.1159/000534100] [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: 06/21/2023] [Accepted: 09/11/2023] [Indexed: 02/16/2024] Open
Abstract
Introduction TPP1 variants have been identified as a causative agent of neuronal ceroid lipofuscinosis 2 disease, that ataxia is one of its clinical features. Therefore, here, molecular study of TPP1 variants is presented in an Iranian cohort and a novel pathogenic variant is described. Methods This investigation was conducted as a cross-sectional study in a tertiary referral hospital, Children's Medical Center, Pediatrics Center of Excellence. Clinical presentations and pedigrees were documented. Patients with cerebellar ataxia were enrolled in this study. Next-generation sequencing was applied to confirm the diagnosis. Segregation and bioinformatics analyses were also done for the variants using Sanger sequencing. Results Forty-five patients were included in our study. The mean age of onset was 104 (+55.60) months (minimum = 31 months, maximum = 216 months). The majority of cases (73.3%) were born to consanguineous parents and only 1 patient (2.2%) had an affected sibling. Of the 45 patients, only 1 patient with a novel pathogenic variant (c.1425_1425+1delinsAT, p.A476Cfs*15) in the TPP1 gene was identified. Discussion The main strength of current study is the relatively large sample size. Besides, a novel pathogenic variant could be important toward the diagnosis and management of this condition. With significant advances in various therapies, early diagnosis could improve the treatments using personalized-based medicine.
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Affiliation(s)
- Nahid Vafaei
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Mohebbi
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Rezaei
- Pediatrics Center of Excellence, Department of Pediatric Neurology, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Morteza Heidari
- Pediatric Neurology Division, Children’s Medical Center, Pediatrics Center of Excellence, Myelin Disorders Clinic, Tehran University of Medical Sciences, Tehran, Iran
| | - Sareh Hosseinpour
- Pediatrics Center of Excellence, Department of Pediatric Neurology, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Zare Dehnavi
- Pediatrics Center of Excellence, Department of Pediatric Neurology, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Azin Ghamari
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Salehipour
- Department of Biology, Parand Branch, Islamic Azad University, Parand, Iran
| | - Ali Rabbani
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nejat Mahdieh
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Cardiogenetic Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahmoud Reza Ashrafi
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Pediatrics Center of Excellence, Department of Pediatric Neurology, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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Heusel-Gillig LL, Hall CD. Effectiveness of Vestibular Rehabilitation for Patients with Degenerative Cerebellar Ataxia: A Retrospective Cohort Study. Brain Sci 2023; 13:1520. [PMID: 38002480 PMCID: PMC10669586 DOI: 10.3390/brainsci13111520] [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: 09/25/2023] [Revised: 10/16/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023] Open
Abstract
Many patients with cerebellar ataxia have dizziness caused by oculomotor or peripheral vestibular deficits; however, there is little evidence supporting the use of vestibular rehabilitation for this population. The purpose of this study was to determine whether patients with degenerative cerebellar diseases improve following rehabilitation including vestibular exercises. A secondary aim was to identify variables associated with the outcomes. A retrospective chart review identified 42 ambulatory patients (23 men and 19 women; mean age = 54.5 ± 14.4 years) with cerebellar degeneration. Fourteen patients had ataxia only, twenty had ataxia and oculomotor abnormalities, and eight had ataxia with oculomotor and peripheral vestibular deficits. Patients received customized physical therapy including balance and gait training, as well as gaze stabilization and habituation exercises for vestibular hypofunction and motion-provoked dizziness. Primary outcome measures (Activities-specific Balance Confidence Scale, Tinetti Performance Oriented Mobility Assessment, Dynamic Gait index, and Sensory Organization Test) were evaluated at baseline and discharge. Patients improved (p < 0.05) on all outcome measures. Patients with vestibular deficits were seen for more visits compared to those with gait ataxia only (7.1 vs. 4.8 visits). This study provides evidence that patients with degenerative cerebellar disease improve in balance confidence, fall risk and sensory integration with therapy that includes vestibular rehabilitation.
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Affiliation(s)
| | - Courtney D. Hall
- James H. Quillen Veterans Affairs Medical Center, Mountain Home, TN 37684, USA
- Physical Therapy Program, East Tennessee State University, Johnson City, TN 37614, USA
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Corben LA, Collins V, Milne S, Farmer J, Musheno A, Lynch D, Subramony S, Pandolfo M, Schulz JB, Lin K, Delatycki MB, Bidichandani SI, Boesch S, Cnop M, Corti M, Duquette A, Durr A, Eigentler A, Emmanuel A, Flynn JM, Foroush NC, Fournier A, França MC, Giunti P, Goh EW, Graf L, Hadjivassiliou M, Huckabee ML, Kearney MG, Koeppen AH, Lie Y, Lin KY, Lowit A, Mariotti C, Mathews K, McCormack SE, Montenegro L, Morlet T, Naeije G, Panicker JN, Parkinson MH, Patel A, Payne RM, Perlman S, Peverill RE, Pousset F, Puccio H, Rai M, Rance G, Reetz K, Rowland TJ, Sansom P, Savvatis K, Schalling ET, Schöls L, Smith B, Soragni E, Spencer C, Synofzik M, Szmulewicz DJ, Tai G, Tamaroff J, Treat L, Carpentier AV, Vogel AP, Walther SE, Weber DR, Weisbrod NJ, Wilmot G, Wilson RB, Yoon G, Zesiewicz T. Clinical management guidelines for Friedreich ataxia: best practice in rare diseases. Orphanet J Rare Dis 2022; 17:415. [PMID: 36371255 PMCID: PMC9652828 DOI: 10.1186/s13023-022-02568-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Individuals with Friedreich ataxia (FRDA) can find it difficult to access specialized clinical care. To facilitate best practice in delivering healthcare for FRDA, clinical management guidelines (CMGs) were developed in 2014. However, the lack of high-certainty evidence and the inadequacy of accepted metrics to measure health status continues to present challenges in FRDA and other rare diseases. To overcome these challenges, the Grading of Recommendations Assessment and Evaluation (GRADE) framework for rare diseases developed by the RARE-Bestpractices Working Group was adopted to update the clinical guidelines for FRDA. This approach incorporates additional strategies to the GRADE framework to support the strength of recommendations, such as review of literature in similar conditions, the systematic collection of expert opinion and patient perceptions, and use of natural history data. METHODS A panel representing international clinical experts, stakeholders and consumer groups provided oversight to guideline development within the GRADE framework. Invited expert authors generated the Patient, Intervention, Comparison, Outcome (PICO) questions to guide the literature search (2014 to June 2020). Evidence profiles in tandem with feedback from individuals living with FRDA, natural history registry data and expert clinical observations contributed to the final recommendations. Authors also developed best practice statements for clinical care points that were considered self-evident or were not amenable to the GRADE process. RESULTS Seventy clinical experts contributed to fifteen topic-specific chapters with clinical recommendations and/or best practice statements. New topics since 2014 include emergency medicine, digital and assistive technologies and a stand-alone section on mental health. Evidence was evaluated according to GRADE criteria and 130 new recommendations and 95 best practice statements were generated. DISCUSSION AND CONCLUSION Evidence-based CMGs are required to ensure the best clinical care for people with FRDA. Adopting the GRADE rare-disease framework enabled the development of higher quality CMGs for FRDA and allows individual topics to be updated as new evidence emerges. While the primary goal of these guidelines is better outcomes for people living with FRDA, the process of developing the guidelines may also help inform the development of clinical guidelines in other rare diseases.
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Affiliation(s)
- Louise A. Corben
- grid.1058.c0000 0000 9442 535XBruce Lefroy Centre for Genetic Health Research, Murdoch Children’s Research Institute, Parkville, VIC 3052 Australia ,grid.1008.90000 0001 2179 088XDepartment of Paediatrics, Melbourne University, Melbourne, VIC Australia ,grid.1002.30000 0004 1936 7857Turner Institute for Brain and Mental Health, Monash University, Clayton, VIC Australia
| | - Veronica Collins
- grid.1058.c0000 0000 9442 535XBruce Lefroy Centre for Genetic Health Research, Murdoch Children’s Research Institute, Parkville, VIC 3052 Australia
| | - Sarah Milne
- grid.1058.c0000 0000 9442 535XBruce Lefroy Centre for Genetic Health Research, Murdoch Children’s Research Institute, Parkville, VIC 3052 Australia ,grid.1008.90000 0001 2179 088XDepartment of Paediatrics, Melbourne University, Melbourne, VIC Australia ,grid.419789.a0000 0000 9295 3933Monash Health, Clayton, VIC Australia ,grid.1002.30000 0004 1936 7857School of Primary and Allied Health Care, Monash University, Clayton, VIC Australia
| | - Jennifer Farmer
- grid.428632.9Friedreich’s Ataxia Research Alliance, Downingtown, PA USA
| | - Ann Musheno
- grid.428632.9Friedreich’s Ataxia Research Alliance, Downingtown, PA USA
| | - David Lynch
- grid.239552.a0000 0001 0680 8770Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA USA
| | - Sub Subramony
- grid.15276.370000 0004 1936 8091Fixel Center for Neurological Disorders, University of Florida College of Medicine, Gainesville, FL USA
| | - Massimo Pandolfo
- grid.14709.3b0000 0004 1936 8649McGill University, Montreal, QC Canada
| | - Jörg B. Schulz
- grid.412301.50000 0000 8653 1507Department of Neurology, University Hospital, Aachen, Germany ,grid.1957.a0000 0001 0728 696XJARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Kim Lin
- grid.239552.a0000 0001 0680 8770Department of Pediatrics, Children’s Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA USA
| | - Martin B. Delatycki
- grid.1058.c0000 0000 9442 535XBruce Lefroy Centre for Genetic Health Research, Murdoch Children’s Research Institute, Parkville, VIC 3052 Australia ,grid.1008.90000 0001 2179 088XDepartment of Paediatrics, Melbourne University, Melbourne, VIC Australia ,grid.507857.8Victorian Clinical Genetics Services, Parkville, VIC Australia
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Ghosh S. Breathing disorders in neurodegenerative diseases. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:223-239. [PMID: 36031306 DOI: 10.1016/b978-0-323-91532-8.00008-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Neurodegenerative disorders are a diverse group of conditions caused by progressive degeneration of neurons resulting in cognitive, motor, sensory, and autonomic dysfunction, leading to severe disability and death. Pulmonary dysfunction is relatively common in these conditions, may be present early in the disease, and is less well recognized and treated than other symptoms. There are variable disorders of upper and lower airways, central control of ventilation, strength of respiratory muscles, and breathing during sleep which further impact daily activities and quality of life and have the potential to injure vulnerable neurons. Laryngopharyngeal dysfunction affects speech, swallowing, and clearance of secretions, increases the risk of aspiration pneumonia, and can cause stridor and sudden death. In Parkinson's disease, L-Dopa benefits some pulmonary symptoms but there are limited pharmacological treatment options for pulmonary dysfunction. Targeted treatments include strengthening of respiratory muscles, positive airway pressure in sleep and techniques to improve cough efficacy. Well-designed clinical trials are needed to evaluate the long-term benefits of these interventions. Challenges for the future include earlier identification of pulmonary dysfunction in the clinic, institution of the most effective treatments (based on clinical trials that measure long-term meaningful outcomes) and the development of neuroprotective treatment.
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Affiliation(s)
- Soumya Ghosh
- Perron Institute for Neurological and Translational Science, University of Western Australia and Department of Neurology, Sir Charles Gairdner and Perth Children's Hospitals, Nedlands, WA, Australia.
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Hurvitz N, Azmanov H, Kesler A, Ilan Y. Establishing a second-generation artificial intelligence-based system for improving diagnosis, treatment, and monitoring of patients with rare diseases. Eur J Hum Genet 2021; 29:1485-1490. [PMID: 34276056 PMCID: PMC8484657 DOI: 10.1038/s41431-021-00928-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/06/2021] [Accepted: 06/16/2021] [Indexed: 02/07/2023] Open
Abstract
Patients with rare diseases are a major challenge for healthcare systems. These patients face three major obstacles: late diagnosis and misdiagnosis, lack of proper response to therapies, and absence of valid monitoring tools. We reviewed the relevant literature on first-generation artificial intelligence (AI) algorithms which were designed to improve the management of chronic diseases. The shortage of big data resources and the inability to provide patients with clinical value limit the use of these AI platforms by patients and physicians. In the present study, we reviewed the relevant literature on the obstacles encountered in the management of patients with rare diseases. Examples of currently available AI platforms are presented. The use of second-generation AI-based systems that are patient-tailored is presented. The system provides a means for early diagnosis and a method for improving the response to therapies based on clinically meaningful outcome parameters. The system may offer a patient-tailored monitoring tool that is based on parameters that are relevant to patients and caregivers and provides a clinically meaningful tool for follow-up. The system can provide an inclusive solution for patients with rare diseases and ensures adherence based on clinical responses. It has the potential advantage of not being dependent on large datasets and is a dynamic system that adapts to ongoing changes in patients' disease and response to therapy.
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Affiliation(s)
- Noa Hurvitz
- Faculty of Medicine, Department of Medicine, Hebrew University, Hadassah Medical Center, Jerusalem, Israel
| | - Henny Azmanov
- Faculty of Medicine, Department of Medicine, Hebrew University, Hadassah Medical Center, Jerusalem, Israel
| | - Asa Kesler
- Faculty of Medicine, Department of Medicine, Hebrew University, Hadassah Medical Center, Jerusalem, Israel
| | - Yaron Ilan
- Faculty of Medicine, Department of Medicine, Hebrew University, Hadassah Medical Center, Jerusalem, Israel.
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Mello NMD, Zonta MB, Teive HAG, Meira AT, Lopes Neto FDN, Silva JTDSND, Camargo CHF, Zeigelboim BS. Assessment of ventilatory function in patients with spinocerebellar ataxia type 2. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:96-102. [PMID: 32022136 DOI: 10.1590/0004-282x20190156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/30/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Subclinical ventilatory dysfunction is observed in individuals with spinocerebellar ataxias (SCA). No studies have correlated ventilatory dysfunction to clinical and functional decline in SCA2. OBJECTIVE To evaluate the relationship between the values of peak expiratory flow (PEF), maximum inspiratory pressure (MIP), and presence of respiratory complaints with age, disease duration, age at onset of symptoms, balance scores, independence in basic (ADL) and instrumental (IADL) Activities of Daily Living (ADLs), and severity of ataxia (SARA) in individuals with SCA2. METHODS Cross-sectional study evaluating age, disease duration, age at onset of symptoms, scores in the Berg Balance Scale and in the SARA, Functional Independence Measure and Lawton's scale, values of PEF and MIP, and the presence of respiratory complaints. RESULTS The study included 36 individuals with SCA2, with a mean age of 42.5±2.4 years, disease duration of 7.6±8.2 years, age 33.7±11.5 years at onset of symptoms, and 9.9±10.3 points in the SARA scale. The lowest PEF values correlated with the longer disease duration (p=0.021). The lowest values of PEF and MIP correlated with greater balance impairment (p=0.019 and p=0.045, respectively), increased degree of dependence in the ADL (p=0.006 and p=0.050, respectively) and IADL (p=0.003 and p=0.001, respectively) scales, and highest severity of ataxia (p=0.00 and p=0.017, respectively). Respiratory complaints were observed in 12 (33.3%) individuals and were not related to age, disease duration, age at onset of symptoms, balance, independence, ataxia severity, or PEF and MIP values. CONCLUSION Ventilatory dysfunction, even when asymptomatic, is related to balance impairment, independence, and ataxia severity in individuals with SCA2.
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Affiliation(s)
- Neliana Maria de Mello
- Universidade Federal do Paraná, Hospital de Clínicas, Unidade Multiprofissional, Serviço de Fisioterapia, Curitiba PR, Brazil
| | - Marise Bueno Zonta
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Setor de Distúrbios do Movimento, Curitiba PR, Brazil
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Programa de Pós-Graduação em Medicina Interna (Neurologia), Curitiba PR, Brazil
| | - Hélio Afonso Ghizoni Teive
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Setor de Distúrbios do Movimento, Curitiba PR, Brazil
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Programa de Pós-Graduação em Medicina Interna (Neurologia), Curitiba PR, Brazil
| | - Alex Tiburtino Meira
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Serviço de Neurologia, Setor de Distúrbios do Movimento, Curitiba PR, Brazil
| | | | | | - Carlos Henrique Ferreira Camargo
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Programa de Pós-Graduação em Medicina Interna (Neurologia), Curitiba PR, Brazil
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Kalla R, Strupp M. Aminopyridines and Acetyl-DL-leucine: New Therapies in Cerebellar Disorders. Curr Neuropharmacol 2019; 17:7-13. [PMID: 30182858 PMCID: PMC6341500 DOI: 10.2174/1570159x16666180905093535] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/23/2017] [Accepted: 08/30/2018] [Indexed: 12/27/2022] Open
Abstract
Cerebellar ataxia is a frequent and often disabling syndrome severely impairing motor functioning and quality of life. Patients suffer from reduced mobility, and restricted autonomy, experiencing an even lower quality of life than, e.g., stroke survivors. Aminopyridines have been demonstrated viable for the symptomatic treatment of certain forms of cerebellar ataxia. This article will give an outline of the present pharmacotherapy of different cerebellar disorders. As a current key-therapy for the treatment of downbeat nystagmus 4-aminopyridine (4-AP) is suggested for the treatment of downbeat nystagmus (5-10 mg Twice a day [TID]), a frequent type of persisting nystagmus, due to a compromise of the vestibulo-cerebellum. Studies with animals have demonstrated, that a nonselective blockage of voltage-gated potassium channels (mainly Kv1.5) increases Purkinje- cell (PC) excitability. In episodic ataxia type 2 (EA2), which is frequently caused by mutations of the PQ-calcium channel, the efficacy of 4-AP (5-10 mg TID) has been shown in a randomized controlled trial (RCT). 4-AP was well tolerated in the recommended dosages. 4-AP was also effective in elevating symptoms in cerebellar gait ataxia of different etiologies (2 case series). A new treatment option for cerebellar disease is the amino-acid acetyl-DL-leucine, which has significantly improved cerebellar symptoms in three case series. There are on-going randomized controlled trials for cerebellar ataxia (acetyl-DL-leucine vs placebo; ALCAT), cerebellar gait disorders (SR-form of 4-AP vs placebo; FACEG) and EA2 (sustained-release/SR-form of 4-AP vs acetazolamide vs placebo; EAT2TREAT), which will provide new insights into the pharmacological treatment of cerebellar disorders.
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Affiliation(s)
- Roger Kalla
- Department of Neurology, University Hospital Bern, Bern, Switzerland.,Department of Neurology, German Center for Vertigo and Balance Disorders, and Institute for Clinical Neurosciences, University Hospital Munich, Campus Grosshadern, Munich, Germany
| | - Michael Strupp
- Department of Neurology, German Center for Vertigo and Balance Disorders, and Institute for Clinical Neurosciences, University Hospital Munich, Campus Grosshadern, Munich, Germany
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Buijsen RAM, Toonen LJA, Gardiner SL, van Roon-Mom WMC. Genetics, Mechanisms, and Therapeutic Progress in Polyglutamine Spinocerebellar Ataxias. Neurotherapeutics 2019; 16:263-286. [PMID: 30607747 PMCID: PMC6554265 DOI: 10.1007/s13311-018-00696-y] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Autosomal dominant cerebellar ataxias (ADCAs) are a group of neurodegenerative disorders characterized by degeneration of the cerebellum and its connections. All ADCAs have progressive ataxia as their main clinical feature, frequently accompanied by dysarthria and oculomotor deficits. The most common spinocerebellar ataxias (SCAs) are 6 polyglutamine (polyQ) SCAs. These diseases are all caused by a CAG repeat expansion in the coding region of a gene. Currently, no curative treatment is available for any of the polyQ SCAs, but increasing knowledge on the genetics and the pathological mechanisms of these polyQ SCAs has provided promising therapeutic targets to potentially slow disease progression. Potential treatments can be divided into pharmacological and gene therapies that target the toxic downstream effects, gene therapies that target the polyQ SCA genes, and stem cell replacement therapies. Here, we will provide a review on the genetics, mechanisms, and therapeutic progress in polyglutamine spinocerebellar ataxias.
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Affiliation(s)
- Ronald A M Buijsen
- Department of Human Genetics, LUMC, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Lodewijk J A Toonen
- Department of Human Genetics, LUMC, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Sarah L Gardiner
- Department of Human Genetics, LUMC, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Neurology, LUMC, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
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Abstract
The cerebellum plays an integral role in the control of limb and ocular movements, balance, and walking. Cerebellar disorders may be classified as sporadic or hereditary with clinical presentation varying with the extent and site of cerebellar damage and extracerebellar signs. Deficits in balance and walking reflect the cerebellum's proposed role in coordination, sensory integration, coordinate transformation, motor learning, and adaptation. Cerebellar dysfunction results in increased postural sway, hypermetric postural responses to perturbations and optokinetic stimuli, and postural responses that are poorly coordinated with volitional movement. Gait variability is characteristic and may arise from a combination of balance impairments, interlimb incoordination, and incoordination between postural activity and leg movement. Intrinsic problems with balance lead to a high prevalence of injurious falls. Evidence for pharmacologic management is limited, although aminopyridines reduce attacks in episodic ataxias and may have a role in improving gait ataxia in other conditions. Intensive exercises targeting balance and coordination lead to improvements in balance and walking but require ongoing training to maintain/maximize any effects. Noninvasive brain stimulation of the cerebellum may become a useful adjunct to therapy in the future. Walking aids, orthoses, specialized footwear and seating may be required for more severe cases of cerebellar ataxia.
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Affiliation(s)
- Jonathan F Marsden
- Department of Rehabilitation, School of Health Professions, University of Plymouth, Plymouth, United Kingdom.
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Feil K, Adrion C, Teufel J, Bösch S, Claassen J, Giordano I, Hengel H, Jacobi H, Klockgether T, Klopstock T, Nachbauer W, Schöls L, Stendel C, Uslar E, van de Warrenburg B, Berger I, Naumann I, Bayer O, Müller HH, Mansmann U, Strupp M. Effects of acetyl-DL-leucine on cerebellar ataxia (ALCAT trial): study protocol for a multicenter, multinational, randomized, double-blind, placebo-controlled, crossover phase III trial. BMC Neurol 2017; 17:7. [PMID: 28068987 PMCID: PMC5223431 DOI: 10.1186/s12883-016-0786-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 12/14/2016] [Indexed: 01/06/2023] Open
Abstract
Background Cerebellar ataxia (CA) is a frequent and often disabling condition that impairs motor functioning and impacts on quality of life (QoL). No medication has yet been proven effective for the symptomatic or even causative treatment of hereditary or non-hereditary, non-acquired CA. So far, the only treatment recommendation is physiotherapy. Therefore, new therapeutic options are needed. Based on three observational studies, the primary objective of the acetyl-DL-leucine on ataxia (ALCAT) trial is to examine the efficacy and tolerability of a symptomatic therapy with acetyl-DL-leucine compared to placebo on motor function measured by the Scale for the Assessment and Rating of Ataxia (SARA) in patients with CA. Methods/Design An investigator-initiated, multicenter, European, randomized, double-blind, placebo-controlled, 2-treatment 2-period crossover phase III trial will be carried out. In total, 108 adult patients who meet the clinical criteria of CA of different etiologies (hereditary or non-hereditary, non-acquired) presenting with a SARA total score of at least 3 points will be randomly assigned in a 1:1 ratio to one of two different treatment sequences, either acetyl-DL-leucine (up to 5 g per day) followed by placebo or vice versa. Each sequence consists of two 6-week treatment periods, separated by a 4-week wash-out period. A follow-up examination is scheduled 4 weeks after the end of treatment. The primary efficacy outcome is the absolute change in the SARA total score. Secondary objectives are to demonstrate that acetyl-DL-leucine is effective in improving (1) motor function measured by the Spinocerebellar Ataxia Functional Index (SCAFI) and SARA subscore items and (2) QoL (EuroQoL 5 dimensions and 5 level version, EQ-5D-5 L), depression (Beck Depression Inventory, BDI-II) and fatigue (Fatigue Severity Score, FSS). Furthermore, the incidence of adverse events will be investigated. Discussion The results of this trial will inform whether symptomatic treatment with the modified amino-acid acetyl-DL-leucine is a worthy candidate for a new drug therapy to relieve ataxia symptoms and to improve patient care. If superiority of the experimental drug to placebo can be established it will also be re-purposing of an agent that has been previously used for the symptomatic treatment of dizziness. Trial registration The trial was prospectively registered at www.clinicaltrialsregister.eu (EudraCT no. 2015–000460–34) and at https://www.germanctr.de (DRKS-ID: DRKS00009733).
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Affiliation(s)
- Katharina Feil
- Department of Neurology with Friedrich-Baur-Institute, University Hospital, Munich, Germany. .,German Center for Vertigo and Balance Disorders (DSGZ), University Hospital, Munich, Germany. .,Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital, Campus Grosshadern, Marchioninistrasse 15, Munich, 81377, Germany.
| | - Christine Adrion
- Institute for Medical Informatics, Biometry and Epidemiology (IBE), University Hospital, Munich, Germany
| | - Julian Teufel
- Department of Neurology with Friedrich-Baur-Institute, University Hospital, Munich, Germany.,German Center for Vertigo and Balance Disorders (DSGZ), University Hospital, Munich, Germany
| | - Sylvia Bösch
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Jens Claassen
- Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ilaria Giordano
- German Center for Neurodegenerative Diseases (DZNE), Center for Clinical Research, Bonn, Germany
| | - Holger Hengel
- Department of Neurology and Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Tübingen, Germany
| | - Heike Jacobi
- German Center for Neurodegenerative Diseases (DZNE), Center for Clinical Research, Bonn, Germany
| | - Thomas Klockgether
- German Center for Neurodegenerative Diseases (DZNE), Center for Clinical Research, Bonn, Germany
| | - Thomas Klopstock
- Department of Neurology with Friedrich-Baur-Institute, University Hospital, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE), Munich, 80336, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, 80336, Germany
| | - Wolfgang Nachbauer
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Ludger Schöls
- Department of Neurology and Hertie Institute for Clinical Brain Research, University Hospital Tübingen, Tübingen, Germany
| | - Claudia Stendel
- Department of Neurology with Friedrich-Baur-Institute, University Hospital, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE), Munich, 80336, Germany
| | - Ellen Uslar
- Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Bart van de Warrenburg
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Ingrid Berger
- German Center for Vertigo and Balance Disorders (DSGZ), University Hospital, Munich, Germany
| | - Ivonne Naumann
- German Center for Vertigo and Balance Disorders (DSGZ), University Hospital, Munich, Germany
| | - Otmar Bayer
- German Center for Vertigo and Balance Disorders (DSGZ), University Hospital, Munich, Germany
| | - Hans-Helge Müller
- Institute for Medical Biometry and Epidemiology, Philipps University Marburg, Marburg, Germany
| | - Ulrich Mansmann
- Institute for Medical Informatics, Biometry and Epidemiology (IBE), University Hospital, Munich, Germany
| | - Michael Strupp
- Department of Neurology with Friedrich-Baur-Institute, University Hospital, Munich, Germany.,German Center for Vertigo and Balance Disorders (DSGZ), University Hospital, Munich, Germany
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11
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Abstract
The autosomal dominant spinocerebellar ataxias (SCA) are a genetically heterogeneous group of neurodegenerative disorders characterized by progressive motor incoordination, in some cases with ataxia alone and in others in association with additional progressive neurological deficits. Spinocerebellar ataxia type 6 (SCA6) is the prototype of a pure cerebellar ataxia, associated with a severe form of progressive ataxia and cerebellar dysfunction. SCA6, originally classified as such by Zhuchenko et al. (1997), is caused by a CAG repeat expansion in the CACNA1A gene which encodes the α1A subunit of the P/Q-type voltage-gated calcium channel. SCA6 is one of ten polyglutamine-encoding CAG nucleotide repeat expansion disorders comprising other neurodegenerative disorders such as Huntington's disease. The present review describes clinical, genetic, and pathological manifestations associated with this illness. Currently, there is no treatment for this neurodegenerative disease. Successful therapeutic strategies must target a valid pathological mechanism; thus, understanding the underlying mechanisms of disease is crucial to finding a proper treatment. Hence, this chapter will discuss as well the molecular mechanisms possibly associated with SCA6 pathology and their implication for the development of future treatment.
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Affiliation(s)
- Ana Solodkin
- Department of Neurology, University of Chicago Medical Center, Chicago, IL 606337, USA.
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12
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Perlman SL. Treatment and management issues in ataxic diseases. HANDBOOK OF CLINICAL NEUROLOGY 2012; 103:635-54. [PMID: 21827924 DOI: 10.1016/b978-0-444-51892-7.00046-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Susan L Perlman
- David Geffen School of Medicine at the University of California at Los Angeles, CA 90095, USA.
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13
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Abstract
The spinocerebellar ataxias (SCA) are a large group of inherited disorders affecting the cerebellum and its afferent and efferent pathways. Their hallmark symptom is slowly progressive, symmetrical, midline, and appendicular ataxia. Some may also have associated hyperkinetic movements (chorea, dystonia, myoclonus, postural/action tremor, restless legs, rubral tremor, tics), which may aid in differential diagnosis and provide treatable targets to improve performance and quality of life in these progressive, incurable conditions. The typical dominant ataxias with associated hyperkinetic movements are SCA1-3, 6-8, 12, 14, 15, 17, 19-21, and 27. The common recessive ataxias with associated hyperkinetic movements are ataxia telangiectasia and Friedreich's ataxia. Fragile X tremor-ataxia syndrome (FXTAS) and multiple-system atrophy (a sporadic ataxia which is felt to have a genetic substrate) also have hyperkinetic features. A careful work-up should be done in all apparently sporadic cases, to rule out acquired causes of ataxia, some of which can cause hyperkinetic movements in addition to ataxia. Some testing should be done even in individuals with a confirmed genetic cause, as the presence of a secondary factor (nutritional deficiency, thyroid dysfunction) can contribute to the phenotype.
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Affiliation(s)
- Susan L Perlman
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA.
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14
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Sriranjini SJ, Pal PK, Krishna N, Sathyaprabha TN. Subclinical pulmonary dysfunction in spinocerebellar ataxias 1, 2 and 3. Acta Neurol Scand 2010; 122:323-8. [PMID: 20002004 DOI: 10.1111/j.1600-0404.2009.01306.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Evaluation of pulmonary function in patients with spinocerebellar ataxias (SCA) 1, 2 and 3 without clinical evidence of pulmonary dysfunction. METHODS Thirty patients (F:M = 7:23; age: 35 ± 11.3 years; SCA1 - 13, SCA2 - 9 and SCA3 - 8) without clinical manifestations of respiratory dysfunction and 30 controls underwent pulmonary function tests. The percentage predicted values of forced vital capacity (FVC), volume of air exhaled during first second of FVC (FEV1), peak expiratory flow rate (PEFR) and maximal voluntary ventilation (MVV), actual values of maximal inspiratory and expiratory pressures (MIP and MEP in mmHg), and ratios of actual values of FEV1/FVC (%) and FEV1/PEFR (ml/l/min) were analyzed. RESULTS Compared with controls SCA patients had significant reductions of FVC (71.1 ± 17.5 vs 85.5 ± 18.7; P < 0.01), PEFR (51.5 ± 20.7 vs 77.1 ± 24.9; P < 0.001), MVV (64.4 ± 21.6 vs 97.2 ± 22.7; P < 0.001), MIP (27.7 ± 16.8 vs 50.1 ± 15.1; P < 0.001) and MEP (38.1 ± 18.7 vs 74.7 ± 16.0; P < 0.001), elevation of FEV1/PEFR (10.5 ± 2.8 vs 7.4 ± 2.1; P < 0.001), but no significant change of FEV1 and FEV1/FVC. FEV1/PEFR correlated positively with illness duration and MVV negatively with severity of illness. CONCLUSIONS The present study showed subclinical restrictive type of pulmonary dysfunction in SCA, and possible presence of upper airway obstruction. Chest physiotherapy and breathing exercises should be introduced early in management of SCA.
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Affiliation(s)
- S J Sriranjini
- Department of Neurophysiology, National Institute of Mental Health and Neurosciences, Bangalore, India
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15
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Massella A, Gusciglio M, D'Intino G, Sivilia S, Ferraro L, Calzà L, Giardino L. Gabapentin treatment improves motor coordination in a mice model of progressive ataxia. Brain Res 2009; 1301:135-42. [DOI: 10.1016/j.brainres.2009.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 08/27/2009] [Accepted: 09/01/2009] [Indexed: 02/07/2023]
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16
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López-Bastida J, Perestelo-Pérez L, Montón-Alvarez F, Serrano-Aguilar P. Social economic costs and health-related quality of life in patients with degenerative cerebellar ataxia in Spain. Mov Disord 2008; 23:212-7. [PMID: 17999424 DOI: 10.1002/mds.21798] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
To determine the economic burden (direct and indirect costs), as well as health-related quality of life (HRQOL) in patients diagnosed with spinocerebellar ataxia (SCA) in Spain. A cross-sectional study was carried out on 84 patients with SCA from the Spanish Ataxia Federation (FEDAES) during 2004. A retrospective assessment of the use of resources was obtained through questionnaires filled out by the patients or the patient's caregivers. The approach used was the cost-of-illness study based on a societal perspective. To assess HRQOL in patients with SCA, they were asked to fill out the EQ-5D generic questionnaire. The mean annual cost per patient with SCA was 18,776 euros. The most important categories of costs were informal care, early retirement (permanent disability), medications, and orthopaedic devises. The mean EQ-5D index score was 0.48 (0.38 for high and 0.58 for low severity patients) and the mean EQ-5D VAS score was 48 (43 for high and 52 for low severity patients). Considerations of the costs related to caregivers due to the patients' disabilities, as well as the high indirect costs resulting from permanent disabilities in patients with SCA, should become a priority for health authorities. Furthermore, the patients' quality of life, as determined by the EQ-5D questionnaire, was very low and substantially influenced by the degree of severity of SCA.
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Affiliation(s)
- Julio López-Bastida
- Planning and Evaluation Service, Canary Islands Health Service, Santa Cruz de Tenerife, Canary Islands, Spain.
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17
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Fogel BL, Perlman S. Clinical features and molecular genetics of autosomal recessive cerebellar ataxias. Lancet Neurol 2007; 6:245-57. [PMID: 17303531 DOI: 10.1016/s1474-4422(07)70054-6] [Citation(s) in RCA: 175] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Among the hereditary ataxias, autosomal recessive spinocerebellar ataxias comprise a diverse group of neurodegenerative disorders. Clinical phenotypes vary from predominantly cerebellar syndromes to sensorimotor neuropathy, ophthalmological disturbances, involuntary movements, seizures, cognitive dysfunction, skeletal anomalies, and cutaneous disorders, among others. Molecular pathogenesis also ranges from disorders of mitochondrial or cellular metabolism to impairments of DNA repair or RNA processing functions. Diagnosis can be improved by a systematic approach to the categorisation of these disorders, which is used to direct further, more specific, biochemical and genetic investigations. In this Review, we discuss the clinical characteristics and molecular genetics of the more common autosomal recessive ataxias and provide a framework for assessment and differential diagnosis of patients with these disorders.
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Affiliation(s)
- Brent L Fogel
- Department of Neurology, David Geffen School of Medicine at UCLA, University of California at Los Angeles, 90095, USA
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18
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Abstract
Gait disorders in elderly individuals are a major cause of falls and their attendant morbidities. Ataxia is one of the neurologic components of fall risk, as are inattention or confusion, visual impairment, vestibular impairment, subcortical white matter disease, parkinsonism, weakness, sensory loss, orthostasis or arrhythmia with alterations in blood pressure, pain, medication use, and environmental hazards. Ataxia in the geriatric population has many causes. Correctly identifying them can improve clinicians' ability to offer treatment and management strategies to patients and their families. The goals should be safe mobility and preserved activities of daily living.
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Affiliation(s)
- Susan L Perlman
- Division of Neurogenetics, Department of Neurology, David Geffen School of Medicine at University of California, Los Angeles, 300 UCLA Medical Plaza, Suite B200, Los Angeles, CA 90095, USA.
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19
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Fogel BL, Perlman S. An approach to the patient with late-onset cerebellar ataxia. ACTA ACUST UNITED AC 2006; 2:629-35; quiz 1 p following 635. [PMID: 17057750 DOI: 10.1038/ncpneuro0319] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 08/15/2006] [Indexed: 11/08/2022]
Abstract
BACKGROUND An 83-year-old man presented with hypertension, hyperlipidemia, and a previous basal cell carcinoma, having developed progressive worsening of his balance and difficulty walking at the age of 78 years. He was initially diagnosed with stroke, but MRI revealed only isolated cerebellar atrophy. The patient then underwent multiple evaluations for an underlying paraneoplastic process, all of which were negative, but his symptoms progressed and he remained undiagnosed for several years. INVESTIGATIONS Neurological examination, laboratory blood tests, MRI, and directed genetic testing. DIAGNOSIS Five years after becoming symptomatic, the patient was re-evaluated for a possible genetic ataxia syndrome, which was subsequently confirmed by gene testing as spinocerebellar ataxia type 6 (SCA6). MANAGEMENT Symptomatic medical treatment and physical, occupational, and speech therapy.
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Affiliation(s)
- Brent L Fogel
- Department of Neurology, University of California, Los Angeles, CA 90095, USA
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