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Curie A, Lion-François L, Valayannopoulos V, Perreton N, Gavanon M, Touil N, Brun-Laurisse A, Gheurbi F, Buchy M, Halep H, Cheillan D, Mercier C, Brassier A, Desnous B, Kassai B, De Lonlay P, Des Portes V. Clinical Characteristics, Developmental Trajectory, and Caregiver Burden of Patients With Creatine Transporter Deficiency ( SLC6A8). Neurology 2024; 102:e209243. [PMID: 38531017 DOI: 10.1212/wnl.0000000000209243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 01/19/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Creatine transporter deficiency (CTD) is a rare X-linked genetic disorder characterized by intellectual disability (ID). We evaluated the clinical characteristics and trajectory of patients with CTD and the impact of the disease on caregivers to identify relevant endpoints for future therapeutic trials. METHODS As part of a French National Research Program, patients with CTD were included based on (1) a pathogenic SLC6A8 variant and (2) ID and/or autism spectrum disorder. Families and patients were referred by the physician who ordered the genetic analysis through Reference Centers of ID from rare causes and inherited metabolic diseases. After we informed the patients and their parents/guardians about the study, all of them gave written consent and were included. A control group of age-matched and sex-matched patients with Fragile X syndrome was also included. Physical examination, neuropsychological assessments, and caregiver impact were assessed. All data were analyzed using R software. RESULTS Thirty-one patients (27 male, 4 female) were included (25/31 aged 18 years or younger). Most of the patients (71%) had symptoms at <24 months of age. The mean age at diagnosis was 6.5 years. Epilepsy occurred in 45% (mean age at onset: 8 years). Early-onset behavioral disorder occurred in 82%. Developmental trajectory was consistently delayed (fine and gross motor skills, language, and communication/sociability). Half of the patients with CTD had axial hypotonia during the first year of life. All patients were able to walk without help, but 7/31 had ataxia and only 14/31 could walk tandem gait. Most of them had abnormal fine motor skills (27/31), and most of them had language impairment (30/31), but 12/23 male patients (52.2%) completed the Peabody Picture Vocabulary Test. Approximately half (14/31) had slender build. Most of them needed nursing care (20/31), generally 1-4 h/d. Adaptive assessment (Vineland) confirmed that male patients with CTD had moderate-to-severe ID. Most caregivers (79%) were at risk of burnout, as shown by Caregiver Burden Inventory (CBI) > 36 (significantly higher than for patients with Fragile X syndrome) with a high burden of time dependence. DISCUSSION In addition to clinical endpoints, such as the assessment of epilepsy and the developmental trajectory of the patient, the Vineland scale, PPVT5, and CBI are of particular interest as outcome measures for future trials. TRIAL REGISTRATION INFORMATION ANSM Registration Number 2010-A00327-32.
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Affiliation(s)
- Aurore Curie
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Laurence Lion-François
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Vassili Valayannopoulos
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Nathalie Perreton
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Marie Gavanon
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Nathalie Touil
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Amandine Brun-Laurisse
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Fahra Gheurbi
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Marion Buchy
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Hulya Halep
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - David Cheillan
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Catherine Mercier
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Anaïs Brassier
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Béatrice Desnous
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Behrouz Kassai
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Pascale De Lonlay
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Vincent Des Portes
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
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Hawksworth O, Chatters R, Julious S, Cook A, Biggs K, Solaiman K, Quah MCH, Cheong SC. A methodological review of randomised n-of-1 trials. Trials 2024; 25:263. [PMID: 38622638 PMCID: PMC11020886 DOI: 10.1186/s13063-024-08100-1] [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: 06/29/2023] [Accepted: 04/09/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND n-of-1 trials are a type of crossover trial designed to optimise the evaluation of health technologies in individual patients. This trial design may be considered for the evaluation of health technologies in rare conditions where fewer patients are available to take part in research. This review describes the characteristics of randomised n-of-1 trials conducted over the span of 12 years, including how the n-of-1 design has been employed to study both rare and non-rare conditions. METHODS Databases and clinical trials registries were searched for articles including "n-of-1" in the title between 2011 and 2023. The reference lists of reviews identified by the searches were searched for any additional eligible articles. Randomised n-of-1 trials were selected for inclusion and data were extracted on a range of design, population, and analysis characteristics. Descriptive statistics were produced for all variables. RESULTS We identified 74 studies meeting our eligibility criteria, 13 of which (17.6%) were conducted in rare conditions. They were conducted in a range of clinical areas with the most common being neurological conditions (n = 16, 21.6%). The median (Q1, Q3) number of participants randomised was 9 (4, 20) and 12 trials (16.2%) involved a single patient only. Forty-six (62.2%) trials evaluated pharmaceutical interventions and 49 (66.2%) trials were placebo controlled. Trials had a median (Q1, Q3) of six (4, 8) periods and 61 (82.4%) compared two health technologies. Fifty-seven (77.0%) trials incorporated blinding and 32 (43.2%) had a washout period. Forty-nine trials (66.2%) used patient-reported outcome measures (PROMs) to assess the primary outcome. Trials used a range of approaches to analysis and 48 (64.9%) combined data from multiple patients. The characteristics of the n-of-1 trials conducted in rare conditions were generally consistent with those in non-rare conditions. CONCLUSIONS n-of-1 trials are still underused and the application of the n-of-1 design for the evaluation of health technologies for rare diseases has been particularly limited. We have summarised the characteristics of randomised n-of-1 trials in rare and non-rare conditions. We hope that it can inform researchers in the design of future n-of-1 studies. Further work is required to provide guidance on specific design considerations, implementation, and statistical analysis of these studies. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Olivia Hawksworth
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK.
| | - Robin Chatters
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Steven Julious
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Andrew Cook
- Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Katie Biggs
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Kiera Solaiman
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Michael C H Quah
- School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - Sxe Chang Cheong
- School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
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Bakkum L, Paalman C, Müller A, van Eeghen A, Schuengel C. Accessibility and feasibility of experience sampling methods for mental health research with people with intellectual disability: Scoping of research and stakeholder views. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2024; 37:e13190. [PMID: 38361385 DOI: 10.1111/jar.13190] [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: 06/01/2023] [Revised: 10/18/2023] [Accepted: 12/10/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND Experience sampling may be useful for mental health research with people with intellectual disability, and evidence of the potential benefits is starting to emerge. This multiple-method study identified potential avenues for tailoring this method to the needs of people with intellectual disability. METHOD A scoping review was conducted. Five databases were searched for experience sampling studies involving people with intellectual disability. In addition, seven adults with an intellectual disability tested experience sampling apps with standardised questions about mental health and were interviewed about their experiences in semi-structured interviews. RESULTS Seven studies were included in the scoping review. Two studies investigated acceptability and feasibility. In the interviews, participants reported on the acceptability, availability, and appropriateness of experience sampling applications. CONCLUSIONS There are still important gaps in knowledge about acceptability, availability, and appropriateness of experience sampling for this population. Researchers are recommended to tailor experience sampling applications to the needs and interests of individual users.
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Affiliation(s)
- Lianne Bakkum
- Department of Educational and Family Sciences and Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Célinde Paalman
- Department of Educational and Family Sciences and Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Annelieke Müller
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands & Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Agnies van Eeghen
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands & Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Carlo Schuengel
- Department of Educational and Family Sciences and Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Neul JL. Challenges in developing therapies in fragile X syndrome: how the FXLEARN trial can guide research. J Clin Invest 2024; 134:e175036. [PMID: 38426491 PMCID: PMC10904042 DOI: 10.1172/jci175036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Fragile X syndrome (FXS), the most common inherited cause of intellectual disability and the single-gene cause of autism, is caused by decreased expression of the fragile X messenger ribonucleoprotein protein (FMRP), a ribosomal-associated RNA-binding protein involved in translational repression. Extensive preclinical work in several FXS animal models supported the therapeutic potential of decreasing metabotropic glutamate receptor (mGluR) signaling to correct translation of proteins related to synaptic plasticity; however, multiple clinical trials failed to show conclusive evidence of efficacy. In this issue of the JCI, Berry-Kravis and colleagues conducted the FXLEARN clinical trial to address experimental design concerns from previous trials. Unfortunately, despite treatment of young children with combined pharmacological and learning interventions for a prolonged period, no efficacy of blocking mGluR activity was observed. Future systematic evaluation of potential therapeutic approaches should evaluate consistency between human and animal pathophysiological mechanisms, utilize innovative clinical trial design from FXLEARN, and incorporate translatable biomarkers.
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Müller AR, den Hollander B, van de Ven PM, Roes KCB, Geertjens L, Bruining H, van Karnebeek CDM, Jansen FE, de Wit MCY, Ten Hoopen LW, Rietman AB, Dierckx B, Wijburg FA, Boot E, Brands MMG, van Eeghen AM. Cannabidiol (Epidyolex®) for severe behavioral manifestations in patients with tuberous sclerosis complex, mucopolysaccharidosis type III and fragile X syndrome: protocol for a series of randomized, placebo-controlled N-of-1 trials. BMC Psychiatry 2024; 24:23. [PMID: 38177999 PMCID: PMC10768432 DOI: 10.1186/s12888-023-05422-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Many rare genetic neurodevelopmental disorders (RGNDs) are characterized by intellectual disability (ID), severe cognitive and behavioral impairments, potentially diagnosed as a comorbid autism spectrum disorder or attention-deficit hyperactivity disorder. Quality of life is often impaired due to irritability, aggression and self-injurious behavior, generally refractory to standard therapies. There are indications from previous (case) studies and patient reporting that cannabidiol (CBD) may be an effective treatment for severe behavioral manifestations in RGNDs. However, clear evidence is lacking and interventional research is challenging due to the rarity as well as the heterogeneity within and between disease groups and interindividual differences in treatment response. Our objective is to examine the effectiveness of CBD on severe behavioral manifestations in three RGNDs, including Tuberous Sclerosis Complex (TSC), mucopolysaccharidosis type III (MPS III), and Fragile X syndrome (FXS), using an innovative trial design. METHODS We aim to conduct placebo-controlled, double-blind, block-randomized, multiple crossover N-of-1 studies with oral CBD (twice daily) in 30 patients (aged ≥ 6 years) with confirmed TSC, MPS III or FXS and severe behavioral manifestations. The treatment is oral CBD up to a maximum of 25 mg/kg/day, twice daily. The primary outcome measure is the subscale irritability of the Aberrant Behavior Checklist. Secondary outcome measures include (personalized) patient-reported outcome measures with regard to behavioral and psychiatric outcomes, disease-specific outcome measures, parental stress, seizure frequency, and adverse effects of CBD. Questionnaires will be completed and study medication will be taken at the participants' natural setting. Individual treatment effects will be determined based on summary statistics. A mixed model analysis will be applied for analyzing the effectiveness of the intervention per disorder and across disorders combining data from the individual N-of-1 trials. DISCUSSION These N-of-1 trials address an unmet medical need and will provide information on the effectiveness of CBD for severe behavioral manifestations in RGNDs, potentially generating generalizable knowledge at an individual-, disorder- and RGND population level. TRIAL REGISTRATION EudraCT: 2021-003250-23, registered 25 August 2022, https://www.clinicaltrialsregister.eu/ctr-search/trial/2021-003250-23/NL .
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Affiliation(s)
- A R Müller
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- 's Heeren Loo Care Group, Amersfoort, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
| | - B den Hollander
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - P M van de Ven
- Department of Data Science and Biostatistics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K C B Roes
- Department of Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L Geertjens
- Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam UMC, Amsterdam Neuroscience, Amsterdam Reproduction and Development, N=You Neurodevelopmental Precision Center, Amsterdam, The Netherlands
| | - H Bruining
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam UMC, Amsterdam Neuroscience, Amsterdam Reproduction and Development, N=You Neurodevelopmental Precision Center, Amsterdam, The Netherlands
- Levvel, Center for Child and Adolescent Psychiatry, Amsterdam, The Netherlands
| | - C D M van Karnebeek
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
- Department of Human Genetics, Amsterdam UMC, Amsterdam, The Netherlands
| | - F E Jansen
- Department of Pediatric Neurology, Brain, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M C Y de Wit
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - L W Ten Hoopen
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A B Rietman
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - B Dierckx
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - F A Wijburg
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - E Boot
- 's Heeren Loo Care Group, Amersfoort, The Netherlands
- The Dalglish Family 22Q Clinic, Toronto, ON, Canada
- Department of Psychiatry & Neuropsychology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - M M G Brands
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - A M van Eeghen
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
- 's Heeren Loo Care Group, Amersfoort, The Netherlands.
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands.
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Godbole NP, Haxton E, Rowe OE, Locascio JJ, Schmahmann JD, Eichler FS, Ratai E, Stephen CD. Clinical and imaging predictors of late-onset GM2 gangliosidosis: A scoping review. Ann Clin Transl Neurol 2024; 11:207-224. [PMID: 38009419 PMCID: PMC10791033 DOI: 10.1002/acn3.51947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/03/2023] [Indexed: 11/28/2023] Open
Abstract
OBJECTIVE Late-onset GM2 gangliosidosis (LOGG) subtypes late-onset Tay-Sachs (LOTS) and Sandhoff disease (LOSD) are ultra-rare neurodegenerative lysosomal storage disorders presenting with weakness, ataxia, and neuropsychiatric symptoms. Previous studies considered LOTS and LOSD clinically indistinguishable; recent studies have challenged this. We performed a scoping review to ascertain whether imaging and clinical features may differentiate these diseases. METHODS We examined MEDLINE/non-MEDLINE databases up to May 2022. Articles reporting brain imaging findings in genetically/enzymatically confirmed LOGG, symptom onset at age ≥ 10 years (or evaluated at least once ≥18 years) were included, yielding 170 LOGG patients (LOTS = 127, LOSD = 43) across 68 papers. We compared LOTS versus LOSD and performed regression analyses. Results were corrected for multiple comparisons. RESULTS Age of onset was lower in LOTS versus LOSD (17.9 ± 8.2 vs. 23.9 ± 14.4 years, p = 0.017), although disease duration was similar (p = 0.34). LOTS more commonly had psychosis/bipolar symptoms (35.0% vs. 9.30%, p = 0.011) but less frequent swallowing problems (4.10% vs. 18.60%, p = 0.041). Cerebellar atrophy was more common in LOTS (89.0%) versus LOSD (60.5%), p < 0.0001, with more severe atrophy in LOTS (p = 0.0005). Brainstem atrophy was documented only in LOTS (14.2%). Independent predictors of LOTS versus LOSD (odds ratio [95% confidence interval]) included the presence of psychosis/bipolar symptoms (4.95 [1.59-19.52], p = 0.011), no swallowing symptoms (0.16 [0.036-0.64], p = 0.011), and cerebellar atrophy (5.81 [2.10-17.08], p = 0.0009). Lower age of onset (0.96 [0.93-1.00], p = 0.075) and tremor (2.50 [0.94-7.43], p = 0.078) were marginally statistically significant but felt relevant to include in the model. INTERPRETATION These data suggest significant differences in symptomatology, disease course, and imaging findings between LOTS and LOSD.
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Affiliation(s)
- Neha P. Godbole
- Center for Rare Neurological Diseases, Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Elizabeth Haxton
- Center for Rare Neurological Diseases, Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Olivia E. Rowe
- Athinoula A. Martinos Center for Biomedical Imaging, Division of Neuroradiology, Department of RadiologyMassachusetts General Hospital and Harvard Medical SchoolCharlestownMassachusettsUSA
| | - Joseph J. Locascio
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Harvard Catalyst Biostatistical Consulting Group, Harvard Medical SchoolBostonMassachusettsUSA
| | - Jeremy D. Schmahmann
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Laboratory for Neuroanatomy and Cerebellar Neurobiology, Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Florian S. Eichler
- Center for Rare Neurological Diseases, Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Eva‐Maria Ratai
- Athinoula A. Martinos Center for Biomedical Imaging, Division of Neuroradiology, Department of RadiologyMassachusetts General Hospital and Harvard Medical SchoolCharlestownMassachusettsUSA
| | - Christopher D. Stephen
- Center for Rare Neurological Diseases, Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Laboratory for Neuroanatomy and Cerebellar Neurobiology, Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
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Müller AR, van Silfhout NY, den Hollander B, Kampman DHC, Bakkum L, Brands MMMG, Haverman L, Terwee CB, Schuengel C, Daams J, Hessl D, Wijburg FA, Boot E, van Eeghen AM. Navigating the outcome maze: a scoping review of outcomes and instruments in clinical trials in genetic neurodevelopmental disorders and intellectual disability. THERAPEUTIC ADVANCES IN RARE DISEASE 2024; 5:26330040241245721. [PMID: 38681798 PMCID: PMC11047260 DOI: 10.1177/26330040241245721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 03/14/2024] [Indexed: 05/01/2024]
Abstract
Background Individuals with genetic neurodevelopmental disorders (GNDs) or intellectual disability (ID) are often affected by complex neuropsychiatric comorbidities. Targeted treatments are increasingly available, but due to the heterogeneity of these patient populations, choosing a key outcome and corresponding outcome measurement instrument remains challenging. Objectives The aim of this scoping review was to describe the research on outcomes and instruments used in clinical trials in GNDs and ID. Eligibility criteria Clinical trials in individuals with GNDs and ID for any intervention over the past 10 years were included in the review. Sources of evidence MEDLINE, PsycINFO, and Cochrane CENTRAL were searched. Titles and abstracts were independently screened for eligibility with a subsample of 10% double-screening for interrater reliability. Data from full texts were independently reviewed. Discrepancies were discussed until consensus was reached. Charting methods Information was recorded on patient populations, interventions, designs, outcomes, measurement instruments, and type of reporter when applicable. Qualitative and descriptive analyses were performed. Results We included 312 studies reporting 91 different outcomes, with cognitive function most frequently measured (28%). Various outcome measurement instruments (n = 457) were used, with 288 in only a single clinical trial. There were 18 genetic condition-specific instruments and 16 measures were designed ad-hoc for one particular trial. Types of report included proxy-report (39%), self-report (22%), clinician-report (16%), observer-report (6%), self-assisted report (1%), or unknown (16%). Conclusion This scoping review of current practice reveals a myriad of outcomes and outcome measurement instruments for clinical trials in GNDs and ID. This complicates generalization, evidence synthesis, and evaluation. It underlines the need for consensus on suitability, validity, and relevancy of instruments, ultimately resulting in a core outcome set. A series of steps is proposed to move from the myriad of measures to a more unified approach.
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Affiliation(s)
- Annelieke R. Müller
- Department of Pediatrics, Emma Children’s Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Advisium, ’s Heeren Loo, Amersfoort, Utrecht, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Nadia Y. van Silfhout
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Child Development, Amsterdam, The Netherlands
- Emma Children’s Hospital, Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Bibiche den Hollander
- Department of Pediatrics, Emma Children’s Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, The Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - Dick H. C. Kampman
- Faculty of Science, Operational Management, ICT Department, Utrecht University, Utrecht, The Netherlands
| | - Lianne Bakkum
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Clinical Child and Family Studies, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marion M. M. G. Brands
- Department of Pediatrics, Emma Children’s Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Child Development, Amsterdam, The Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - Lotte Haverman
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Child Development, Amsterdam, The Netherlands
- Emma Children’s Hospital, Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Caroline B. Terwee
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Epidemiology and Data Science, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Carlo Schuengel
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Clinical Child and Family Studies, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Joost Daams
- Medical Library, Research Support, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - David Hessl
- MIND Institute and Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, CA, USA
| | - Frits A. Wijburg
- Department of Pediatrics, Emma Children’s Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Erik Boot
- Advisium, ’s Heeren Loo, Amersfoort, Utrecht, The Netherlands
- The Dalglish Family 22q Clinic, Toronto, ON, Canada
- Department of Psychiatry & Neuropsychology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Agnies M. van Eeghen
- Emma Center for Personalized Medicine, Amsterdam UMC, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
- Advisium, ’s Heeren Loo, Berkenweg 11, 3818 LA, Amersfoort, The Netherlands
- Amsterdam Public Health Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Child Development, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Bayat A, Iavarone S, Miceli F, Jakobsen AV, Johannesen KM, Nikanorova M, Ploski R, Szymanska K, Flamini R, Cooper EC, Weckhuysen S, Taglialatela M, Møller RS. Phenotypic and functional assessment of two novel KCNQ2 gain-of-function variants Y141N and G239S and effects of amitriptyline treatment. Neurotherapeutics 2024; 21:e00296. [PMID: 38241158 PMCID: PMC10903081 DOI: 10.1016/j.neurot.2023.10.006] [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: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 01/21/2024] Open
Abstract
While loss-of-function (LoF) variants in KCNQ2 are associated with a spectrum of neonatal-onset epilepsies, gain-of-function (GoF) variants cause a more complex phenotype that precludes neonatal-onset epilepsy. In the present work, the clinical features of three patients carrying a de novo KCNQ2 Y141N (n = 1) or G239S variant (n = 2) respectively, are described. All three patients had a mild global developmental delay, with prominent language deficits, and strong activation of interictal epileptic activity during sleep. Epileptic seizures were not reported. The absence of neonatal seizures suggested a GoF effect and prompted functional testing of the variants. In vitro whole-cell patch-clamp electrophysiological experiments in Chinese Hamster Ovary cells transiently-transfected with the cDNAs encoding Kv7.2 subunits carrying the Y141N or G239S variants in homomeric or heteromeric configurations with Kv7.2 subunits, revealed that currents from channels incorporating mutant subunits displayed increased current densities and hyperpolarizing shifts of about 10 mV in activation gating; both these functional features are consistent with an in vitro GoF phenotype. The antidepressant drug amitriptyline induced a reversible and concentration-dependent inhibition of current carried by Kv7.2 Y141N and G239S mutant channels. Based on in vitro results, amitriptyline was prescribed in one patient (G239S), prompting a significant improvement in motor, verbal, social, sensory and adaptive behavior skillsduring the two-year-treatment period. Thus, our results suggest that KCNQ2 GoF variants Y141N and G239S cause a mild DD with prominent language deficits in the absence of neonatal seizures and that treatment with the Kv7 channel blocker amitriptyline might represent a potential targeted treatment for patients with KCNQ2 GoF variants.
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Affiliation(s)
- Allan Bayat
- Department of Epilepsy Genetics and Personalized Medicine, Danish Epilepsy Center, Filadelfia, Dianalund, Denmark; Department for Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark.
| | - Stefano Iavarone
- Section of Pharmacology, Department of Neuroscience, University of Naples "Federico II", Naples, Italy
| | - Francesco Miceli
- Section of Pharmacology, Department of Neuroscience, University of Naples "Federico II", Naples, Italy
| | - Anne V Jakobsen
- Department of Pediatrics, Danish Epilepsy Center, Filadelfia, Dianalund, Denmark
| | - Katrine M Johannesen
- Department of Epilepsy Genetics and Personalized Medicine, Danish Epilepsy Center, Filadelfia, Dianalund, Denmark; Department of Genetics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Marina Nikanorova
- Department of Pediatrics, Danish Epilepsy Center, Filadelfia, Dianalund, Denmark
| | - Rafal Ploski
- Department of Medical Genetics, Medical University of Warsaw, Warsaw, Poland
| | - Krystyna Szymanska
- Department of Pediatric Neurology, Medical University of Warsaw, Warsaw, Poland
| | | | - Edward C Cooper
- Departments of Neurology, Neuroscience, and Molecular and Human Genetics, Baylor College of Medicine, Houston TX, USA
| | - Sarah Weckhuysen
- Applied and Translational Genomics Group, VIB-Center for Molecular Neurology, VIB, University of Antwerp, Antwerp, Belgium; Neurology Department, University Hospital Antwerp, Antwerp, Belgium; Translational Neurosciences, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium; μNEURO Research Centre of Excellence, University of Antwerp, Antwerp, Belgium
| | - Maurizio Taglialatela
- Section of Pharmacology, Department of Neuroscience, University of Naples "Federico II", Naples, Italy
| | - Rikke S Møller
- Department of Epilepsy Genetics and Personalized Medicine, Danish Epilepsy Center, Filadelfia, Dianalund, Denmark; Department for Regional Health Research, University of Southern Denmark, Odense, Denmark
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Balestrini S, Mei D, Sisodiya SM, Guerrini R. Steps to Improve Precision Medicine in Epilepsy. Mol Diagn Ther 2023; 27:661-672. [PMID: 37755653 PMCID: PMC10590329 DOI: 10.1007/s40291-023-00676-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/28/2023]
Abstract
Precision medicine is an old concept, but it is not widely applied across human health conditions as yet. Numerous attempts have been made to apply precision medicine in epilepsy, this has been based on a better understanding of aetiological mechanisms and deconstructing disease into multiple biological subsets. The scope of precision medicine is to provide effective strategies for treating individual patients with specific agent(s) that are likely to work best based on the causal biological make-up. We provide an overview of the main applications of precision medicine in epilepsy, including the current limitations and pitfalls, and propose potential strategies for implementation and to achieve a higher rate of success in patient care. Such strategies include establishing a definition of precision medicine and its outcomes; learning from past experiences, from failures and from other fields (e.g. oncology); using appropriate precision medicine strategies (e.g. drug repurposing versus traditional drug discovery process); and using adequate methods to assess efficacy (e.g. randomised controlled trials versus alternative trial designs). Although the progress of diagnostic techniques now allows comprehensive characterisation of each individual epilepsy condition from a molecular, biological, structural and clinical perspective, there remain challenges in the integration of individual data in clinical practice to achieve effective applications of precision medicine in this domain.
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Affiliation(s)
- S Balestrini
- Neuroscience Department, Meyer Children's Hospital IRCSS, Florence, Italy
- University of Florence, Florence, Italy
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
| | - D Mei
- Neuroscience Department, Meyer Children's Hospital IRCSS, Florence, Italy
| | - S M Sisodiya
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, UK
| | - Renzo Guerrini
- Neuroscience Department, Meyer Children's Hospital IRCSS, Florence, Italy.
- University of Florence, Florence, Italy.
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Defelippe VM, J M W van Thiel G, Otte WM, Schutgens REG, Stunnenberg B, Cross HJ, O'Callaghan F, De Giorgis V, Jansen FE, Perucca E, Brilstra EH, Braun KPJ. Toward responsible clinical n-of-1 strategies for rare diseases. Drug Discov Today 2023; 28:103688. [PMID: 37356616 DOI: 10.1016/j.drudis.2023.103688] [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: 01/17/2023] [Revised: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 06/27/2023]
Abstract
N-of-1 strategies can provide high-quality evidence of treatment efficacy at the individual level and optimize evidence-based selection of off-label treatments for patients with rare diseases. Given their design characteristics, n-of-1 strategies are considered to lay at the intersection between medical research and clinical care. Therefore, whether n-of-1 strategies should be governed by research or care regulations remains a debated issue. Here, we delineate differences between medical research and optimized clinical care, and distinguish the regulations which apply to either. We also set standards for responsible optimized clinical n-of-1 strategies with (off-label) treatments for rare diseases. Implementing clinical n-of-1 strategies as defined here could aid in optimized treatment selection for such diseases.
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Affiliation(s)
- Victoria M Defelippe
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands; European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France.
| | - Ghislaine J M W van Thiel
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Willem M Otte
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, Benign Hematology Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; European Reference Network for Oncological and non-oncological Rare Hematological Diseases (EuroBloodNet), Hôpital St Louis / Université Paris 7, 1 Avenue Claude Vellefaux, 75475 Paris, France
| | - Bas Stunnenberg
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Thomas van Aquinostraat 4, 6525 GD Nijmegen, the Netherlands
| | - Helen J Cross
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; University College London (UCL) Great Ormond Street, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Finbar O'Callaghan
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Paediatric Neuroscience, UCL Great Ormond Street, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Valentina De Giorgis
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Fondazione Mondino National Institute of Neurology, University of Pavia, Via Mondino 2, 27100 Pavia, Italy
| | - Floor E Jansen
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands; European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France
| | - Emilio Perucca
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Department of Medicine, University of Melbourne (Austin Health), Heidelberg, VIC 3084, Australia; Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Eva H Brilstra
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Department of Genetics, Center for Molecular Medicine, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Kees P J Braun
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
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Lewis SA, Chopra M, Cohen JS, Bain J, Aravamuthan B, Carmel JB, Fahey MC, Segel R, Wintle RF, Zech M, May H, Haque N, Fehlings D, Srivastava S, Kruer MC. Clinical actionability of genetic findings in cerebral palsy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.08.23295195. [PMID: 37745357 PMCID: PMC10516062 DOI: 10.1101/2023.09.08.23295195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Background and objectives Single gene mutations are increasingly recognized as causes of cerebral palsy (CP) phenotypes, yet there is currently no standardized framework for measuring their clinical impact. We evaluated Pathogenic/Likely Pathogenic (P/LP) variants identified in individuals with CP to determine how frequently genetic testing results would prompt changes in care. Methods We analyzed published P/LP variants in OMIM genes identified in clinical (n = 1,345 individuals) or research (n = 496) cohorts using exome sequencing of CP patients. We established a working group of clinical and research geneticists, developmental pediatricians, genetic counselors, and neurologists and performed a systematic review of existing literature for evidence of clinical management approaches linked to genetic disorders. Scoring rubrics were adapted, and a modified Delphi approach was used to build consensus and establish the anticipated impact on patient care. Overall clinical utility was calculated from metrics assessing outcome severity if left untreated, safety/practicality of the intervention, and anticipated intervention efficacy . Results We found 140/1,841 (8%) of individuals in published CP cohorts had a genetic diagnosis classified as actionable , defined as prompting a change in clinical management based on knowledge related to the genetic etiology. 58/243 genes with P/LP variants were classified as actionable; 16 had treatment options targeting the primary disease mechanism , 16 had specific prevention strategies , and 26 had specific symptom management recommendations. The level of evidence was also graded according to ClinGen criteria; 44.6% of interventions had evidence class "D" or below. The potential interventions have clinical utility with 97% of outcomes being moderate-high severity if left untreated and 62% of interventions predicted to be of moderate-high efficacy . Most interventions (71%) were considered moderate-high safety/practicality . Discussion Our findings indicate that actionable genetic findings occur in 8% of individuals referred for genetic testing with CP. Evaluation of potential efficacy , outcome severity , and intervention safety / practicality indicates moderate-high clinical utility of these genetic findings. Thus, genetic sequencing to identify these individuals for precision medicine interventions could improve outcomes and provide clinical benefit to individuals with CP. The relatively limited evidence base for most interventions underscores the need for additional research.
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12
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Lewis SA, Shetty S, Gamble S, Heim J, Zhao N, Stitt G, Pankratz M, Mangum T, Marku I, Rosenberg RB, Wilfong AA, Fahey MC, Kim S, Myers SJ, Appavu B, Kruer MC. Intrathecal magnesium delivery for Mg++-insensitive NMDA receptor activity due to GRIN1 mutation. Orphanet J Rare Dis 2023; 18:225. [PMID: 37537625 PMCID: PMC10398931 DOI: 10.1186/s13023-023-02756-9] [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: 07/29/2022] [Accepted: 06/04/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Mutations in the NMDA receptor are known to disrupt glutamatergic signaling crucial for early neurodevelopment, often leading to severe global developmental delay/intellectual disability, epileptic encephalopathy, and cerebral palsy phenotypes. Both seizures and movement disorders can be highly treatment-refractory. RESULTS We describe a targeted ABA n-of-1 treatment trial with intrathecal MgSO4, rationally designed based on the electrophysiologic properties of this gain of function mutation in the GRIN1 NMDA subunit. CONCLUSION Although the invasive nature of the trial necessitated a short-term, non-randomized, unblinded intervention, quantitative longitudinal neurophysiologic monitoring indicated benefit, providing class II evidence in support of intrathecal MgSO4 for select forms of GRIN disorders.
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Affiliation(s)
- Sara A Lewis
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
- Departments of Child Health, Neurology, Cellular & Molecular Medicine, and Program in Genetics, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Sheetal Shetty
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
- Departments of Child Health, Neurology, Cellular & Molecular Medicine, and Program in Genetics, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Sean Gamble
- Valley Anesthesia, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Jennifer Heim
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
| | - Ningning Zhao
- Department of Nutritional Sciences, University of Arizona, Tucson, AZ, USA
| | - Gideon Stitt
- Department of Pharmacy & Therapeutics, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Matthew Pankratz
- Phoenix Children's Hospital Biorepository, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Tara Mangum
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
| | - Iris Marku
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
| | - Robert B Rosenberg
- Division of Pediatric Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Angus A Wilfong
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
| | - Michael C Fahey
- Departments of Paediatrics and Neurology, Monash University, Melbourne, VIC, Australia
| | - Sukhan Kim
- Center for Functional Evaluation of Rare Variants, Emory University, Atlanta, GA, USA
| | - Scott J Myers
- Center for Functional Evaluation of Rare Variants, Emory University, Atlanta, GA, USA
| | - Brian Appavu
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA
| | - Michael C Kruer
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, 85016, USA.
- Departments of Child Health, Neurology, Cellular & Molecular Medicine, and Program in Genetics, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.
- Programs in Neuroscience, Molecular & Cellular Biology, and Biomedical Informatics, Arizona State University, Tempe, AZ, USA.
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13
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Tkemaladze T, Bratland E, Bregvadze K, Shatirishvili T, Tatishvili N, Abzianidze E, Houge G, Douzgou S. MSMO1 deficiency: a potentially partially treatable, ultrarare neurodevelopmental disorder with psoriasiform dermatitis, alopecia and polydactyly. Clin Dysmorphol 2023; 32:97-105. [PMID: 37195326 DOI: 10.1097/mcd.0000000000000461] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
MSMO1 deficiency (OMIM #616834) is an ultrarare autosomal recessive disorder of distal cholesterol metabolism with only five cases reported to date. The disorder is caused by missense variants in the MSMO1 gene encoding methylsterol monooxygenase 1, leading to the accumulation of methylsterols. Clinically, MSMO1 deficiency is characterized by growth and developmental delay, often in association with congenital cataracts, microcephaly, psoriasiform dermatitis and immune dysfunction. Treatment with oral and topical cholesterol supplements and statins was reported to improve the biochemical, immunological, and cutaneous findings, supporting a potential treatment following the precision diagnosis of MSMO1 deficiency. We describe two siblings from a consanguineous family presenting with novel clinical features of polydactyly, alopecia and spasticity. Whole-exome sequencing revealed a novel, homozygous c.548A > C, p.(Glu183Ala) variant. Based on previously published treatment algorithms, we initiated a modified dosage regime with systemic cholesterol supplementation, statins and bile acid along with topical application of a cholesterol/statin formulation. This resulted in a marked improvement of psoriasiform dermatitis and some hair growth.
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Affiliation(s)
- Tinatin Tkemaladze
- Department of Molecular and Medical Genetics, Tbilisi State Medical University
- Department of Child Neurology, M. Iashvili Children's Central Hospital, Tbilisi, Georgia
| | - Eirik Bratland
- Department of Medical Genetics, Haukeland University Hospital
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kakha Bregvadze
- Department of Molecular and Medical Genetics, Tbilisi State Medical University
| | - Teona Shatirishvili
- Department of Child Neurology, M. Iashvili Children's Central Hospital, Tbilisi, Georgia
| | - Nino Tatishvili
- Department of Child Neurology, M. Iashvili Children's Central Hospital, Tbilisi, Georgia
| | - Elene Abzianidze
- Department of Molecular and Medical Genetics, Tbilisi State Medical University
| | - Gunnar Houge
- Department of Medical Genetics, Haukeland University Hospital
- Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Sofia Douzgou
- Department of Medical Genetics, Haukeland University Hospital
- Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
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14
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Harel T. Rare disease informs mechanism and possible treatment of statin-associated myopathy. Proc Natl Acad Sci U S A 2023; 120:e2300988120. [PMID: 36848568 PMCID: PMC10013738 DOI: 10.1073/pnas.2300988120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Affiliation(s)
- Tamar Harel
- Department of Genetics, Hadassah Medical Center, Jerusalem91120, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem91120, Israel
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15
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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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16
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Cheung K, Mitsumoto H. Evaluating Personalized (N-of-1) Trials in Rare Diseases: How Much Experimentation Is Enough? HARVARD DATA SCIENCE REVIEW 2022; 2022:10.1162/99608f92.e11adff0. [PMID: 38283317 PMCID: PMC10813653 DOI: 10.1162/99608f92.e11adff0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
For rare diseases, conducting large, randomized trials of new treatments can be infeasible due to limited sample size, and it may answer the wrong scientific questions due to heterogeneity of treatment effects. Personalized (N-of-1) trials are multi-period crossover studies that aim to estimate individual treatment effects, thereby identifying the optimal treatments for individuals. This article examines the statistical design issues of evaluating a personalized (N-of-1) treatment program in people with amyotrophic lateral sclerosis (ALS). We propose an evaluation framework based on an analytical model for longitudinal data observed in a personalized trial. Under this framework, we address two design parameters: length of experimentation in each trial and number of trials needed. For the former, we consider patient-centric design criteria that aim to maximize the benefits of enrolled patients. Using theoretical investigation and numerical studies, we demonstrate that, from a patient's perspective, the duration of an experimentation period should be no longer than one-third of the entire follow-up period of the trial. For the latter, we provide analytical formulae to calculate the power for testing quality improvement due to personalized trials in a randomized evaluation program and hence determine the required number of trials needed for the program. We apply our theoretical results to design an evaluation program for ALS treatments informed by pilot data and show that the length of experimentation has a small impact on power relative to other factors such as the degree of heterogeneity of treatment effects.
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Affiliation(s)
- Ken Cheung
- Mailman School of Public Health, Columbia University, New York City, New York, United States of America
| | - Hiroshi Mitsumoto
- Columbia University Irving Medical Center, Columbia University, New York City, New York, United States of America
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17
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Gilbert LA, Fehlings DL, Gross P, Kruer MC, Kwan W, Mink JW, Shusterman M, Aravamuthan BR. Top 10 Research Themes for Dystonia in Cerebral Palsy: A Community-Driven Research Agenda. Neurology 2022; 99:237-245. [PMID: 35715199 PMCID: PMC9442618 DOI: 10.1212/wnl.0000000000200911] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 05/16/2022] [Indexed: 11/15/2022] Open
Abstract
Dystonia in cerebral palsy (DCP) is a common, debilitating, but understudied condition. The CP community (people with CP and caregivers) is uniquely equipped to help determine the research questions that best address their needs. We developed a community-driven DCP research agenda using the well-established James Lind Alliance methodology. CP community members, researchers, and clinicians were recruited through multiple advocacy, research, and professional organizations. To ensure shared baseline knowledge, participants watched webinars outlining our current knowledge on DCP prepared by a Steering Group of field experts (cprn.org/research-cp-dystonia-edition). Participants next submitted their remaining uncertainties about DCP. These were vetted by the Steering Group and consolidated to eliminate redundancy to generate a list of unique uncertainties, which were then prioritized by the participants. The top-prioritized uncertainties were aggregated into themes through iterative consensus-building discussions within the Steering Group. 166 webinar viewers generated 67 unique uncertainties. 29 uncertainties (17 generated by community members) were prioritized higher than their randomly matched pairs. These were coalesced into the following top 10 DCP research themes: (1) develop new treatments; (2) assess rehabilitation, psychological, and environmental management approaches; (3) compare effectiveness of current treatments; (4) improve diagnosis and severity assessments; (5) assess the effect of mixed tone (spasticity and dystonia) in outcomes and approaches; (6) assess predictors of treatment responsiveness; (7) identify pathophysiologic mechanisms; (8) characterize the natural history; (9) determine the best treatments for pain; and (10) increase family awareness. This community-driven research agenda reflects the concerns most important to the community, both in perception and in practice. We therefore encourage future DCP research to center around these themes. Furthermore, noting that community members (not clinicians or researchers) generated the majority of top-prioritized uncertainties, our results highlight the important contributions community members can make to research agendas, even beyond DCP.
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Affiliation(s)
- Laura A Gilbert
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Darcy L Fehlings
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Paul Gross
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Michael C Kruer
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Wendy Kwan
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Jonathan W Mink
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Michele Shusterman
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Bhooma R Aravamuthan
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT.
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18
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Konigorski S, Wernicke S, Slosarek T, Zenner AM, Strelow N, Ruether DF, Henschel F, Manaswini M, Pottbäcker F, Edelman JA, Owoyele B, Danieletto M, Golden E, Zweig M, Nadkarni GN, Böttinger E. StudyU: A Platform for Designing and Conducting Innovative Digital N-of-1 Trials. J Med Internet Res 2022; 24:e35884. [PMID: 35787512 PMCID: PMC9297132 DOI: 10.2196/35884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/17/2022] [Accepted: 04/18/2022] [Indexed: 11/28/2022] Open
Abstract
N-of-1 trials are the gold standard study design to evaluate individual treatment effects and derive personalized treatment strategies. Digital tools have the potential to initiate a new era of N-of-1 trials in terms of scale and scope, but fully functional platforms are not yet available. Here, we present the open source StudyU platform, which includes the StudyU Designer and StudyU app. With the StudyU Designer, scientists are given a collaborative web application to digitally specify, publish, and conduct N-of-1 trials. The StudyU app is a smartphone app with innovative user-centric elements for participants to partake in trials published through the StudyU Designer to assess the effects of different interventions on their health. Thereby, the StudyU platform allows clinicians and researchers worldwide to easily design and conduct digital N-of-1 trials in a safe manner. We envision that StudyU can change the landscape of personalized treatments both for patients and healthy individuals, democratize and personalize evidence generation for self-optimization and medicine, and can be integrated in clinical practice.
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Affiliation(s)
- Stefan Konigorski
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
- Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sarah Wernicke
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
- Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Tamara Slosarek
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
- Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Alexander M Zenner
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
- Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
| | - Nils Strelow
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
- Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
| | - Darius F Ruether
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
- Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Henschel
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
- Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
| | - Manisha Manaswini
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
- Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
| | - Fabian Pottbäcker
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
- Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
| | - Jonathan A Edelman
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
- The Center for Advanced Design Studies, Palo Alto, CA, United States
| | - Babajide Owoyele
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
| | - Matteo Danieletto
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Eddye Golden
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Micol Zweig
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Girish N Nadkarni
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Erwin Böttinger
- Digital Health Center, Hasso Plattner Institute for Digital Engineering, University of Potsdam, Potsdam, Germany
- Digital Engineering Faculty, University of Potsdam, Potsdam, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Veenvliet AR, Garrelfs MR, Udink ten Cate FE, Ferdinandusse S, Denis S, Fuchs SA, Schwantje M, Geurtzen R, van Wegberg AM, Huigen MC, Kluijtmans LA, Wanders RJ, Derks TG, de Boer L, Houtkooper RH, de Vries MC, van Karnebeek CD. Neonatal Long-Chain 3-Ketoacyl-CoA Thiolase deficiency: Clinical-biochemical phenotype, sodium-D,L-3-hydroxybutyrate treatment experience and cardiac evaluation using speckle echocardiography. Mol Genet Metab Rep 2022; 31:100873. [PMID: 35782614 PMCID: PMC9248206 DOI: 10.1016/j.ymgmr.2022.100873] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 04/16/2022] [Indexed: 02/08/2023] Open
Abstract
Isolated long-chain 3-keto-acyl CoA thiolase (LCKAT) deficiency is a rare long-chain fatty acid oxidation disorder caused by mutations in HADHB. LCKAT is part of a multi-enzyme complex called the mitochondrial trifunctional protein (MTP) which catalyzes the last three steps in the long-chain fatty acid oxidation. Until now, only three cases of isolated LCKAT deficiency have been described. All patients developed a severe cardiomyopathy and died before the age of 7 weeks. Here, we describe a newborn with isolated LCKAT deficiency, presenting with neonatal-onset cardiomyopathy, rhabdomyolysis, hypoglycemia and lactic acidosis. Bi-allelic 185G > A (p.Arg62His) and c1292T > C (p.Phe431Ser) mutations were found in HADHB. Enzymatic analysis in both lymphocytes and cultured fibroblasts revealed LCKAT deficiency with a normal long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD, also part of MTP) enzyme activity. Clinically, the patient showed recurrent cardiomyopathy, which was monitored by speckle tracking echocardiography. Subsequent treatment with special low-fat formula, low in long chain triglycerides (LCT) and supplemented with medium chain triglycerides (MCT) and ketone body therapy in (sodium-D,L-3-hydroxybutyrate) was well tolerated and resulted in improved carnitine profiles and cardiac function. Resveratrol, a natural polyphenol that has been shown to increase fatty acid oxidation, was also considered as a potential treatment option but showed no in vitro benefits in the patient's fibroblasts. Even though our patient deceased at the age of 13 months, early diagnosis and prompt initiation of dietary management with addition of sodium-D,L-3-hydroxybutyrate may have contributed to improved cardiac function and a much longer survival when compared to the previously reported cases of isolated LCKAT-deficiency.
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Improving clinical trial readiness to accelerate development of new therapeutics for Rett syndrome. Orphanet J Rare Dis 2022; 17:108. [PMID: 35246185 PMCID: PMC8894842 DOI: 10.1186/s13023-022-02240-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 02/06/2022] [Indexed: 12/16/2022] Open
Abstract
Rett syndrome is associated with severe functional impairments and many comorbidities, each in urgent need of treatments. Mutations in the MECP2 gene were identified as causing Rett syndrome in 1999. Over the past 20 years there has been an abundance of preclinical research with some studies leading to human clinical trials. Despite this, few viable therapeutic options have emerged from this investment of effort. Reasons for this lack of success as they relate both to preclinical research and the clinical trial landscape are discussed. Considering what needs to be done to promote further success in the field, we take a positive and constructive approach and introduce the concept of clinical trial readiness and its necessary ingredients for Rett syndrome. These include: listening to the needs of families; support from advocacy groups; optimising use of existing clinic infrastructures and available natural history data; and, finally, the validation of existing outcome measures and/or the development and validation of new measures. We conclude by reiterating the need for a collaborative and coordinated approach amongst the many different stakeholder groups and the need to engage in new types of trial design which could be much more efficient, less costly and much less burdensome on families.
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van der Knaap MS, Bonkowsky JL, Vanderver A, Schiffmann R, Krägeloh-Mann I, Bertini E, Bernard G, Fatemi SA, Wolf NI, Saunier-Vivar E, Rauner R, Dekker H, van Bokhoven P, van de Ven P, Leferink PS. Therapy Trial Design in Vanishing White Matter: An Expert Consortium Opinion. Neurol Genet 2022; 8:e657. [PMID: 35128050 PMCID: PMC8811717 DOI: 10.1212/nxg.0000000000000657] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/21/2021] [Indexed: 01/04/2023]
Abstract
Vanishing white matter (VWM) is a leukodystrophy caused by recessive variants in the genes EIF2B1-EIF2B5. It is characterized by chronic neurologic deterioration with superimposed stress-provoked episodes of rapid decline. Disease onset spans from the antenatal period through senescence. Age at onset predicts disease evolution for patients with early onset, whereas disease evolution is unpredictable for later onset; patients with infantile and early childhood onset consistently have severe disease with rapid neurologic decline and often early death, whereas patients with later onset have highly variable disease. VWM is rare, but likely underdiagnosed, particularly in adults. Apart from measures to prevent stressors that could provoke acute deteriorations, only symptomatic care is currently offered. With increased insight into VWM disease mechanisms, opportunities for treatment have emerged. EIF2B1-EIF2B5 encode the 5-subunit eukaryotic initiation factor 2B complex, which is essential for translation of mRNAs into proteins and is a principal regulator of the integrated stress response (ISR). ISR deregulation is central to VWM pathology. Targeting components of the ISR has proven beneficial in mutant VWM mouse models, and several drugs are now in clinical development. However, clinical trials in VWM pose considerable challenges: low numbers of known patients with VWM, unpredictable disease course for patients with onset after early childhood, absence of intermediate biomarkers, and novel first-in-human molecular targets. Given these challenges and considering the critical need to offer therapies, we have formulated recommendations for enhanced diagnosis, drug trial setup, and patient selection, based on our expert evaluation of molecular, laboratory, and clinical data.
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Affiliation(s)
- Marjo S van der Knaap
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Joshua L Bonkowsky
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Adeline Vanderver
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Raphael Schiffmann
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Ingeborg Krägeloh-Mann
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Enrico Bertini
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Genevieve Bernard
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Seyed Ali Fatemi
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Nicole I Wolf
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Elise Saunier-Vivar
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Robert Rauner
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Hanka Dekker
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Pieter van Bokhoven
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Peter van de Ven
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Prisca S Leferink
- Department of Pediatric Neurology (M.S.v.d.K., N.I.W.), Amsterdam Leukodystrophy Center, Emma Children's Hospital, Amsterdam University Medical Centers; Amsterdam Neuroscience (M.S.v.d.K., N.I.W.); Department of Functional Genomics (M.S.v.d.K.), Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, the Netherlands; Division of Pediatric Neurology (J.L.B.), Department of Pediatrics, University of Utah School of Medicine; Primary Children's Hospital (J.L.B.), Intermountain Healthcare, Salt Lake City, UT; Division of Neurology (A.V.), Children's Hospital of Philadelphia; Department of Neurology (A.V.), Perelman School of Medicine, University of Pennsylvania, PA; 4D Molecular Therapeutics (R.S.), Emeryville, CA; Department of Developmental and Child Neurology (I.K.-M.), Social Pediatrics, University Children's Hospital Tübingen, Germany; Department of Neuroscience (E.B.), Unit of Neuromuscular and Neurodegenerative Diseases, Laboratory of Molecular Medicine, Genetics and Rare Diseases Research Division, IRCCS Ospedale Pediatrico Bambino Gesù, Rome 00146, Italy; Departments of Neurology and Neurosurgery (G.B.), Pediatrics and Human Genetics, McGill University; Department Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Center; Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Center, Montreal, Canada; Kennedy Krieger Institute (S.A.F.), Johns Hopkins University, Baltimore, MD; Research Department (E.S.-V.), European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France; United Leukodystrophy Foundation (R.R.), DeKalb, IL; Vereniging Volwassenen, Kinderen en Stofwisselingsziekten (H.D.), Zwolle, the Netherlands; Industry Alliance Office (P.v.B., P.S.L.), Amsterdam Neuroscience, Amsterdam University Medical Centers; and Department of Epidemiology and Data Science (P.v.d.V.), Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
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22
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Personalized medicine for rare neurogenetic disorders: can we make it happen? Cold Spring Harb Mol Case Stud 2022; 8:mcs.a006200. [PMID: 35332073 PMCID: PMC8958924 DOI: 10.1101/mcs.a006200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Rare neurogenetic disorders are collectively common, affecting 3% of the population, and often manifest with complex multiorgan comorbidity. With advances in genetic, -omics, and computational analysis, more children can be diagnosed and at an earlier age. Innovations in translational research facilitate the identification of treatment targets and development of disease-modifying drugs such as gene therapy, nutraceuticals, and drug repurposing. This increasingly allows targeted therapy to prevent the often devastating manifestations of rare neurogenetic disorders. In this perspective, successes in diagnosis, prevention, and treatment are discussed with a focus on inherited disorders of metabolism. Barriers for the identification, development, and implementation of rare disease-specific therapies are discussed. New methodologies, care networks, and collaborative frameworks are proposed to optimize the potential of personalized genomic medicine to decrease morbidity and improve lives of these vulnerable patients.
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23
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Gene-Targeted Therapies in Pediatric Neurology: Challenges and Opportunities in Diagnosis and Delivery. Pediatr Neurol 2021; 125:53-57. [PMID: 34628144 PMCID: PMC9472447 DOI: 10.1016/j.pediatrneurol.2021.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Gene-targeted therapies are becoming a reality for infants and children with diseases of the nervous system. Rapid scientific advances have led to disease-modifying or even curative treatments. However, delays and gaps in diagnosis, inequitable delivery, and the need for long-term surveillance pose unresolved challenges. OBJECTIVE AND METHODS The goal of the Child Neurology Society Research Committee was to evaluate and provide guidance on the obstacles, opportunities, and uncertainties in gene-targeted therapies for pediatric neurological disease. The Child Neurology Society Research Committee engaged in collaborative, iterative literature review and committee deliberations to prepare this consensus statement. RESULTS We identified important challenges for gene-targeted therapies that require resource investments, infrastructure development, and strategic planning. Barriers include inequities in diagnosis and delivery of therapies, high costs, and a need for long-term surveillance of efficacy and safety, including systematic tracking of unanticipated effects. Key uncertainties regarding technical aspects and usage of gene-targeted therapies should be addressed, and characterization of new natural histories of diseases will be needed. Counterbalanced with these obstacles and uncertainties is the tremendous potential being demonstrated in treatments and clinical trials of gene-targeted therapies. CONCLUSIONS Given that gene-targeted therapies for neurological diseases are in their earliest phase, the pediatric neurology community can play a vital role in their guidance and implementation. This role includes facilitating development of infrastructure and guidelines; ensuring efficient, equitable, and ethical implementation of treatments; and advocating for affordable and broad access for all children.
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24
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Da Silva JD, Costa MD, Almeida B, Lopes F, Maciel P, Teixeira-Castro A. Case Report: A Novel GNB1 Mutation Causes Global Developmental Delay With Intellectual Disability and Behavioral Disorders. Front Neurol 2021; 12:735549. [PMID: 34646230 PMCID: PMC8504539 DOI: 10.3389/fneur.2021.735549] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/27/2021] [Indexed: 01/26/2023] Open
Abstract
Diseases of neurodevelopment mostly exhibit neurological and psychiatric symptoms that go from very mild to extremely severe. While the etiology of most cases of neurodevelopmental disease is still unknown, the discovery of underlying genetic causes is rapidly increasing, with hundreds of genes being currently implicated as disease-causing. Here, we report a clinical case of a patient with a previously undiagnosed syndrome comprising severe global developmental delay, intellectual disability, and behavioral disorders (such as attention-deficit/hyperactivity disorder, autism spectrum disorder and recurrent bouts of aggressive behavior). After genetic testing, a pathogenic variant was detected in the GNB1 gene, which codes for the G-protein subunit β1. The detected variant (c.217G>A, p.A73T) has not been previously reported in any of the 58 published cases of GNB1 encephalopathy. However, it localizes to the mutational hotspot in exons 6 and 7 in which 88% of all missense mutations occur. An in silico model predicts that this mutation is likely to disrupt the WD40 domain of the GNB1 protein, which is required for its interaction with other G-proteins and, consequently, for downstream signal transduction. In conclusion, we reported an additional GNB1 encephalopathy patient, bearing a novel mutation, taking another step toward a better understanding of its clinical presentation and prospective development of treatments for the disease.
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Affiliation(s)
- Jorge Diogo Da Silva
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-Portuguese Government Associate Laboratory, Braga, Guimarães, Portugal.,Pediatrics Department, Hospital of Santa Maria Maior, Barcelos, Portugal
| | - Marta Daniela Costa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-Portuguese Government Associate Laboratory, Braga, Guimarães, Portugal
| | - Bruno Almeida
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-Portuguese Government Associate Laboratory, Braga, Guimarães, Portugal
| | - Fátima Lopes
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-Portuguese Government Associate Laboratory, Braga, Guimarães, Portugal
| | - Patrícia Maciel
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-Portuguese Government Associate Laboratory, Braga, Guimarães, Portugal
| | - Andreia Teixeira-Castro
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-Portuguese Government Associate Laboratory, Braga, Guimarães, Portugal
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25
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Moloney PB, Cavalleri GL, Delanty N. Epilepsy in the mTORopathies: opportunities for precision medicine. Brain Commun 2021; 3:fcab222. [PMID: 34632383 PMCID: PMC8495134 DOI: 10.1093/braincomms/fcab222] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/23/2021] [Accepted: 08/30/2021] [Indexed: 01/16/2023] Open
Abstract
The mechanistic target of rapamycin signalling pathway serves as a ubiquitous regulator of cell metabolism, growth, proliferation and survival. The main cellular activity of the mechanistic target of rapamycin cascade funnels through mechanistic target of rapamycin complex 1, which is inhibited by rapamycin, a macrolide compound produced by the bacterium Streptomyces hygroscopicus. Pathogenic variants in genes encoding upstream regulators of mechanistic target of rapamycin complex 1 cause epilepsies and neurodevelopmental disorders. Tuberous sclerosis complex is a multisystem disorder caused by mutations in mechanistic target of rapamycin regulators TSC1 or TSC2, with prominent neurological manifestations including epilepsy, focal cortical dysplasia and neuropsychiatric disorders. Focal cortical dysplasia type II results from somatic brain mutations in mechanistic target of rapamycin pathway activators MTOR, AKT3, PIK3CA and RHEB and is a major cause of drug-resistant epilepsy. DEPDC5, NPRL2 and NPRL3 code for subunits of the GTPase-activating protein (GAP) activity towards Rags 1 complex (GATOR1), the principal amino acid-sensing regulator of mechanistic target of rapamycin complex 1. Germline pathogenic variants in GATOR1 genes cause non-lesional focal epilepsies and epilepsies associated with malformations of cortical development. Collectively, the mTORopathies are characterized by excessive mechanistic target of rapamycin pathway activation and drug-resistant epilepsy. In the first large-scale precision medicine trial in a genetically mediated epilepsy, everolimus (a synthetic analogue of rapamycin) was effective at reducing seizure frequency in people with tuberous sclerosis complex. Rapamycin reduced seizures in rodent models of DEPDC5-related epilepsy and focal cortical dysplasia type II. This review outlines a personalized medicine approach to the management of epilepsies in the mTORopathies. We advocate for early diagnostic sequencing of mechanistic target of rapamycin pathway genes in drug-resistant epilepsy, as identification of a pathogenic variant may point to an occult dysplasia in apparently non-lesional epilepsy or may uncover important prognostic information including, an increased risk of sudden unexpected death in epilepsy in the GATORopathies or favourable epilepsy surgery outcomes in focal cortical dysplasia type II due to somatic brain mutations. Lastly, we discuss the potential therapeutic application of mechanistic target of rapamycin inhibitors for drug-resistant seizures in GATOR1-related epilepsies and focal cortical dysplasia type II.
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Affiliation(s)
- Patrick B Moloney
- FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Royal College of Surgeons in Ireland, Dublin, D02 VN51, Ireland
| | - Gianpiero L Cavalleri
- FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Royal College of Surgeons in Ireland, Dublin, D02 VN51, Ireland
| | - Norman Delanty
- FutureNeuro, the Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, Royal College of Surgeons in Ireland, Dublin, D02 VN51, Ireland
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26
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Kane PB, Bittlinger M, Kimmelman J. Individualized therapy trials: navigating patient care, research goals and ethics. Nat Med 2021; 27:1679-1686. [PMID: 34642487 DOI: 10.1038/s41591-021-01519-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023]
Abstract
'Individualized therapy' trials (sometimes called n-of-1 trials) use patients as their own controls to evaluate treatments. Here we divide such trials into three categories: multi-crossover trials aimed at individual patient management, multi-crossover trial series and pre-post trials. These trials all customize interventions for patients; however, the latter two categories also aim to inform medical practice and thus embody tensions between the goals of care and research that are typical of other types of clinical trials. In this Perspective, we discuss four domains where such tensions play out-clinical equipoise, informed consent, reporting and funding, and we provide recommendations for addressing each.
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Affiliation(s)
- Patrick Bodilly Kane
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Merlin Bittlinger
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Jonathan Kimmelman
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada.
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27
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Müller AR, Zinkstok JR, Rommelse NNJ, van de Ven PM, Roes KCB, Wijburg FA, de Rooij-Askes E, Linders C, Boot E, van Eeghen AM. Methylphenidate for attention-deficit/hyperactivity disorder in patients with Smith-Magenis syndrome: protocol for a series of N-of-1 trials. Orphanet J Rare Dis 2021; 16:380. [PMID: 34496899 PMCID: PMC8424817 DOI: 10.1186/s13023-021-02003-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/24/2021] [Indexed: 12/29/2022] Open
Abstract
Background Smith–Magenis syndrome (SMS) is a rare genetic neurodevelopmental disorder characterized by intellectual disability and severe behavioural and sleep disturbances. Often, patients with SMS are diagnosed with attention-deficit/hyperactivity disorder (ADHD). However, the effectiveness of methylphenidate (MPH), the first-line pharmacological treatment for ADHD, in patients with SMS is unclear. Our objective is to examine the effectiveness of MPH for ADHD symptoms in individuals with SMS, proposing an alternative trial design as traditional randomized controlled trials are complex in these rare and heterogeneous patient populations. Methods and analysis We will initiate an N-of-1 series of double-blind randomized and placebo-controlled multiple crossover trials in six patients aged ≥ 6 years with a genetically confirmed SMS diagnosis and a multidisciplinary established ADHD diagnosis, according to a power analysis based on a summary measures analysis of the treatment effect. Each N-of-1 trial consists of a baseline period, dose titration phase, three cycles each including randomized intervention, placebo and washout periods, and follow-up. The intervention includes twice daily MPH (doses based on age and body weight). The primary outcome measure will be the subscale hyperactivity/inattention of the Strengths and Difficulties Questionnaire (SDQ), rated daily. Secondary outcome measures are the shortened version of the Emotion Dysregulation Inventory (EDI) reactivity index, Goal Attainment Scaling (GAS), and the personal questionnaire (PQ). Statistical analysis will include a mixed model analysis. All subjects will receive an assessment of their individual treatment effect and data will be aggregated to investigate the effectiveness of MPH for ADHD in SMS at a population level. Conclusions This study will provide information on the effectiveness of MPH for ADHD in SMS, incorporating personalized outcome measures. This protocol presents the first properly powered N-of-1 study in a rare genetic neurodevelopmental disorder, providing a much-needed bridge between science and practice to optimize evidence-based and personalized care. Trial registration This study is registered in the Netherlands Trial Register (NTR9125).
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Affiliation(s)
- A R Müller
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands.,Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - J R Zinkstok
- Department of Psychiatry and Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N N J Rommelse
- Karakter, Child and Adolescent Psychiatry, Nijmegen, The Netherlands.,Department of Psychiatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P M van de Ven
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - K C B Roes
- Department of Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - F A Wijburg
- Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - C Linders
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands
| | - E Boot
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands.,Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands.,The Dalglish Family 22Q Clinic, University Health Network, Toronto, ON, Canada
| | - A M van Eeghen
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands. .,Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands.
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28
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Zarbin MA, Novack G. N-of-1 Clinical Trials: A Scientific Approach to Personalized Medicine for Patients with Rare Retinal Diseases Such as Retinitis Pigmentosa. J Ocul Pharmacol Ther 2021; 37:495-501. [PMID: 34491833 DOI: 10.1089/jop.2021.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
N-of-1 trials are randomized, prospective, controlled, multiple crossover trials in a single patient. Effects of one or more treatments are studied by following individual patients who receive alternative treatments (eg, therapeutic intervention). Such trials may provide a path to assess treatments for rare diseases with rigor equal to or greater than that afforded by parallel group randomized clinical trials provided that the condition is reasonably stable during the trial and has a sign/symptom that responds reversibly to the therapy and that can be measured repeatedly. In this article, the authors propose that N-of-1 trials may improve the feasibility and affordability of clinical trials for patients with rare inherited retinal diseases.
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Affiliation(s)
- Marco A Zarbin
- Institute of Ophthalmology and Visual Science, Rutgers-New Jersey Medical School, Rutgers University, Newark, New Jersey, USA
| | - Gary Novack
- PharmaLogic Development, Inc., San Rafael, California, USA.,Department of Ophthalmology & Visual Sciences, School of Medicine, University of California, Davis, Sacramento, California, USA
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29
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[Brain tumor immunotherapy-Possibilities and challenges of personalization]. DER NERVENARZT 2021; 92:996-1001. [PMID: 34476518 DOI: 10.1007/s00115-021-01178-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
Brain tumors represent a special interdisciplinary challenge in the treatment of neurological disorders. Insights into the interindividual as well as the spatial and temporal intraindividual heterogeneity require entirely new personalized treatment approaches. Particularly in the field of immunotherapy there are possibilities for targeted interventions and systematic follow-up for assessment of response to treatment. Although not yet integrated into the standard treatment, early clinical trials in recent years have shown the feasibility of systematic personalized treatment approaches. The conceptual and regulatory implications of these approaches reach far beyond the field of neuro-oncology.
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30
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Nikles J, Onghena P, Vlaeyen JW, Wicksell RK, Simons LE, McGree JM, McDonald S. Establishment of an International Collaborative Network for N-of-1 Trials and Single-Case Designs. Contemp Clin Trials Commun 2021; 23:100826. [PMID: 34401597 PMCID: PMC8350373 DOI: 10.1016/j.conctc.2021.100826] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 06/15/2021] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
In this article we briefly examine the unique features of Single-Case Designs (SCDs) (studies in a single participant), their history and current trends, and real-world clinical applications. The International Collaborative Network for N-of-1 Trials and Single-Case Designs (ICN) is a formal collaborative network for individuals with an interest in SCDs. The ICN was established in 2017 to support the SCD scientific community and provide opportunities for collaboration, a global communication channel, resource sharing and knowledge exchange. In May 2021, there were more than 420 members in 31 countries. A member survey was undertaken in 2019 to identify priorities for the ICN for the following few years. This article outlines the key priorities identified and the ICN's progress to date in these key areas including network activities (developing a communications strategy to increase awareness, collecting/sharing a comprehensive set of resources, guidelines and tips, and incorporating the consumer perspective) and scientific activities (writing position papers and guest editing special journal issues, exploring key stakeholder perspectives about SCDs, and working to streamline ethical approval processes for SCDs). The ICN provides a practical means to engage with this methodology through membership. We encourage clinicians, researchers, industry, and healthcare consumers to learn more about and conduct SCDs, and to join us in our mission of using SCDs to improve health outcomes for individuals and populations.
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Affiliation(s)
- Jane Nikles
- Centre for Clinical Research, The University of Queensland, Australia
| | | | | | | | | | | | - Suzanne McDonald
- Centre for Clinical Research, The University of Queensland, Australia
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31
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Response to pyridoxine in CACNA1A epilepsy-ataxia does not imply a causal effect. Seizure 2021; 91:196-197. [PMID: 34225085 DOI: 10.1016/j.seizure.2021.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/19/2021] [Indexed: 11/20/2022] Open
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32
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Abstract
Genetic testing has yielded major advances in our understanding of the causes of epilepsy. Seizures remain resistant to treatment in a significant proportion of cases, particularly in severe, childhood-onset epilepsy, the patient population in which an underlying causative genetic variant is most likely to be identified. A genetic diagnosis can be explanatory as to etiology, and, in some cases, might suggest a therapeutic approach; yet, a clear path from genetic diagnosis to treatment remains unclear in most cases. Here, we discuss theoretical considerations behind the attempted use of small molecules for the treatment of genetic epilepsies, which is but one among various approaches currently under development. We explore a few salient examples and consider the future of the small molecule approach for genetic epilepsies. We conclude that significant additional work is required to understand how genetic variation leads to dysfunction of epilepsy-associated protein targets, and how this impacts the function of diverse subtypes of neurons embedded within distributed brain circuits to yield epilepsy and epilepsy-associated comorbidities. A syndrome- or even variant-specific approach may be required to achieve progress. Advances in the field will require improved methods for large-scale target validation, compound identification and optimization, and the development of accurate model systems that reflect the core features of human epilepsy syndromes, as well as novel approaches towards clinical trials of such compounds in small rare disease cohorts.
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Affiliation(s)
- Ethan M Goldberg
- Department of Pediatrics, Division of Neurology, Abramson Research Center, The Epilepsy Neurogenetics Initiative, The Children's Hospital of Philadelphia, Abramson Research Center Room 502A, 19104, Philadelphia, PA, USA.
- Departments of Neurology and Neuroscience, The University of Pennsylvania Perelman School of Medicine, 19104, Philadelphia, PA, USA.
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33
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Cognitive and neurological outcome of patients in the Dutch pyridoxine-dependent epilepsy (PDE-ALDH7A1) cohort, a cross-sectional study. Eur J Paediatr Neurol 2021; 33:112-120. [PMID: 34153871 DOI: 10.1016/j.ejpn.2021.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 05/14/2021] [Accepted: 06/02/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pyridoxine monotherapy in PDE-ALDH7A1 often results in adequate seizure control, but neurodevelopmental outcome varies. Detailed long-term neurological outcome is unknown. Here we present the cognitive and neurological features of the Dutch PDE-ALDH7A1 cohort. METHODS Neurological outcome was assessed in 24 patients (age 1-26 years); classified as normal, complex minor neurological dysfunction (complex MND) or abnormal. Intelligence quotient (IQ) was derived from standardized IQ tests with five severity levels of intellectual disability (ID). MRI's and treatments were assessed. RESULTS Ten patients (42%) showed unremarkable neurological examination, 11 (46%) complex MND, and 3 (12%) cerebral palsy (CP). Minor coordination problems were identified in 17 (71%), fine motor disability in 11 (46%), posture/muscle tone deviancies in 11 (46%) and abnormal reflexes in 8 (33%). Six patients (25%) had an IQ > 85, 7 (29%) borderline, 7 (29%) mild, 3 (13%) moderate, and 1 severe ID. Cerebral ventriculomegaly on MRI was progressive in 11. Three patients showed normal neurologic exam, IQ, and MRI. Eleven patients were treated with pyridoxine only and 13 by additional lysine reduction therapy (LRT). LRT started at age <3 years demonstrated beneficial effect on IQ results in 3 patients. DISCUSSION Complex MND and CP occurred more frequently in PDE-ALDH7A1 (46% and 12%) than in general population (7% and 0.2%, Peters et al., 2011, Schaefer et al., 2008). Twenty-five percent had a normal IQ. Although LRT shows potential to improve outcomes, data are heterogeneous in small patient numbers. More research with longer follow-up via the International PDE Registry (www.pdeonline.org) is needed.
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Treatment of ARS deficiencies with specific amino acids. Genet Med 2021; 23:2202-2207. [PMID: 34194004 PMCID: PMC8244667 DOI: 10.1038/s41436-021-01249-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 02/01/2023] Open
Abstract
Purpose Recessive cytosolic aminoacyl-tRNA synthetase (ARS) deficiencies are severe multiorgan diseases, with limited treatment options. By loading transfer RNAs (tRNAs) with their cognate amino acids, ARS are essential for protein translation. However, it remains unknown why ARS deficiencies lead to specific symptoms, especially early life and during infections. We set out to increase pathophysiological insight and improve therapeutic possibilities. Methods In fibroblasts from patients with isoleucyl-RS (IARS), leucyl-RS (LARS), phenylalanyl-RS-beta-subunit (FARSB), and seryl-RS (SARS) deficiencies, we investigated aminoacylation activity, thermostability, and sensitivity to ARS-specific amino acid concentrations, and developed personalized treatments. Results Aminoacylation activity was reduced in all patients, and further diminished at 38.5/40 °C (PLARS and PFARSB), consistent with infectious deteriorations. With lower cognate amino acid concentrations, patient fibroblast growth was severely affected. To prevent local and/or temporal deficiencies, we treated patients with corresponding amino acids (follow-up: 1/2–2 2/3rd years), and intensified treatment during infections. All patients showed beneficial treatment effects, most strikingly in growth (without tube feeding), head circumference, development, coping with infections, and oxygen dependency. Conclusion For these four ARS deficiencies, we observed a common disease mechanism of episodic insufficient aminoacylation to meet translational demands and illustrate the power of amino acid supplementation for the expanding ARS patient group. Moreover, we provide a strategy for personalized preclinical functional evaluation. ![]()
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Husain M. Time for N-of-1 trials in clinical decision-making. Brain 2021; 144:1031-1032. [PMID: 33871604 DOI: 10.1093/brain/awab107] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
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Hartman AL. N-of-1 Trials in Rare Genetic Neurodevelopmental Disorders: Opportunities for Improvement. Neurology 2021; 96:513-514. [PMID: 33504644 DOI: 10.1212/wnl.0000000000011603] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Adam L Hartman
- From the National Institute of Neurological Disorders and Stroke, NIH, Rockville, MD.
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