Current and emerging pharmacotherapy for Gaucher disease in pediatric populations

INTRODUCTION

The past decades have witnessed a remarkable improvement in the health of patients with Gaucher disease, the inherited deficiency of the lysosomal enzyme glucocerebrosidase, resulting from the availability of enzyme replacement and substrate reduction therapies. Especially in pediatric populations, early diagnosis and initiation of treatment is essential to achieving optimal outcomes.

AREAS COVERED

The authors review the literature pertaining to the effectiveness of currently available therapies and describe new pharmacotherapies under development, especially for young patients.

EXPERT OPINION

For pediatric patients with non-neuronopathic Gaucher disease, there may be new therapeutic options on the horizon in the form of gene therapy or small molecule glucocerebrosidase chaperones. These have the potential to result in a cure for systemic disease manifestations and/or to reduce the cost and convenience of treatment. For children with neuronopathic Gaucher disease, the challenge of targeting therapy to the central nervous system is being explored through new modalities including brain-targeted gene therapy, in-utero therapy, brain-penetrant small molecule chaperones, and other methods that convey enzyme across the blood-brain barrier. Indeed, these are exciting times for both pediatric patients with Gaucher disease and those with other lysosomal storage disorders.

A class of viral inducer of degradation of the necroptosis adaptor RIPK3 regulates virus-induced inflammation

The vaccine strain against smallpox, vaccinia virus (VACV), is highly immunogenic yet causes relatively benign disease. These attributes are believed to be caused by gene loss in VACV. Using a targeted small interfering RNA (siRNA) screen, we identified a viral inhibitor found in cowpox virus (CPXV) and other orthopoxviruses that bound to the host SKP1-Cullin1-F-box (SCF) machinery and the essential necroptosis kinase receptor interacting protein kinase 3 (RIPK3). This "viral inducer of RIPK3 degradation" (vIRD) triggered ubiquitination and proteasome-mediated degradation of RIPK3 and inhibited necroptosis. In contrast to orthopoxviruses, the distantly related leporipoxvirus myxoma virus (MYXV), which infects RIPK3-deficient hosts, lacks a functional vIRD. Introduction of vIRD into VACV, which encodes a truncated and defective vIRD, enhanced viral replication in mice. Deletion of vIRD reduced CPXV-induced inflammation, viral replication, and mortality, which were reversed in RIPK3- and MLKL-deficient mice. Hence, vIRD-RIPK3 drives pathogen-host evolution and regulates virus-induced inflammation and pathogenesis.

Modulating electrophysiology of motor neural networks via optogenetic stimulation during neurogenesis and synaptogenesis

Control of electrical activity in neural circuits through network training is a grand challenge for biomedicine and engineering applications. Past efforts have not considered evoking long-term changes in firing patterns of in-vitro networks by introducing training regimens with respect to stages of neural development. Here, we used Channelrhodopsin-2 (ChR2) transfected mouse embryonic stem cell (mESC) derived motor neurons to explore short and long-term programming of neural networks by using optical stimulation implemented during neurogenesis and synaptogenesis. Not only did we see a subsequent increase of neurite extensions and synaptophysin clustering, but by using electrophysiological recording with micro electrode arrays (MEA) we also observed changes in signal frequency spectra, increase of network synchrony, coordinated firing of actions potentials, and enhanced evoked response to stimulation during network formation. Our results demonstrate that optogenetic stimulation during neural differentiation can result in permanent changes that extended to the genetic expression of neurons as demonstrated by RNA Sequencing. To our knowledge, this is the first time that a correlation between training regimens during neurogenesis and synaptogenesis and the resulting plastic responses has been shown in-vitro and traced back to changes in gene expression. This work demonstrates new approaches for training of neural circuits whose electrical activity can be modulated and enhanced, which could lead to improvements in neurodegenerative disease research and engineering of in-vitro multi-cellular living systems.

Small Molecule Chaperones for the Treatment of Gaucher Disease and GBA1-Associated Parkinson Disease

Parkinson disease, the second most common movement disorder, is a complex neurodegenerative disorder hallmarked by the accumulation of alpha-synuclein, a neural-specific small protein associated with neuronal synapses. Mutations in the glucocerebrosidase gene (GBA1), implicated in the rare, autosomal recessive lysosomal disorder Gaucher disease, are the most common known genetic risk factor for Parkinson disease. Insights into the inverse relationship between glucocerebrosidase and alpha-synuclein have led to new therapeutic approaches for the treatment of Gaucher disease and GBA1-associated Parkinson disease. Unlike the current drugs used to treat Gaucher disease, which are highly expensive and do not cross the blood-brain-barrier, new small molecules therapies, including competitive and non-competitive chaperones that enhance glucocerebrosidase levels are being developed to overcome these limitations. Some of these include iminosugars, ambroxol, other competitive glucocerebrosidase inhibitors, and non-inhibitory chaperones or activators that do not compete for the active site. These drugs, which have been shown in different disease models to increase glucocerebrosidase activity, could have potential as a therapy for Gaucher disease and GBA1- associated Parkinson disease. Some have been demonstrated to reduce α-synuclein levels in pre-clinical studies using cell-based or animal models of GBA1-associated Parkinson disease, and may also have utility for idiopathic Parkinson disease.

Glucocerebrosidase as a therapeutic target for Parkinson's disease

Introduction: The association between Gaucher disease, caused by the inherited deficiency of glucocerebrosidase, and Parkinson's disease was first recognized in the clinic, noting that patients with Gaucher disease and their carrier relatives had an increased incidence of Parkinson's disease. Currently, mutations in glucocerebrosidase (GBA1) are the most common genetic risk factor for Parkinson's disease and dementia with Lewy bodies, with an inverse relationship between glucocerebrosidase and α-synuclein, a key factor in Parkinson pathogenesis. The hypothesis that therapeutic enhancement of brain glucocerebrosidase levels might reduce the aggregation, accumulation or spread of α-synuclein has spurred great interest in glucocerebrosidase as a novel therapeutic target.Area covered: This article explores the potential molecular mechanisms underlying the association between GBA1 mutations and Parkinson's disease and outlines therapeutic strategies to increase brain glucocerebrosidase, including gene therapy, targeted delivery of recombinant glucocerebrosidase to the brain, small-molecule chaperones to rescue mutant glucocerebrosidase, and small-molecule modulators to activate wild-type glucocerebrosidase.Expert opinion: Although an improved understanding of the mechanistic basis for GBA1-associated parkinsonism is essential, enhancing levels of brain glucocerebrosidase may have wide therapeutic implications. While gene therapy may ultimately be effective, less expensive and invasive small-molecule non-inhibitory chaperones or activators could significantly impact the disease course.

Engineering geometrical 3-dimensional untethered in vitro neural tissue mimic

Formation of tissue models in 3 dimensions is more effective in recapitulating structure and function compared to their 2-dimensional (2D) counterparts. Formation of 3D engineered tissue to control shape and size can have important implications in biomedical research and in engineering applications such as biological soft robotics. While neural spheroids routinely are created during differentiation processes, further geometric control of in vitro neural models has not been demonstrated. Here, we present an approach to form functional in vitro neural tissue mimic (NTM) of different shapes using stem cells, a fibrin matrix, and 3D printed molds. We used murine-derived embryonic stem cells for optimizing cell-seeding protocols, characterization of the resulting internal structure of the construct, and remodeling of the extracellular matrix, as well as validation of electrophysiological activity. Then, we used these findings to biofabricate these constructs using neurons derived from human embryonic stem cells. This method can provide a large degree of design flexibility for development of in vitro functional neural tissue models of varying forms for therapeutic biomedical research, drug discovery, and disease modeling, and engineering applications.

Optical excitation and detection of neuronal activity

Optogenetics has emerged as an exciting tool for manipulating neural activity, which in turn, can modulate behavior in live organisms. However, detecting the response to the optical stimulation requires electrophysiology with physical contact or fluorescent imaging at target locations, which is often limited by photobleaching and phototoxicity. In this paper, we show that phase imaging can report the intracellular transport induced by optogenetic stimulation. We developed a multimodal instrument that can both stimulate cells with subcellular spatial resolution and detect optical pathlength (OPL) changes with nanometer scale sensitivity. We found that OPL fluctuations following stimulation are consistent with active organelle transport. Furthermore, the results indicate a broadening in the transport velocity distribution, which is significantly higher in stimulated cells compared to optogenetically inactive cells. It is likely that this label-free, contactless measurement of optogenetic response will provide an enabling approach to neuroscience.

Sildenafil in Dialysis Patients

Some of the highest rates of erectile dysfunction are seen in patients with renal failure, especially those on dialysis. The treatment of erectile dysfunction has been revolutionized in the last decade by the introduction of sildenafil. The literature on sildenafil in dialysis patients is here reviewed. Sildenafil seems to be both safe and effective in the treatment of sexual dysfunction in the dialysis population.

The significance of trace proteinuria

BACKGROUND

The clinical significance of a trace protein reading on urinalysis is unclear, and such a result is often ignored by the clinician.

METHODS

We examined 185 samples of urine with trace proteinuria by both Chemstrips and sulfosalicylic acid testing, and compared the results with those of urinary albumin and total protein concentrations.

RESULTS

Taking for the purposes of this study an arbitrary upper limit of normal of 20 mg/l for albumin and 100 mg/l for total protein concentration, we found abnormal albumin excretion in 87% and abnormal total protein excretion in 88% of trace samples. In this study, a negative urinalysis for protein excluded microalbuminuria in 87% and proteinuria in 78% of cases.

CONCLUSION

Qualitative testing for protein by urinalysis has a high sensitivity and specificity for diagnosing or ruling out microalbuminuria. Trace proteinuria usually means microalbuminuria; negative proteinuria tends to rule it out.

The utilisation of superficial venous surgery for chronic venous insufficiency by the U.K. Asian population

BACKGROUND

The epidemiology of superficial venous disease is relatively well defined in the U.K. Caucasian population. By contrast, there are currently no data available for Asians, who comprise 3.6% of the U.K., and 14.1% of this institution's catchment population. The aim of this study was to compare surgery for superficial venous disease in Caucasians and Asians in this institution, in the context of our local population.

METHODS

A prospectively gathered database of all 2011 superficial venous operations performed between January 1997 and April 2002 was retrospectively analysed with regard to ethnicity. The ethnic, gender and age composition of our catchment area was determined from U.K. census data. The full institutional records of 100 Asian and 100 randomly selected age and sex-matched Caucasian patients were compared in a case control study.

RESULTS

After adjusting for age and gender according to census data, Asians were 40% less likely to undergo superficial venous surgery (SVS). Considering the 2011 operated patients as a whole, Asians were significantly younger and more likely to be male. In the case control study, Asians were significantly less likely to be operated for recurrent disease and significantly more likely to be operated for advanced disease.

CONCLUSIONS

Although Asians are significantly less likely to undergo SVS; those that do are more likely to be young, male and operated for skin changes and ulcers. This strongly suggests that the under-representation of Asians is due to cultural, genetic or environmental factors and unmet health care need, rather than a lower prevalence of clinically significant venous disease in the Asian population.

Transjugular renal biopsy in patients with liver disease

Although transjugular renal biopsy has been used extensively in Europe, experience with its use in the United States has been limited. We report 25 patients who underwent both transjugular liver and renal biopsies in the same sitting and 4 patients who underwent only a transjugular renal biopsy. All 29 patients had both liver disease and renal abnormalities. Each patient was also believed to have a relative or absolute contraindication to a percutaneous renal biopsy (usually in the form of a bleeding abnormality). Transjugular renal biopsy yielded a quantity of tissue sufficient for diagnosis in all but 1 patient. The mean number of glomeruli obtained per biopsy was 19.4 +/- 12.2 (SD). Pathological diagnoses found were tubular injury in 5 patients, membranoproliferative glomerulonephritis in 5 patients, nephrosclerosis in 3 patients, diabetic nephropathy in 2 patients, immunoglobulin A (IgA) nephropathy in 2 patients, minimal change disease in 2 patients, end-stage renal disease in 2 patients, nonspecific changes in 1 patient, early glomerulosclerosis in 1 patient, tubular atrophy only in 1 patient, and normal renal histological characteristics in 4 patients. One patient with suspected IgA nephropathy had no histological diagnosis established because of a lack of glomeruli in the biopsy specimen. There were no instances of major bleeding from the perirenal area; however, a small perirenal hematoma was identified in 3 patients by postbiopsy computed tomography or sonography. Thus, based on our experience, transjugular renal biopsy appears to be a safe and effective procedure for establishing a histological diagnosis and is an attractive alternative biopsy method for patients with advanced liver disease and contraindications to conventional percutaneous renal biopsy.

Development of a cervical cancer control intervention program for Cambodian American women

Southeast Asian immigrants have lower levels of Pap testing than any other racial/ethnic group in the US, and are particularly unfamiliar with western culture and biomedical concepts of prevention. We completed an ethnographic study (N = 42) focusing on cervical cancer screening among Cambodian American women. We also conducted a community-based survey (N = 413) to examine the generalizability of our qualitative results. This report summarizes the results, and describes how we used our findings to influence the content of a multifaceted intervention program targeting Cambodian immigrants. The following constructs were found to be barriers to cervical cancer control: a traditional orientation to the prevention, causation, and treatment of disease; lack of familiarity with western early detection concepts; low levels of knowledge about cervical cancer; concerns about the Pap testing procedure; and health care access issues. In general, the quantitative results confirmed our ethnographic findings. The intervention program, which is delivered by bicultural outreach workers, includes home visits, presentations at small group meetings, barrier-specific counseling, use of a Khmer-language video, and tailored logistic assistance (e.g., transportation and medical interpretation). Both the video and presentation provide cultural context while simultaneously addressing multiple barriers to screening (e.g., women's fear of surgery and preference for female providers). Outreach workers are trained to counsel women about 10 potential barriers including avoidance of biomedicine, perceptions that gynecologic exams are embarrassing, and lack of English proficiency. Our results reinforce the importance of considering health problems within the context of a population's traditional belief systems and daily routines.

Removal of Foscarnet by Hemodialysis using Dialysate-Side Values

Foscarnet is an antiviral agent widely used in the treatment of cytomegalovirus (CMV) infection. We describe a cardiac transplant patient, who while being maintained with hemodialysis because of tobramycin-induced acute renal failure, was given Foscarnet for disseminated CMV infection. Using dialysate-side clearance methodology, we found the dialyzer clearance of Foscarnet to be in the order of 89 ml/min. (Int J Artif Organs 2000; 23: 165–7)

Removal of Foscarnet by hemodialysis using dialysate-side values

Foscarnet is an antiviral agent widely used in the treatment of cytomegalovirus (CMV) infection. We describe a cardiac transplant patient, who while being maintained with hemodialysis because of tobramycin-induced acute renal failure, was given Foscarnet for disseminated CMV infection. Using dialysate-side clearance methodology, we found the dialyzer clearance of Foscarnet to be in the order of 89 ml/min.

Bridging cultures through the development of a cervical cancer screening video for Cambodian women in the United States

BACKGROUND

Southeast Asian women have higher invasive cervical cancer rates than any other U.S. racial/ethnic population subgroup, and their levels of Pap testing do not even approach the year 2000 goals. Video is a particularly useful medium for cancer education in Cambodian refugee communities because of low literacy levels and high rates of VCR ownership.

METHODS

The authors produced a motivational Pap-testing video for Cambodian American women. The 18-minute Khmer-language video is entitled "The Preservation of Traditions." Content, with respect to cervical cancer screening barriers and facilitators, was guided by intensive qualitative data collection. Barriers addressed were: beliefs that traditional postpartum practices protect against cervical disease, Cambodians do not get cervical cancer, and screening is unnecessary; fear of cancer as well as surgery; lack of understanding about preventive concepts and familiarity with the Pap test; concerns about embarrassment and pain; and problems with transportation and child care. Facilitators included the availability of female physicians and interpreters. A community coalition of Cambodian women and two community advisors participated in all aspects of the video development and production. Video techniques frequently used in American productions were adapted to the target audience. For example, cultural context was provided, use of biomedical terminology minimized, role modeling emphasized, and testimonial accounts avoided.

CONCLUSION

The processes used to translate empirical evidence into meaningful educational messages, and to adapt American behavioral change techniques to Cambodian cultural norms, are generalizable to other less acculturated immigrant groups and cancer education topics.

Functional analysis of glucocorticoid and insulin response sequences in the rat insulin-like growth factor-binding protein-1 promoter

Insulin-like growth factor-binding protein-1 (IGFBP-1) is produced by the liver and regulated by glucocorticoids and insulin at the level of gene transcription. To identify DNA sequences mediating the effects of glucocorticoids and insulin on IGFBP-1 promoter activity we created luciferase reporter gene constructs and performed transfection studies in H4IIE hepatoma cells. Initial studies confirmed that the IGFBP-1 promoter is functional when inserted in the correct orientation, but not in the reverse orientation. Dexamethasone (DEX) increased promoter activity 10-fold, and insulin reversed this effect of DEX by 85% at 8 h. The effects of DEX were abolished when constructs were truncated to 89 bases from the RNA cap site, and DNase footprinting with the DNA-binding domain of the human glucocorticoid receptor identified an imperfect palindrome containing two receptor-binding sites separated by three nucleotides typical of a glucocorticoid response element (GRE) at this location. Mutation of either binding site (or half-site) disrupted the effects of DEX, confirming that this sequence functions as a GRE. Two other regions of the promoter also footprinted with the glucocorticoid receptor protein and contained sequences consistent with glucocorticoid receptor-binding sites; however, neither of these footprints contained the full structure expected of a functional GRE, and neither mutation nor deletion of these other sequences altered the effects of DEX on promoter activity. To identify the DNA sequences required for the effects of insulin on glucocorticoid-stimulated promoter activity, we created internal deletions throughout the IGFBP-1 promoter region. Deletion of the 22-basepair (bp) sequence immediately 5' from the GRE disrupted the effect of insulin and appeared to increase basal promoter activity at least 2-fold in each of eight experiments (P < 0.001 vs. intact promoter). This region of the IGFBP-1 promoter contains a 19-bp palindrome (CAAAACAAACTTATTTTG) that overlaps the 5'-end of the GRE and is fully conserved in the human IGFBP-1 promoter. Each half of this palindrome resembles previously identified insulin response sequences, and deletion/mutation analysis suggests that each half may contribute to the effects of insulin on promoter activity. Gel shift studies confirmed that this palindrome binds H4IIE nuclear proteins. In summary, we have identified a GRE in the 5'-promoter region of the rat IGFBP-1 gene approximately 90 bp up-stream from the RNA cap site as well as a contiguous 22-bp region that plays a critical role in mediating the effects of insulin on glucocorticoid-stimulated promoter activity.(ABSTRACT TRUNCATED AT 400 WORDS)