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Simuni T, Chahine LM, Poston K, Brumm M, Buracchio T, Campbell M, Chowdhury S, Coffey C, Concha-Marambio L, Dam T, DiBiaso P, Foroud T, Frasier M, Gochanour C, Jennings D, Kieburtz K, Kopil CM, Merchant K, Mollenhauer B, Montine T, Nudelman K, Pagano G, Seibyl J, Sherer T, Singleton A, Stephenson D, Stern M, Soto C, Tanner CM, Tolosa E, Weintraub D, Xiao Y, Siderowf A, Dunn B, Marek K. A biological definition of neuronal α-synuclein disease: towards an integrated staging system for research. Lancet Neurol 2024; 23:178-190. [PMID: 38267190 DOI: 10.1016/s1474-4422(23)00405-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/27/2023] [Accepted: 10/06/2023] [Indexed: 01/26/2024]
Abstract
Parkinson's disease and dementia with Lewy bodies are currently defined by their clinical features, with α-synuclein pathology as the gold standard to establish the definitive diagnosis. We propose that, given biomarker advances enabling accurate detection of pathological α-synuclein (ie, misfolded and aggregated) in CSF using the seed amplification assay, it is time to redefine Parkinson's disease and dementia with Lewy bodies as neuronal α-synuclein disease rather than as clinical syndromes. This major shift from a clinical to a biological definition of Parkinson's disease and dementia with Lewy bodies takes advantage of the availability of tools to assess the gold standard for diagnosis of neuronal α-synuclein (n-αsyn) in human beings during life. Neuronal α-synuclein disease is defined by the presence of pathological n-αsyn species detected in vivo (S; the first biological anchor) regardless of the presence of any specific clinical syndrome. On the basis of this definition, we propose that individuals with pathological n-αsyn aggregates are at risk for dopaminergic neuronal dysfunction (D; the second biological anchor). Our biological definition establishes a staging system, the neuronal α-synuclein disease integrated staging system (NSD-ISS), rooted in the biological anchors (S and D) and the degree of functional impairment caused by clinical signs or symptoms. Stages 0-1 occur without signs or symptoms and are defined by the presence of pathogenic variants in the SNCA gene (stage 0), S alone (stage 1A), or S and D (stage 1B). The presence of clinical manifestations marks the transition to stage 2 and beyond. Stage 2 is characterised by subtle signs or symptoms but without functional impairment. Stages 2B-6 require both S and D and stage-specific increases in functional impairment. A biological definition of neuronal α-synuclein disease and an NSD-ISS research framework are essential to enable interventional trials at early disease stages. The NSD-ISS will evolve to include the incorporation of data-driven definitions of stage-specific functional anchors and additional biomarkers as they emerge and are validated. Presently, the NSD-ISS is intended for research use only; its application in the clinical setting is premature and inappropriate.
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Affiliation(s)
- Tanya Simuni
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Lana M Chahine
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kathleen Poston
- Department of Neurology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Michael Brumm
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Teresa Buracchio
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Michelle Campbell
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Sohini Chowdhury
- The Michael J Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Christopher Coffey
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | | | | | - Peter DiBiaso
- Patient Advisory Council, New York, NY, USA; Clinical Solutions and Strategic Partnerships, WCG Clinical, Princeton, NJ, USA
| | - Tatiana Foroud
- Department of Medical and Molecular Genetics, Indiana University, Indianapolis, IN, USA
| | - Mark Frasier
- The Michael J Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Caroline Gochanour
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | | | - Karl Kieburtz
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Catherine M Kopil
- The Michael J Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Kalpana Merchant
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brit Mollenhauer
- Department of Neurology, University Medical Center Göttingen and Paracelsus-Elena-Klinik, Kassel, Germany
| | - Thomas Montine
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Kelly Nudelman
- Department of Medical and Molecular Genetics, Indiana University, Indianapolis, IN, USA
| | | | - John Seibyl
- Institute for Neurodegenerative Disorders, New Haven, CT, USA
| | - Todd Sherer
- The Michael J Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Andrew Singleton
- National Institute on Aging, National Institutes of Health, Bethesda, MD, USA
| | - Diane Stephenson
- Critical Path for Parkinson's, Critical Path Institute, Tucson, AZ, USA
| | - Matthew Stern
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Claudio Soto
- Amprion, San Diego, CA, USA; Mitchell Center for Alzheimer's Disease and Related Brain Disorders, Department of Neurology, University of Texas McGovern Medical School at Houston, Houston, TX, USA
| | - Caroline M Tanner
- Movement Disorders and Neuromodulation Center, Department of Neurology, Weill Institute for Neuroscience, University of California, San Francisco, CA, USA; Parkinson's Disease Research Education and Clinical Center, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Eduardo Tolosa
- Parkinson's Disease and Movement Disorders Unit, Neurology Service, Hospital Clínic de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Daniel Weintraub
- University of Pennsylvania and the Parkinson's Disease and Mental Illness Research, Education and Clinical Centers, Philadelphia Veterans Affairs Medical Center Philadelphia, PA, USA
| | - Yuge Xiao
- The Michael J Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Andrew Siderowf
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Billy Dunn
- The Michael J Fox Foundation for Parkinson's Research, New York, NY, USA
| | - Kenneth Marek
- Institute for Neurodegenerative Disorders, New Haven, CT, USA
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Shapiro E, Bernstein J, Adams HR, Barbier AJ, Buracchio T, Como P, Delaney KA, Eichler F, Goldsmith JC, Hogan M, Kovacs S, Mink JW, Odenkirchen J, Parisi MA, Skrinar A, Waisbren SE, Mulberg AE. Neurocognitive clinical outcome assessments for inborn errors of metabolism and other rare conditions. Mol Genet Metab 2016; 118:65-9. [PMID: 27132782 PMCID: PMC4895194 DOI: 10.1016/j.ymgme.2016.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 01/03/2023]
Abstract
Well-defined and reliable clinical outcome assessments are essential for determining whether a drug provides clinically meaningful treatment benefit for patients. In 2015, FDA convened a workshop, "Assessing Neurocognitive Outcomes in Inborn Errors of Metabolism." Topics covered included special challenges of clinical studies of inborn errors of metabolism (IEMs) and other rare diseases; complexities of identifying treatment effects in the context of the dynamic processes of child development and disease progression; and the importance of natural history studies. Clinicians, parents/caregivers, and participants from industry, academia, and government discussed factors to consider when developing measures to assess treatment outcomes, as well as tools and methods that may contribute to standardizing measures. Many issues examined are relevant to the broader field of rare diseases in addition to specifics of IEMs.
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Affiliation(s)
- Elsa Shapiro
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA; Shapiro & Delaney, LLC, Mendota Heights, MN, USA.
| | - Jessica Bernstein
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.
| | - Heather R Adams
- Department of Neurology, Division of Child Neurology, University of Rochester Medical Center, Rochester, NY, USA.
| | | | - Teresa Buracchio
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.
| | - Peter Como
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, USA.
| | - Kathleen A Delaney
- Shapiro & Delaney, LLC, Mendota Heights, MN, USA; Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA.
| | - Florian Eichler
- Department of Neurology, Center for Rare Neurological Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Jonathan C Goldsmith
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.
| | - Melissa Hogan
- Saving Case & Friends, Inc., Thompson's Station, TN, USA.
| | - Sarrit Kovacs
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.
| | - Jonathan W Mink
- Department of Neurology, Division of Child Neurology, University of Rochester Medical Center, Rochester, NY, USA.
| | - Joanne Odenkirchen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Melissa A Parisi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
| | - Alison Skrinar
- Clinical Outcomes Research and Evaluation, Ultragenyx Pharmaceutical Inc., Novato, CA, USA.
| | - Susan E Waisbren
- Metabolism Program, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Andrew E Mulberg
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.
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Kaye J, Mattek N, Dodge H, Buracchio T, Austin D, Hagler S, Pavel M, Hayes T. One walk a year to 1000 within a year: continuous in-home unobtrusive gait assessment of older adults. Gait Posture 2012; 35:197-202. [PMID: 22047773 PMCID: PMC3278504 DOI: 10.1016/j.gaitpost.2011.09.006] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 08/31/2011] [Accepted: 09/04/2011] [Indexed: 02/02/2023]
Abstract
Physical performance measures predict health and function in older populations. Walking speed in particular has consistently predicted morbidity and mortality. However, single brief walking measures may not reflect a person's typical ability. Using a system that unobtrusively and continuously measures walking activity in a person's home we examined walking speed metrics and their relation to function. In 76 persons living independently (mean age, 86) we measured every instance of walking past a line of passive infra-red motion sensors placed strategically in their home during a four-week period surrounding their annual clinical evaluation. Walking speeds and the variance in these measures were calculated and compared to conventional measures of gait, motor function and cognition. Median number of walks per day was 18±15. Overall mean walking speed was 61±17 cm/s. Characteristic fast walking speed was 96 cm/s. Men walked as frequently and fast as women. Those using a walking aid walked significantly slower and with greater variability. Morning speeds were significantly faster than afternoon/evening speeds. In-home walking speeds were significantly associated with several neuropsychological tests as well as tests of motor performance. Unobtrusive home walking assessments are ecologically valid measures of walking function. They provide previously unattainable metrics (periodicity, variability, range of minimum and maximum speeds) of everyday motor function.
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Affiliation(s)
- Jeffrey Kaye
- Oregon Center for Aging & Technology, Oregon Health & Science University,Department of Neurology, Oregon Health & Science University,Neurology Service, Portland Veteran Affairs Medical Center,Department of Biomedical Engineering, Oregon Health & Science University
| | - Nora Mattek
- Oregon Center for Aging & Technology, Oregon Health & Science University,Department of Neurology, Oregon Health & Science University
| | - Hiroko Dodge
- Oregon Center for Aging & Technology, Oregon Health & Science University,Department of Neurology, Oregon Health & Science University
| | - Teresa Buracchio
- Department of Neurology, Oregon Health & Science University,Neurology Service, Portland Veteran Affairs Medical Center
| | - Daniel Austin
- Oregon Center for Aging & Technology, Oregon Health & Science University,Department of Biomedical Engineering, Oregon Health & Science University
| | - Stuart Hagler
- Oregon Center for Aging & Technology, Oregon Health & Science University,Department of Biomedical Engineering, Oregon Health & Science University
| | - Misha Pavel
- Oregon Center for Aging & Technology, Oregon Health & Science University,Department of Biomedical Engineering, Oregon Health & Science University
| | - Tamara Hayes
- Oregon Center for Aging & Technology, Oregon Health & Science University,Department of Biomedical Engineering, Oregon Health & Science University
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Abstract
OBJECTIVES To compare the trajectory of motor decline, as measured by gait speed and finger-tapping speed, between elderly people who developed mild cognitive impairment (MCI) and those who remained cognitively intact. We also sought to determine the approximate time at which the decline in motor function accelerated in persons who developed MCI. DESIGN Longitudinal cohort study. PARTICIPANTS Participants were 204 healthy seniors (57.8% women) from the Oregon Brain Aging Study evaluated for up to 20 years using annual neurologic, neuropsychological, and motor examinations. MAIN OUTCOME MEASURES The pattern of motor decline with aging was compared using a mixed-effects model with an interaction term for age and a clinical diagnosis of MCI. The time before diagnosis of MCI, when the change in gait or finger-tapping speed accelerates, was assessed using a mixed-effects model with a change point for men and women, separately and combined, who developed MCI. RESULTS The rates of change, with aging, in gait speed (P < .001) and finger-tapping speed in the dominant hand (P = .003) and nondominant hand (P < .001) were significantly different between participants who developed MCI (converters) and those who did not (nonconverters). Using a change point analysis for MCI converters, the decrease in gait speed accelerated by 0.023 m/s/y (P < .001), occurring 12.1 years before the onset of MCI. An acceleration in gait speed decline occurred earlier in men than women. For tapping speed, the change point occurred after the onset of MCI for both dominant and nondominant hands when men and women were combined. CONCLUSIONS Motor decline as indexed by gait speed accelerates up to 12 years before MCI. Longitudinal changes in motor function may be useful in the early detection of dementia during preclinical stages, when the utility of disease-modifying therapies would be greatest.
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Affiliation(s)
- Teresa Buracchio
- Layton Aging and Alzheimer's Disease Center, Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code CR-131, Portland, OR 97239, USA.
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