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Xu J, Zhou X, Wang Y, Liu W, Shan Y, Zhang D, Lv H, Zhao D, Dai T, Zhao Y, Li W, Liu F, Yan C. Skeletal muscle involvement in systemic amyloidosis is often overlooked. Neuropathol Appl Neurobiol 2024; 50:e12996. [PMID: 38982616 DOI: 10.1111/nan.12996] [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: 01/31/2024] [Revised: 06/05/2024] [Accepted: 06/22/2024] [Indexed: 07/11/2024]
Abstract
AIM Systemic amyloidosis is a condition in which misfolded amyloid fibrils are deposited within tissues. Amyloid myopathy is a rare manifestation of systemic amyloidosis. However, whether skeletal muscle involvement is underestimated and whether such deposition guarantees clinical and pathological myopathic features remain to be investigated. METHODS We retrospectively reviewed patients with systemic amyloidosis, in whom skeletal muscle biopsies were performed at our centre between January 2018 and June 2023. In total, 28 patients with suspected systemic amyloidosis were included. Among these, 21 presented with cardiomyopathy but lacked myopathic symptoms. The clinical and pathological data of these patients were further analysed. The amyloid type was confirmed by immunohistochemistry. RESULTS Twenty-eight patients with suspected systemic amyloidosis underwent muscle biopsy. Amyloid deposition in the skeletal muscle was confirmed in 24 patients, including 22 with light-chain amyloidosis (AL) and two with transthyretin amyloidosis (ATTR). Among the 24 patients, seven presented with muscle weakness and decreased muscle strength (Group 1, symptomatic myopathy), whereas the remaining 17 exhibited normal muscle strength (Group 2, asymptomatic myopathy). Group 1 included four patients with AL-λ, one with AL-κ and two with ATTR. Group 2 included 15 patients with AL-λ and two patients with AL-κ. In Group 1, six patients exhibited neuropathy, whereas only one patient in Group 2 presented with subclinical neuropathy on nerve conduction studies. Amyloid deposition in the interstitium was the most obvious change, observed in all 24 patients. Neuropathic changes, including denervation atrophy and muscle fibre grouping, were also common. Except for type 2 fibre atrophy, the other myopathic changes were mild and nonspecific. No sarcolemmal disruption was observed. Immunohistochemical analysis revealed marked positivity for MAC and MHC1 expression in the regions with amyloid deposits. Clinicopathological analysis revealed no significant differences in the extent of muscular amyloid deposition between the two groups. Nevertheless, patients in Group 1 displayed more pronounced neurogenic atrophy on skeletal muscle biopsies. CONCLUSIONS Our study indicates that amyloid deposition in skeletal muscle is commonly observed but rarely causes symptomatic myopathy in systemic amyloidosis.
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Affiliation(s)
- Jingwen Xu
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyu Zhou
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yingxin Wang
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wenzhu Liu
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yi Shan
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dong Zhang
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Huixia Lv
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Dandan Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tingjun Dai
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yuying Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Li
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Fuchen Liu
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chuanzhu Yan
- Research Institute of Neuromuscular and Neurodegenerative Diseases, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Sulatsky MI, Stepanenko OV, Stepanenko OV, Povarova OI, Kuznetsova IM, Turoverov KK, Sulatskaya AI. Broken but not beaten: Challenge of reducing the amyloids pathogenicity by degradation. J Adv Res 2024:S2090-1232(24)00161-9. [PMID: 38642804 DOI: 10.1016/j.jare.2024.04.018] [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: 02/26/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND The accumulation of ordered protein aggregates, amyloid fibrils, accompanies various neurodegenerative diseases (such as Parkinson's, Huntington's, Alzheimer's, etc.) and causes a wide range of systemic and local amyloidoses (such as insulin, hemodialysis amyloidosis, etc.). Such pathologies are usually diagnosed when the disease is already irreversible and a large amount of amyloid plaques have accumulated. In recent years, new drugs aimed at reducing amyloid levels have been actively developed. However, although clinical trials have demonstrated a reduction in amyloid plaque size with these drugs, their effect on disease progression has been controversial and associated with significant side effects, the reasons of which are not fully understood. AIM OF REVIEW The purpose of this review is to summarize extensive array of data on the effect of exogenous and endogenous factors (physico-mechanical effects, chemical effects of low molecular weight compounds, macromolecules and their complexes) on the structure and pathogenicity of mature amyloids for proposing future directions of the development of effective and safe anti-amyloid therapeutics. KEY SCIENTIFIC CONCEPTS OF REVIEW Our analysis show that destruction of amyloids is in most cases incomplete and degradation products often retain the properties of amyloids (including high and sometimes higher than fibrils, cytotoxicity), accelerate amyloidogenesis and promote the propagation of amyloids between cells. Probably, the appearance of protein aggregates, polymorphic in structure and properties (such as amorphous aggregates, fibril fragments, amyloid oligomers, etc.), formed because of uncontrolled degradation of amyloids, may be one of the reasons for the ambiguous effectiveness and serious side effects of the anti-amyloid drugs. This means that all medications that are supposed to be used both for degradation and slow down the fibrillogenesis must first be tested on mature fibrils: the mechanism of drug action and cytotoxic, seeding, and infectious activity of the degradation products must be analyzed.
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Affiliation(s)
- Maksim I Sulatsky
- Laboratory of Cell Morphology, Institute of Cytology of the Russian Academy of Sciences, 4 Tikhoretsky ave., 194064 St. Petersburg, Russia
| | - Olga V Stepanenko
- Laboratory of Structural Dynamics, Stability and Folding of Proteins, Institute of Cytology of the Russian Academy of Sciences, 4 Tikhoretsky ave., 194064 St. Petersburg, Russia
| | - Olesya V Stepanenko
- Laboratory of Structural Dynamics, Stability and Folding of Proteins, Institute of Cytology of the Russian Academy of Sciences, 4 Tikhoretsky ave., 194064 St. Petersburg, Russia
| | - Olga I Povarova
- Laboratory of Structural Dynamics, Stability and Folding of Proteins, Institute of Cytology of the Russian Academy of Sciences, 4 Tikhoretsky ave., 194064 St. Petersburg, Russia
| | - Irina M Kuznetsova
- Laboratory of Structural Dynamics, Stability and Folding of Proteins, Institute of Cytology of the Russian Academy of Sciences, 4 Tikhoretsky ave., 194064 St. Petersburg, Russia
| | - Konstantin K Turoverov
- Laboratory of Structural Dynamics, Stability and Folding of Proteins, Institute of Cytology of the Russian Academy of Sciences, 4 Tikhoretsky ave., 194064 St. Petersburg, Russia
| | - Anna I Sulatskaya
- Laboratory of Structural Dynamics, Stability and Folding of Proteins, Institute of Cytology of the Russian Academy of Sciences, 4 Tikhoretsky ave., 194064 St. Petersburg, Russia.
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Montano C, Cassini T, Ziegler SG, Boehm M, Nicoli ER, Mindell JA, Soldatos AG, Manoli I, Wolfe L, Macnamara EF, Malicdan MCV, Adams DR, Tifft CJ, Toro C, Gahl WA. Diagnosis and discovery: Insights from the NIH Undiagnosed Diseases Program. J Inherit Metab Dis 2022; 45:907-918. [PMID: 35490291 DOI: 10.1002/jimd.12506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/14/2022] [Accepted: 04/27/2022] [Indexed: 11/11/2022]
Abstract
Living with an undiagnosed medical condition places a tremendous burden on patients, their families, and their healthcare providers. The Undiagnosed Diseases Program (UDP) was established at the National Institutes of Health (NIH) in 2008 with the primary goals of providing a diagnosis for patients with mysterious conditions and advancing medical knowledge about rare and common diseases. The program reviews applications from referring clinicians for cases that are considered undiagnosed despite a thorough evaluation. Those that are accepted receive clinical evaluations involving deep phenotyping and genetic testing that includes exome and genomic sequencing. Selected candidate gene variants are evaluated by collaborators using functional assays. Since its inception, the UDP has received more than 4500 applications and has completed evaluations on nearly 1300 individuals. Here we present six cases that exemplify the discovery of novel disease mechanisms, the importance of deep phenotyping for rare diseases, and how genetic diagnoses have led to appropriate treatment. The creation of the Undiagnosed Diseases Network (UDN) in 2014 has substantially increased the number of patients evaluated and allowed for greater opportunities for data sharing. Expansion to the Undiagnosed Diseases Network International (UDNI) has the possibility to extend this reach even farther. Together, networks of undiagnosed diseases programs are powerful tools to advance our knowledge of pathophysiology, accelerate accurate diagnoses, and improve patient care for patients with rare conditions.
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Affiliation(s)
- Carolina Montano
- Medical Genetics & Genomic Medicine Training Program, National Human Genome Research Institute (NHGRI), NIH, Bethesda, Maryland, USA
| | - Thomas Cassini
- Medical Genetics & Genomic Medicine Training Program, National Human Genome Research Institute (NHGRI), NIH, Bethesda, Maryland, USA
| | - Shira G Ziegler
- Departments of Pediatrics and Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Manfred Boehm
- Laboratory of Cardiovascular Regenerative Medicine, National Heart, Lung, and Blood Institute (NHLBI), NIH, Bethesda, Maryland, USA
| | - Elena-Raluca Nicoli
- Glycosphingolipid and Glycoprotein Disorders Unit, Medical Genetics Branch, National Human Genome Research Institute (NHGRI), NIH, Bethesda, Maryland, USA
| | - Joseph A Mindell
- Membrane Transport Biophysics Section, National Institute of Neurological Disorders and Stroke (NINDS), NIH, Bethesda, Maryland, USA
| | - Ariane G Soldatos
- Office of the Clinical Director, National Institute of Neurological Disorders and Stroke (NINDS), NIH, Bethesda, Maryland, USA
| | - Irini Manoli
- Organic Acid Research Section, National Human Genome Research Institute (NHGRI), NIH, Bethesda, Maryland, USA
| | - Lynne Wolfe
- Office of the Clinical Director, National Human Genome Research Institute (NHGRI), NIH, Bethesda, Maryland, USA
| | - Ellen F Macnamara
- NIH Undiagnosed Diseases Program, Common Fund, NIH, Bethesda, Maryland, USA
| | | | - David R Adams
- Office of the Clinical Director, National Human Genome Research Institute (NHGRI), NIH, Bethesda, Maryland, USA
- NIH Undiagnosed Diseases Program, Common Fund, NIH, Bethesda, Maryland, USA
| | - Cynthia J Tifft
- Glycosphingolipid and Glycoprotein Disorders Unit, Medical Genetics Branch, National Human Genome Research Institute (NHGRI), NIH, Bethesda, Maryland, USA
- Office of the Clinical Director, National Human Genome Research Institute (NHGRI), NIH, Bethesda, Maryland, USA
- NIH Undiagnosed Diseases Program, Common Fund, NIH, Bethesda, Maryland, USA
| | - Camilo Toro
- NIH Undiagnosed Diseases Program, Common Fund, NIH, Bethesda, Maryland, USA
| | - William A Gahl
- Office of the Clinical Director, National Human Genome Research Institute (NHGRI), NIH, Bethesda, Maryland, USA
- NIH Undiagnosed Diseases Program, Common Fund, NIH, Bethesda, Maryland, USA
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Bak DH, Choi MJ, Lee E, Kwon TR, Kim JH, Nam SH, Kim KY, Ahn SW, Mun SK, Na J, Kim BJ. A comparison study of prabotulinumtoxinA vs onabotulinumtoxinA in myostatin-deficient mice with muscle hypertrophy. Basic Clin Pharmacol Toxicol 2018; 124:491-499. [PMID: 30326173 DOI: 10.1111/bcpt.13151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/10/2018] [Indexed: 12/21/2022]
Abstract
Botulinum toxin A (BoNT-A) is used clinically for various muscle disorders and acts by preventing the release of the neurotransmitter acetylcholine into the synapse space. Here, we compared the efficacy of prabotulinumtoxinA (PRA) and onabotulinumtoxinA (ONA) for the reduction in hypertrophy in myostatin-deficient (Mstn-/- ) mice. Two different BoNT-A products (2.5, 10 and 25 U/kg) were injected to paralyse the hindlimb for 2 months, after which sciatic nerve conduction study, 3D micro-CT, haematoxylin and eosin (H&E) and dystrophin staining were conducted. Administration of BoNT-A products induced denervation-mediated atrophy and alleviated muscle hypertrophy generated in Mstn-/- mice. The present study revealed that each BoNT-A regulates skeletal muscle size, myofibre number and myofibre diameter in Mstn-/- mice. The potential applicability of BoNT-A for the treatment of rare muscle hypertrophic diseases was demonstrated. Compared with ONA, PRA had a comparable ability to act in the local area.
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Affiliation(s)
- Dong-Ho Bak
- Department of Dermatology, College of Medicine, Chung-Ang University, Seoul, Korea.,Department of Medicine, Graduate School, Chung-Ang University, Seoul, Korea
| | - Mi Ji Choi
- Department of Dermatology, College of Medicine, Chung-Ang University, Seoul, Korea.,Department of Medicine, Graduate School, Chung-Ang University, Seoul, Korea
| | - Esther Lee
- Department of Dermatology, College of Medicine, Chung-Ang University, Seoul, Korea.,Department of Medicine, Graduate School, Chung-Ang University, Seoul, Korea
| | - Tae-Rin Kwon
- Department of Dermatology, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Jong Hwan Kim
- Department of Dermatology, College of Medicine, Chung-Ang University, Seoul, Korea.,Department of Medicine, Graduate School, Chung-Ang University, Seoul, Korea
| | | | | | | | - Seog-Kyun Mun
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Jungtae Na
- Department of Dermatology, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Beom Joon Kim
- Department of Dermatology, College of Medicine, Chung-Ang University, Seoul, Korea.,Department of Medicine, Graduate School, Chung-Ang University, Seoul, Korea
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Finsterer J, Löscher WN, Wanschitz J, Quasthoff S, Grisold W. Secondary myopathy due to systemic diseases. Acta Neurol Scand 2016; 134:388-402. [PMID: 26915593 PMCID: PMC7159623 DOI: 10.1111/ane.12576] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2016] [Indexed: 12/27/2022]
Abstract
Background Some systemic diseases also affect the skeletal muscle to various degrees and with different manifestations. This review aimed at summarizing and discussing recent advances concerning the management of muscle disease in systemic diseases. Method Literature review by search of MEDLINE, and Current Contents with appropriate search terms. Results Secondary muscle disease occurs in infectious disease, endocrine disorders, metabolic disorders, immunological disease, vascular diseases, hematological disorders, and malignancies. Muscle manifestations in these categories include pathogen‐caused myositis, muscle infarction, rhabdomyolysis, myasthenia, immune‐mediated myositis, necrotising myopathy, or vasculitis‐associated myopathy. Muscle affection may concern only a single muscle, a group of muscles, or the entire musculature. Severity of muscle affection may be transient or permanent, may be a minor part of or may dominate the clinical picture, or may be mild or severe, requiring invasive measures including artificial ventilation if the respiratory muscles are additionally involved. Diagnostic work‐up is similar to that of primary myopathies by application of non‐invasive and invasive techniques. Treatment of muscle involvement in systemic diseases is based on elimination of the underlying cause and supportive measures. The prognosis is usually fair if the causative disorder is effectively treatable but can be fatal in single cases if the entire musculature including the respiratory muscles is involved, in case of infection, or in case of severe rhabdomyolysis. Conclusion Secondary muscle manifestations of systemic diseases must be addressed and appropriately managed. Prognosis of secondary muscle disease in systemic diseases is usually fair if the underlying condition is accessible to treatment.
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Affiliation(s)
| | - W. N. Löscher
- Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| | - J. Wanschitz
- Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| | - S. Quasthoff
- Department of Neurology; Graz Medical University; Graz Austria
| | - W. Grisold
- Department of Neurology; Kaiser-Franz-Josef Spital; Vienna Austria
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Mazzotti AL, Coletti D. The Need for a Consensus on the Locution "Central Nuclei" in Striated Muscle Myopathies. Front Physiol 2016; 7:577. [PMID: 27932999 PMCID: PMC5120524 DOI: 10.3389/fphys.2016.00577] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 11/10/2016] [Indexed: 01/08/2023] Open
Affiliation(s)
- Anna L Mazzotti
- Assointerpreti, Italian Association of Conference InterpretersRome, Italy; MPS Public SpeakingRome, Italy
| | - Dario Coletti
- Biology of Adaptation and Aging, CNRS, UMR 8256, INSERM ERL U1164, Institut de Biologie Paris-Seine, Université Pierre et Marie CurieParis, France; Department of Anatomical, Histological, Forensic Sciences and Orthopedics, Sapienza University of RomeRome, Italy; Interuniversity Institute of MyologyRome, Italy
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Muscle Hypertrophy in a Patient with Immunoglobulin D Multiple Myeloma. J Gen Intern Med 2016; 31:583-4. [PMID: 26450278 PMCID: PMC4835386 DOI: 10.1007/s11606-015-3528-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gahl WA, Mulvihill JJ, Toro C, Markello TC, Wise AL, Ramoni RB, Adams DR, Tifft CJ. The NIH Undiagnosed Diseases Program and Network: Applications to modern medicine. Mol Genet Metab 2016; 117:393-400. [PMID: 26846157 PMCID: PMC5560125 DOI: 10.1016/j.ymgme.2016.01.007] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 01/19/2016] [Accepted: 01/20/2016] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The inability of some seriously and chronically ill individuals to receive a definitive diagnosis represents an unmet medical need. In 2008, the NIH Undiagnosed Diseases Program (UDP) was established to provide answers to patients with mysterious conditions that long eluded diagnosis and to advance medical knowledge. Patients admitted to the NIH UDP undergo a five-day hospitalization, facilitating highly collaborative clinical evaluations and a detailed, standardized documentation of the individual's phenotype. Bedside and bench investigations are tightly coupled. Genetic studies include commercially available testing, single nucleotide polymorphism microarray analysis, and family exomic sequencing studies. Selected gene variants are evaluated by collaborators using informatics, in vitro cell studies, and functional assays in model systems (fly, zebrafish, worm, or mouse). INSIGHTS FROM THE UDP In seven years, the UDP received 2954 complete applications and evaluated 863 individuals. Nine vignettes (two unpublished) illustrate the relevance of an undiagnosed diseases program to complex and common disorders, the coincidence of multiple rare single gene disorders in individual patients, newly recognized mechanisms of disease, and the application of precision medicine to patient care. CONCLUSIONS The UDP provides examples of the benefits expected to accrue with the recent launch of a national Undiagnosed Diseases Network (UDN). The UDN should accelerate rare disease diagnosis and new disease discovery, enhance the likelihood of diagnosing known diseases in patients with uncommon phenotypes, improve management strategies, and advance medical research.
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Affiliation(s)
- William A Gahl
- NIH Undiagnosed Diseases Network, Common Fund, Office of the Director and the National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States
| | - John J Mulvihill
- NIH Undiagnosed Diseases Network, Common Fund, Office of the Director and the National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States; Department of Pediatrics, University of Oklahoma, Oklahoma City, OK, United States.
| | - Camilo Toro
- NIH Undiagnosed Diseases Network, Common Fund, Office of the Director and the National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States
| | - Thomas C Markello
- NIH Undiagnosed Diseases Network, Common Fund, Office of the Director and the National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States
| | - Anastasia L Wise
- NIH Undiagnosed Diseases Network, Common Fund, Office of the Director and the National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States
| | - Rachel B Ramoni
- Department for Biomedical Informatics, Harvard Medical School, Department of Oral Health Policy and Epidemiology, Harvard Dental School, Cambridge, MA, United States
| | - David R Adams
- NIH Undiagnosed Diseases Network, Common Fund, Office of the Director and the National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States
| | - Cynthia J Tifft
- NIH Undiagnosed Diseases Network, Common Fund, Office of the Director and the National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States
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