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Johnson J, Somerfield W, Johnson SR. Lymphangioleiomyomatosis in patients with tuberous sclerosis: a national centre audit. Orphanet J Rare Dis 2024; 19:137. [PMID: 38532450 DOI: 10.1186/s13023-024-03115-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 03/03/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Lymphangioleiomyomatosis (LAM) is common in tuberous sclerosis complex (TSC) yet under recognised with management mostly based upon evidence obtained from patients with sporadic LAM. We performed a prospective audit of patients with TSC-LAM attending a national referral centre to inform management guidelines. METHODS The UK LAM Centre was established in 2011 and conducts a prospective audit of pre-defined quality outcomes for all subjects. Audit data are reported on all patients with TSC-LAM and a comparator population of patients with sporadic LAM. RESULTS Between 2011 and 2022, 73 patients were seen with TSC-LAM. All were women with a mean (SD) age of 39 (12) years. Referral rates were similar over the study period including after the introduction of CT screening. Median age of diagnosis with TSC was 11 years (range 0-70) with one third diagnosed with TSC as adults. Compared with all TSC patients in the 'TOSCA' registry, TSC-LAM patients tended to have been diagnosed with TSC at an older age, had fewer neuro-cognitive manifestations and were more likely to have angiomyolipoma. The most common presentations of TSC-LAM were following workup for angiomyolipoma, pneumothorax or dyspnoea with only one fifth detected after CT screening. Baseline FEV1 and DLCO at first assessment were reduced to 77 and 63% predicted respectively and were similar to patients with sporadic LAM. During follow-up, FEV1 fell by a mean of 81 ml/year and DLCO fell by 0.309 mmol/ml/kPa/year in patients not being treated with an mTOR inhibitor. 55% required treatment with either sirolimus or Everolimus for LAM or angiomyolipoma respectively. For those treated with an mTOR inhibitor, mean FEV1 fell by 3 ml/year and DLCO increased by 0.032 mmol/ml/kPa/year and was similar to sporadic LAM. Risk of death due to LAM or need for lung transplant in patients with TSC-LAM was 0.67%/year. CONCLUSIONS Despite screening recommendations, LAM is often diagnosed in TSC after symptoms develop which may delay treatment. Complications including pneumothorax and loss of lung function are significant and similar to sporadic LAM. Work is needed to implement the recommended CT screening for LAM and improve respiratory care for TSC-LAM.
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Affiliation(s)
- Jan Johnson
- Centre for Respiratory Research, Translational Medical Sciences and Biodiscovery Institute, School of Medicine, University of Nottingham, Nottingham, UK
| | - Wendy Somerfield
- National Centre for Lymphangioleiomyomatosis, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Simon R Johnson
- Centre for Respiratory Research, Translational Medical Sciences and Biodiscovery Institute, School of Medicine, University of Nottingham, Nottingham, UK.
- National Centre for Lymphangioleiomyomatosis, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- Nottingham NIHR Biomedical Research Centre, Nottingham, UK.
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Osawa T, Oya M, Okanishi T, Kuwatsuru R, Kawano H, Tomita Y, Niida Y, Nonomura N, Hatano T, Fujii Y, Mizuguchi M, Shinohara N. Clinical Practice Guidelines for tuberous sclerosis complex-associated renal angiomyolipoma by the Japanese Urological Association: Summary of the update. Int J Urol 2023; 30:808-817. [PMID: 37278492 DOI: 10.1111/iju.15213] [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: 03/09/2023] [Accepted: 05/14/2023] [Indexed: 06/07/2023]
Abstract
New clinical issues have been raised through an interval of 7 years from the previous version (2016). In this study, we update the "Clinical Practice Guidelines for tuberous sclerosis complex-associated renal angiomyolipoma" as a 2023 version under guidance by the Japanese Urological Association. The present guidelines were cooperatively prepared by the Japanese Urological Association and Japanese Society of Tuberous Sclerosis Complex; committee members belonging to one of the two societies or specializing in the treatment of this disease were selected to prepare the guidelines in accordance with the "Guidance for preparing treatment guidelines" published by Minds (2020 version). The "Introduction" consisted of four sections, "Background Questions (BQ)" consisted of four sections, "Clinical Questions (CQ)" consisted of three sections, and "Future Questions (FQ)" consisted of three sections (total: 14 sections). Concerning CQ, an agreement was confirmed through voting by the committee members based on the direction and strength of recommendation, accuracy of evidence, and recommendation comments. The present guidelines were updated based on the current evidence. We hope that the guidelines will provide guiding principles for the treatment of tuberous sclerosis complex-associated renal angiomyolipoma to many urologists, becoming a foundation for subsequent updating.
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Affiliation(s)
- Takahiro Osawa
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Tohru Okanishi
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Ryohei Kuwatsuru
- Department of Radiology, School of Medicine and Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Haruna Kawano
- Department of Urology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yoshihiko Tomita
- Department of Urology and Department of Molecular Oncology, Niigata University Graduate School of Medicine, Niigata, Japan
| | - Yo Niida
- Center for Clinical Genomics, Kanazawa Medical University Hospital, Uchinada, Japan
| | - Norio Nonomura
- Department of Urology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takashi Hatano
- Department of Urology, Seirei Yokohama Hospital, Yokohama, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masashi Mizuguchi
- Department of Pediatrics, National Rehabilitation Center for Children with Disabilities, Tokyo, Japan
| | - Nobuo Shinohara
- Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Prezioso G, Chiarelli F, Matricardi S. Efficacy and safety of vigabatrin in patients with tuberous sclerosis complex and infantile epileptic spasm syndrome: a systematic review. Expert Rev Neurother 2023; 23:661-671. [PMID: 37243682 DOI: 10.1080/14737175.2023.2216385] [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: 02/14/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Tuberous sclerosis complex (TSC) is a common genetic cause of epilepsy. Infantile epileptic spasm syndrome (IESS) is often the presenting neurologic feature, progressively evolving into refractory epilepsy. Vigabatrin (VGB) is often used in clinical practice as a first-line therapy in TSC with IESS. This systematic review aims to collect and analyze the efficacy data about VGB in TSC cases with IESS, in order to evaluate the strength of evidence in the literature. METHODS A systematic search of trials, observational studies, and case series involving patients with TSC and IESS treated with VGB was performed using MEDLINE, CENTRAL, and the US NIH Clinical Trials Registry. Single case studies, animal and non-English language studies were excluded. Seventeen studies were selected, of which 3 were RCTs and 14 were observational studies. RESULTS An overall response rate of 67% (231/343 responders) resulted from the analysis, with a spasm-free rate restricted to RCTs of 88% (29/33 subjects). CONCLUSIONS Although all the studies analyzed reported beneficial effects of VGB in TSC patients with IESS, with higher response rates in comparison to non-TSC subjects with IESS, a low level of evidence and high heterogeneity do not guarantee sufficient strength for therapeutic recommendations.
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Affiliation(s)
- Giovanni Prezioso
- Pediatric Neurologist, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
| | - Sara Matricardi
- Pediatric Neurologist, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
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Chen D, Xu Y, Fu Y, Wang Y, Liu Y, Ding C, Cai B, Pan J, Wang J, Li R, Guo J, Zhang H, Zeng Y, Shen X, Zhou C. Clinical application of next generation sequencing-based haplotype linkage analysis in the preimplantation genetic testing for germline mosaicisms. Orphanet J Rare Dis 2023; 18:137. [PMID: 37270548 DOI: 10.1186/s13023-023-02736-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/18/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Preimplantation genetic testing (PGT) for monogenic disorders (PGT-M) for germline mosaicism was previously highly dependent on polymerase chain reaction (PCR)-based directed mutation detection combined with linkage analysis of short tandem repeats (STRs). However, the number of STRs is usually limited. In addition, designing suitable probes and optimizing the reaction conditions for multiplex PCR are time-consuming and laborious. Here, we evaluated the effectiveness of next generation sequencing (NGS)-based haplotype linkage analysis in PGT of germline mosaicism. METHODS PGT-M with NGS-based haplotype linkage analysis was performed for two families with maternal germline mosaicism for an X-linked Duchenne muscular dystrophy (DMD) mutation (del exon 45-50) or an autosomal TSC1 mutation (c.2074C > T). Trophectoderm biopsy and multiple displacement amplification (MDA) were performed for a total of nine blastocysts. NGS and Sanger sequencing were performed in genomic DNA of family members and embryonic MDA products to detect DMD deletion and TSC1 mutation, respectively. Single nucleotide polymorphism (SNP) sites closely linked to pathogenic mutations were detected with NGS and served in haplotype linkage analysis. NGS-based aneuploidy screening was performed for all embryos to reduce the risk of pregnancy loss. RESULTS All nine blastocytes showed conclusive PGT results. Each family underwent one or two frozen-thawed embryo transfer cycles to obtain a clinical pregnancy, and the prenatal diagnosis showed that the fetus was genotypically normal and euploid for both families. CONCLUSIONS NGS-SNP could effectively realize PGT for germline mosaicism. Compared with PCR-based methods, the NGS-SNP method with increased polymorphic informative markers can achieve a greater diagnostic accuracy. Further studies are warranted to verify the effectiveness of NGS-based PGT of germline mosaicism cases in the absence of surviving offsprings.
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Affiliation(s)
- Dongjia Chen
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Yan Xu
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Yu Fu
- The First Affiliated Hospital of Hainan Medical University, Hainan Medical University, Haikou, 570102, China
| | - Yali Wang
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Yuliang Liu
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Chenhui Ding
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Bing Cai
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Jiafu Pan
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Jing Wang
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Rong Li
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Jing Guo
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Han Zhang
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Yanhong Zeng
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China
| | - Xiaoting Shen
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China.
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China.
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China.
| | - Canquan Zhou
- The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China.
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, 510080, China.
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China.
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Shaffer RC, Reisinger DL, Schmitt LM, Lamy M, Dominick KC, Smith EG, Coffman MC, Esbensen AJ. Systematic Review: Emotion Dysregulation in Syndromic Causes of Intellectual and Developmental Disabilities. J Am Acad Child Adolesc Psychiatry 2023; 62:518-557. [PMID: 36007813 DOI: 10.1016/j.jaac.2022.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 06/03/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To summarize the current state of the literature regarding emotion dysregulation (ED) in syndromic intellectual disabilities (S-IDs) in 6 of the most common forms of S-IDs-Down syndrome, fragile X syndrome (FXS), tuberous sclerosis complex, Williams syndrome, Prader-Willi syndrome, and Angelman syndrome-and to determine future research directions for identification and treatment of ED. METHOD PubMed bibliographic database was searched from date of inception to May 2021. PRISMA 2020 guidelines were followed with the flowchart, table of included studies, list of excluded studies, and checklist provided. Filters applied included human research and English. Only original research articles were included in the final set, but review articles were used to identify secondary citations of primary studies. All articles were reviewed for appropriateness by 2 authors and summarized. Inclusion criteria were met by 145 articles (Down syndrome = 29, FXS = 55, tuberous sclerosis complex = 11, Williams syndrome = 18, Prader-Willi syndrome = 24, Angelman syndrome = 8). RESULTS Each syndrome review was summarized separately and further subdivided into articles related to underlying neurobiology, behaviors associated with ED, assessment, and targeted intervention. FXS had the most thorough research base, followed by Down syndrome and Prader-Willi syndrome, with the other syndromes having more limited available research. Very limited research was available regarding intervention for all disorders except FXS. CONCLUSION Core underlying characteristics of S-IDs appear to place youth at higher risk for ED, but further research is needed to better assess and treat ED in S-IDs. Future studies should have a standard assessment measure of ED, such as the Emotion Dysregulation Inventory, and explore adapting established curricula for ED from the neurotypical and autism spectrum disorder fields.
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Affiliation(s)
- Rebecca C Shaffer
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati School of Medicine, Cincinnati, Ohio.
| | | | - Lauren M Schmitt
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Martine Lamy
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Kelli C Dominick
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Elizabeth G Smith
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati School of Medicine, Cincinnati, Ohio
| | | | - Anna J Esbensen
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati School of Medicine, Cincinnati, Ohio
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Skrobanski H, Vyas K, Bowditch S, Hubig L, Dziadulewicz E, Fish L, Takhar P, Lo SH. The Burden of Caring for Individuals with Tuberous Sclerosis Complex (TSC) Who Experience Epileptic Seizures: A Descriptive UK Survey. PHARMACOECONOMICS - OPEN 2023; 7:299-312. [PMID: 36757566 PMCID: PMC10043106 DOI: 10.1007/s41669-023-00387-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Tuberous sclerosis complex (TSC) is a rare multisystem genetic condition characterised by benign tumours; prevalent manifestations include epilepsy and neuropsychiatric disorders. This study examined the burden of TSC for primary caregivers and families, exploring the impact of characteristics such as seizures. METHODS Primary caregivers of individuals with TSC in the United Kingdom participated in an online survey, comprising the Pediatric Quality of Life Inventory™ Family Impact Module, Hospital Anxiety and Depression Scale (HADS), and TSC-specific items. Responses were analysed using descriptive and regression analysis statistics (closed-ended) or qualitative content analysis (open-ended). RESULTS Seventy-three participants partially completed and 59 fully completed the survey; 95% were female, and 90% were parents of an individual with TSC. A median (range) of 2 (1-11) household members were carers. Primary caregivers spent a mean (standard deviation [SD]) of 104.3 (51.7) hours caring in the previous week, reporting high mean (SD) HADS scores of 11.2 (4.8) (anxiety) and 7.9 (4.4) (depression) and considerable family burden. Increased seizure frequency increased hours spent caring by primary caregivers (p = 0.01) and was associated with a decreased mean (SD) family functioning score of 46.2 (23.0) and parent health-related quality of life (HRQL) score of 45.4 (20.3) (both p = 0.03). Multivariable models predicted intellectual disability increased hours spent caring by primary caregivers (p = 0.01-0.04), and neuropsychiatric comorbidities decreased family functioning (p = 0.02) and caregiver HRQL (p < 0.01). CONCLUSION These findings highlight the role of epileptic seizures and neuropsychiatric disorders in the considerable burden of TSC on primary caregivers and families.
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Affiliation(s)
| | - Kishan Vyas
- Jazz Pharmaceuticals, Inc., 1 Cavendish Place, London, W1G 0QF, UK
| | - Sally Bowditch
- Jazz Pharmaceuticals, Inc., 1 Cavendish Place, London, W1G 0QF, UK.
| | - Lena Hubig
- Acaster Lloyd Consulting Ltd, London, UK
| | | | - Louise Fish
- Genetic Alliance UK, London, UK
- Tuberous Sclerosis Association, London, UK
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Singh A, Hadjinicolaou A, Peters JM, Salussolia CL. Treatment-Resistant Epilepsy and Tuberous Sclerosis Complex: Treatment, Maintenance, and Future Directions. Neuropsychiatr Dis Treat 2023; 19:733-748. [PMID: 37041855 PMCID: PMC10083014 DOI: 10.2147/ndt.s347327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/22/2023] [Indexed: 04/13/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a neurogenetic disorder that affects multiple organ systems, including the heart, kidneys, eyes, skin, and central nervous system. The neurologic manifestations have the highest morbidity and mortality, in particular in children. Clinically, patients with TSC often present with new-onset seizures within the first year of life. TSC-associated epilepsy is often difficult to treat and refractory to multiple antiseizure medications. Refractory TSC-associated epilepsy is associated with increased risk of neurodevelopmental comorbidities, including developmental delay, intellectual disability, autism spectrum disorder, and attention hyperactivity disorder. An increasing body of research suggests that early, effective treatment of TSC-associated epilepsy during critical neurodevelopmental periods can potentially improve cognitive outcomes. Therefore, it is important to treat TSC-associated epilepsy aggressively, whether it be with pharmacological therapy, surgical intervention, and/or neuromodulation. This review discusses current and future pharmacological treatments for TSC-associated epilepsy, as well as the importance of early surgical evaluation for refractory epilepsy in children with TSC and consideration of neuromodulatory interventions in young adults.
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Affiliation(s)
- Avantika Singh
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Aristides Hadjinicolaou
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Jurriaan M Peters
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Catherine L Salussolia
- Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
- Correspondence: Catherine L Salussolia, 3 Blackfan Circle, Center for Life Sciences 14060, Boston, MA, 02115, USA, Tel +617-355-7970, Email
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A review on role of metformin as a potential drug for epilepsy treatment and modulation of epileptogenesis. Seizure 2022; 101:253-261. [PMID: 36116284 DOI: 10.1016/j.seizure.2022.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 09/01/2022] [Accepted: 09/03/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Available anti-seizure medications (ASMs) target the symptomatology of the disease rather than any significant disease/epileptogenesis modifying actions. There are critical concerns of drug resistance and seizure recurrence during epilepsy management. So, drug repurposing is evolving as a paradigm change in the quest for novel epilepsy treatment strategies. Metformin, a well-known anti-diabetic drug has shown multiple pieces of evidence of its potential antiepileptic action. OBJECTIVE This review elucidates various mechanisms underlying the beneficial role of metformin in seizure control and modulation of the epileptogenesis process. METHODS Preclinical and clinical evidence involving metformin's role in epilepsy and special conditions like tuberous sclerosis have been reviewed in this paper. The putative mechanisms of epileptogenesis modulation through the use of metformin are also summarised. RESULTS This review found the efficacy of metformin in different seizure models including genetic knockout model, chemical induced, and kindling models. Only one clinical study of metformin in tuberous sclerosis has shown a reduction in seizure frequency and tumor volume compared to placebo. The suggested mechanisms of metformin relevant to epileptogenesis modulation mainly encompass AMPK activation, mTOR inhibition, protection against blood-brain-barrier disruption, inhibition of neuronal apoptosis, and reduction of oxidative stress. In addition to seizure protection, metformin has a potential role in attenuating adverse effects associated with epilepsy and ASMs such as cognition and memory impairment. CONCLUSION Metformin has shown promising utility in epilepsy management and epileptogenesis modulation. The evidence in this review substantiates the need for a robust clinical trial to explore the efficacy and safety of metformin in persons with epilepsy.
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Riley VA, Holmberg JC, Sokolov AM, Feliciano DM. Tsc2 shapes olfactory bulb granule cell molecular and morphological characteristics. Front Mol Neurosci 2022; 15:970357. [PMID: 36277492 PMCID: PMC9581303 DOI: 10.3389/fnmol.2022.970357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
Tuberous Sclerosis Complex (TSC) is a neurodevelopmental disorder caused by mutations that inactivate TSC1 or TSC2. Hamartin and tuberin are encoded by TSC1 and TSC2 which form a GTPase activating protein heteromer that inhibits the Rheb GTPase from activating a growth promoting protein kinase called mammalian target of rapamycin (mTOR). Growths and lesions occur in the ventricular-subventricular zone (V-SVZ), cortex, olfactory tract, and olfactory bulbs (OB) in TSC. A leading hypothesis is that mutations in inhibitory neural progenitor cells cause brain growths in TSC. OB granule cells (GCs) are GABAergic inhibitory neurons that are generated through infancy by inhibitory progenitor cells along the V-SVZ. Removal of Tsc1 from mouse OB GCs creates cellular phenotypes seen in TSC lesions. However, the role of Tsc2 in OB GC maturation requires clarification. Here, it is demonstrated that conditional loss of Tsc2 alters GC development. A mosaic model of TSC was created by performing neonatal CRE recombinase electroporation into inhibitory V-SVZ progenitors yielded clusters of ectopic cytomegalic neurons with hyperactive mTOR complex 1 (mTORC1) in homozygous Tsc2 mutant but not heterozygous or wild type mice. Similarly, homozygous Tsc2 mutant GC morphology was altered at postnatal days 30 and 60. Tsc2 mutant GCs had hypertrophic dendritic arbors that were established by postnatal day 30. In contrast, loss of Tsc2 from mature GCs had negligible effects on mTORC1, soma size, and dendrite arborization. OB transcriptome profiling revealed a network of significantly differentially expressed genes following loss of Tsc2 during development that altered neural circuitry. These results demonstrate that Tsc2 has a critical role in regulating neural development and shapes inhibitory GC molecular and morphological characteristics.
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Monaghan M, Takhar P, Langlands L, Knuf M, Amin S. Impact of facial angiofibromas in tuberous sclerosis complex and reported efficacy of available treatments. Front Med (Lausanne) 2022; 9:967971. [PMID: 36106321 PMCID: PMC9467435 DOI: 10.3389/fmed.2022.967971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Tuberous Sclerosis Complex (TSC) is a genetic condition which leads to a loss of inhibition of cellular growth. Facial angiofibromas (FAs) are hamartomatous growths associated with TSC that appear as multiple small, erythematous papules on the skin of the face and may resemble more severe forms of acne vulgaris. FAs have been reported in up to 74.5% of pediatric TSC patients, rising to up to 88% in adults >30 years old. They have not been closely studied, potentially overshadowed by other, systemic features of TSC. To investigate the impact of FAs, a common clinical feature for patients with TSC, we performed a non-interventional study in the form of a survey, completed by people living with TSC and FAs, or their caregiver as a proxy, if necessary. Patients were recruited via patient organizations in the UK and Germany. Data was received from 108 families in the UK (44 patients, 64 caregivers) and 127 families in Germany (50 patients, 64 caregivers). Exclusion criteria were those outside of 6-89 years, those without FAs, or those enrolled in a clinical trial. Where caregivers reported on behalf of an individual unable to consent, they were required to be adults (>18 years). Patient experience in the design of the survey was considered from practical and logistical perspectives with survey questions assessing multiple aspects relating to FAs including age of onset, perceived severity, treatments, perceived efficacy of treatments and perceived psychosocial impacts of the FAs. The psychosocial impacts of FAs for the individuals as well as for caregivers were explored in terms of social, occupational and leisure activities. Results of the survey demonstrated that for those with TSC-related moderate or severe FAs, there is an impact on quality of life and psychosocial impacts in the form of anxiety and depression. This finding was also noted by caregivers of TSC individuals in these categories. The treatment most frequently received to improve FAs, topical rapamycin/sirolimus, was found to be successful in the majority of those who received it.
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Affiliation(s)
- Marie Monaghan
- Department of Paediatric Neurology, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
- *Correspondence: Marie Monaghan
| | - Pooja Takhar
- Tuberous Sclerosis Association, Epsom, United Kingdom
| | | | - Markus Knuf
- Children's Hospital and Tuberous Sclerosis Centre, Worms, Germany
- Tuberous Sclerosis Germany (TSDEV), Wiesbaden, Germany
| | - Sam Amin
- Department of Paediatric Neurology, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
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Fagnani F, Laurendeau C, de Zelicourt M, Marshall J. Epidemiology and disease burden of tuberous sclerosis complex in France: A population-based study based on national health insurance data. Epilepsia Open 2022; 7:633-644. [PMID: 36029029 PMCID: PMC9712482 DOI: 10.1002/epi4.12636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 07/29/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Tuberous sclerosis complex (TSC) is a rare multisystem disorder, often associated with epilepsy. This retrospective study aimed to identify patients with TSC, including those with epilepsy, from a French healthcare claims database, and to report incidence, prevalence, and healthcare costs and resource utilization. METHODS The anonymized French health insurance database (SNDS) covers almost the entire French population. Patients with TSC were identified as having ≥1 International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code Q85.1 or a long-term disease (LTD) registration over the inclusion period (2006-2017). Patients with an ICD-10 epilepsy code or who were dispensed ≥1 antiseizure medication (ASM) in the same year or after their TSC diagnosis were identified as having TSC with epilepsy. Newly diagnosed patients over the inclusion period constituted the incident cohort. Healthcare costs (patients with recorded costs only), healthcare resource use, and ASM dispensation are reported for patients with 2018 data. RESULTS In 2018, 3139 prevalent patients with TSC were identified (crude prevalence, 4.69 per 100 000); the incident cohort comprised 2988 patients (crude incidence, 0.44 per 100 000). Among patients with TSC, 67% (2101/3139) had epilepsy (mean [standard deviation, SD] age: 28.8 [18.8] years; male: 48%). Among patients with epilepsy, total mean (SD) annual healthcare costs were €11 413 (27 620) per capita (outpatient, 63%; inpatient, 37%), 46% were hospitalized during 2018 (mean [SD]: 1.8 [10.9] acute care visits per patient), and 65% visited a hospital specialist. Among patients with epilepsy, medication (mean [SD]: €4518 [12 102] per capita) was the greatest contributor (63%) to outpatient costs, and in 2018, 74% were dispensed ≥1 different ASM and 9% were dispensed ≥4 ASMs. SIGNIFICANCE TSC with epilepsy was associated with substantial healthcare costs and resource utilization, particularly outpatient and medication costs. Many patients with TSC with epilepsy were prescribed multiple ASMs, suggesting refractory epilepsy.
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12
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Gomes I, Jesus Ribeiro J, Palavra F. Monitoring and Managing Patients with Tuberous Sclerosis Complex: Current State of Knowledge. J Multidiscip Healthc 2022; 15:1469-1480. [PMID: 35860622 PMCID: PMC9292455 DOI: 10.2147/jmdh.s266990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/29/2022] [Indexed: 12/05/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare genetic disease of autosomal dominant transmission that, in most cases, results from the presence of pathogenic variants of the TSC1 or TSC2 genes, encoding hamartin and tuberin, respectively. It is a multisystemic disease, affecting most frequently the brain, skin, kidney, and heart. The wide variety of possible clinical manifestations, given this multisystem dimension, makes the follow-up of patients with TSC an exercise of multidisciplinarity. In fact, these patients may require the intervention of various medical specialties, which thus have to combine their efforts to practice a medicine that is truly holistic. The past few years have witnessed a dramatic leap not only in the diagnosis and management of TSC patients, with standard monitoring recommendations, but also in the therapeutic field, with the use of mTORC1 inhibitors. In this article, we review the clinical manifestations associated with TSC, as well as the treatment and follow-up strategies that should be implemented, from a multidisciplinary perspective.
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Affiliation(s)
- Inês Gomes
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | | | - Filipe Palavra
- Center for Child Development - Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Laboratory of Pharmacology and Experimental Therapeutics, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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13
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Genetic analysis of 18 families with tuberous sclerosis complex. Neurogenetics 2022; 23:223-230. [DOI: 10.1007/s10048-022-00694-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
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14
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Genetic pathogenesis of the epileptogenic lesions in Tuberous Sclerosis Complex: Therapeutic targeting of the mTOR pathway. Epilepsy Behav 2022; 131:107713. [PMID: 33431351 DOI: 10.1016/j.yebeh.2020.107713] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 12/14/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic multisystem disease due to the mutation in one of the two genes TSC1 and TSC2, affecting several organs and systems and carrying a significant risk of early onset and refractory seizures. The pathogenesis of this complex disorder is now well known, with most of TSC-related manifestations being a consequence of the overactivation of the mammalian Target of Rapamycin (mTOR) complex. The discovery of this underlying mechanism paved the way for the use of a class of drugs called mTOR inhibitors including rapamycin and everolimus and specifically targeting this pathway. Rapamycin has been widely used in different animal models of TSC-related epilepsy and proved to be able not only to suppress seizures but also to prevent the development of epilepsy, thus demonstrating an antiepileptogenic potential. In some models, it also showed some benefit on neuropsychiatric manifestations associated with TSC. Everolimus has recently been approved by the US Food and Drug Administration and the European Medical Agency for the treatment of refractory seizures associated with TSC starting from the age of 2 years. It demonstrated a clear benefit when compared to placebo on reducing the frequency of different seizure types and exerting a higher effect in younger children. In conclusion, mTOR cascade can be a potentially major cause of TSC-associated epilepsy and neurodevelopmental disability, and additional research should investigate if early suppression of abnormal mTOR signal with mTOR inhibitors before seizure onset can be a more efficient approach and an effective antiepileptogenic and disease-modifying strategy in infants with TSC.
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15
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The Genetics and Diagnosis of Pediatric Neurocutaneous Disorders: Neurofibromatosis and Tuberous Sclerosis Complex. Clin Dermatol 2022; 40:374-382. [PMID: 35248688 DOI: 10.1016/j.clindermatol.2022.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Neurofibromatosis (NF) and tuberous sclerosis complex (TSC) are the two most common neurocutaneous disorders, both transmitted as autosomal dominant or, in the case of NF, also as a mosaic condition. The causative genetic mutations in these neurocutaneous disorders can lead to benign skin changes or uninhibited growth and proliferation in multiple organ systems due to the loss of tumor suppression in mitogen-activated protein kinase and mammalian target of rapamycin signaling pathways. Common clinical features in NF include pigmented lesions, known as café au lait patches, neurofibromas, intertriginous freckles (Crowe's sign), and benign fibrous growths, such as hamartomas in multiple organ systems. Common clinical features in TSC include hypopigmented macules, known as ash leaf spots, in addition to neurologic sequelae, such as autism, seizures, and developmental delays. Advances in genetic sequencing technologies have allowed an exponential expansion in the understanding of NF and TSC. Consensus criteria have been established for both diagnoses that can be confirmed in most cases through gene testing. Once diagnosed, the clinical and diagnostic value of disease-specific surveillance include early identification of benign and malignant tumors. Genetic counseling is important for informed reproductive decision-making for patients and at-risk family members. The improvement in understanding of pathways of pathogenic disease development and oncogenesis in both conditions have produced a new series of therapeutic options that can be used to control seizures and tumor growth. Tremendous advances in life expectancy and quality of life are now a reality due to early introduction of seizure control and novel medications. While we lack cures, early institution of interventions, such as seizure control in tuberous sclerosis, appears to be disease-modifying and holds immense promise to offer patients better lives.
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16
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Nabavi Nouri M, Zak M, Jain P, Whitney R. Epilepsy Management in Tuberous Sclerosis Complex: Existing and Evolving Therapies and Future Considerations. Pediatr Neurol 2022; 126:11-19. [PMID: 34740132 DOI: 10.1016/j.pediatrneurol.2021.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/22/2021] [Accepted: 09/25/2021] [Indexed: 10/20/2022]
Abstract
Tuberous sclerosis complex (TSC) is a rare autosomal dominant condition that affects multiple body systems. Disruption of the mammalian target of rapamycin (mTOR) pathway results in abnormal cell growth, proliferation, protein synthesis, and cell differentiation and migration in TSC. In the central nervous system, mTOR disruption is also believed to influence neuronal excitability and promote epileptogenesis. Epilepsy is the most common neurological manifestation of TSC and affects 80% to 90% of individuals with high rates of treatment resistance (up to 75%). The onset of epilepsy in the majority of individuals with TSC occurs before the age of two years, which is a critical time in neurodevelopment. Both medically refractory epilepsy and early-onset epilepsy are associated with intellectual disability in TSC, while seizure control and remission are associated with lower rates of cognitive impairment. Our current knowledge of the treatment of epilepsy in TSC has expanded immensely over the last decade. Several new therapies such as preemptive vigabatrin therapy in infants, cannabidiol, and mTOR inhibitors have emerged in recent years for the treatment of epilepsy in TSC. This review will provide clinicians with a comprehensive overview of the pharmacological and nonpharmacological therapies available for the treatment of epilepsy related to TSC.
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Affiliation(s)
- Maryam Nabavi Nouri
- Division of Neurology, Department of Pediatrics, Western University, London, Ontario, Canada
| | - Maria Zak
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Puneet Jain
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robyn Whitney
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada.
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17
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Alperin S, Krueger DA, Franz DN, Agricola KD, Stires G, Horn PS, Capal JK. Symptom rates and profile clustering in tuberous sclerosis complex-associated neuropsychiatric disorders (TAND). J Neurodev Disord 2021; 13:60. [PMID: 34903167 PMCID: PMC8903711 DOI: 10.1186/s11689-021-09408-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberous Sclerosis Complex (TSC) is associated with a range of neuropsychiatric difficulties, appropriately termed TSC-Associated Neuropsychiatric Disorders (TAND). The objectives of the study were to analyze the rates of TAND symptoms in a cohort of patients seen at the TSC Center of Excellence at Cincinnati Children's Hospital and to identify clinically meaningful profiles based on TAND symptoms. METHODS Data from the TAND Checklist was obtained from participants seen at the TSC Center of Excellence at Cincinnati Children's Hospital Medical Center from June 2015 to August 2018. Cluster and factor analyses for each TAND symptom were performed. Factor scores were then calculated for participants, and a K-means cluster analysis of these scores was used to empirically identify distinct overall TAND symptom profiles occurring in TSC. RESULTS A total of 1545 checklists was completed for 668 participants (37% adults and 63% children). Approximately 90% of participants reported at least one TAND symptom with an average of 12 symptoms (out of 29). Symptom rates ranged between 5 and 60%. The most common symptoms were neuropsychologic symptoms. A seven-cluster and seven-factor solution were found to be optimal. K-means cluster analysis resulted in a seven-profile solution, ranging from low to high symptom burden. CONCLUSION This study is the first to identify natural phenotypic profiles of TAND symptoms. Study of specific TAND subpopulations with shared profiles may facilitate better understanding of the underlying biology of TAND and better assessment of more targeted treatments.
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Affiliation(s)
- Samuel Alperin
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Darcy A Krueger
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David N Franz
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Karen D Agricola
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gabrielle Stires
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Paul S Horn
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jamie K Capal
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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18
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Willems LM, Schubert-Bast S, Grau J, Hertzberg C, Kurlemann G, Wiemer-Kruel A, Bast T, Bertsche A, Bettendorf U, Fiedler B, Hahn A, Hartmann H, Hornemann F, Immisch I, Jacobs J, Kieslich M, Klein KM, Klotz KA, Kluger G, Knuf M, Mayer T, Marquard K, Meyer S, Muhle H, Müller-Schlüter K, Noda AH, Ruf S, Sauter M, Schlump JU, Syrbe S, Thiels C, Trollmann R, Wilken B, Zöllner JP, Rosenow F, Strzelczyk A. Health-related quality of life in children and adolescents with tuberous sclerosis complex and their caregivers: A multicentre cohort study from Germany. Eur J Paediatr Neurol 2021; 35:111-122. [PMID: 34673401 DOI: 10.1016/j.ejpn.2021.10.003] [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: 03/11/2021] [Revised: 06/17/2021] [Accepted: 10/03/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This study aimed to measure health-related quality of life (HRQOL) in children and adolescents with tuberous sclerosis complex (TSC) and quality of life (QOL) and depressive symptoms among caregivers. METHODS Adequate metrics were used to assess HRQOL in children and adolescents with TSC (4-18 years, KINDLR) as well as QOL (EQ-5D) and symptoms of depression (BDI-II) among caregivers. Predictors for reduced HRQOL and depressive symptoms were identified by variance analysis, ordinal regression, and bivariate correlation. RESULTS The mean HRQOL score was 67.9 ± 12.7, and significantly lower values were associated with increasing age, attending special needs education, TSC-associated psychiatric symptoms, and drug-related adverse events. The mean QOL of caregivers was 85.4 ± 15.7, and caregiver's sex, TSC mutation locus, familial TSC clustering, special needs education, degree of disability, care dependency, presence of TSC-associated psychiatric symptoms, and TSC severity were significant predictors of lower QOL. Depressive symptoms were identified in 45.7% of caregivers, associated with female sex of the caregiver, familial TSC clustering, special needs education, and presence of TSC-associated psychiatric symptoms of the child. Multivariate regression analysis revealed adolescence and drug-related adverse events as significant predictors for lower HRQOL in TSC children, and TSC2 variants predicted lower QOL and depressive symptoms in caregivers. CONCLUSION Compared with other chronic diseases, such as headache, diabetes or obesity, children with TSC have significantly lower HRQOL, which further decreases during adolescence. A decreased HRQOL of patients correlates with a lower QOL and increased symptoms of depression of their caregivers. These results may improve the comprehensive therapy and care of children and adolescents with TSC and their families and caregivers. TRIAL REGISTRATION DRKS, DRKS00016045. Registered 01 March 2019, http://www.drks.de/DRKS00016045.
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Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Janina Grau
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | | | | | | | - Thomas Bast
- Epilepsy Center Kork, Clinic for Children and Adolescents, Kehl-Kork, Germany
| | - Astrid Bertsche
- Department of Neuropediatrics, University Hospital for Children and Adolescents, Rostock, Germany
| | | | - Barbara Fiedler
- Department of General Pediatrics, Division of Neuropediatrics, University Hospital Münster, Germany
| | - Andreas Hahn
- Department of Neuropediatrics, Justus-Liebig-University Gießen, Gießen, Germany
| | - Hans Hartmann
- Clinic for Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Frauke Hornemann
- Department of Neuropediatrics, Leipzig University Hospital for Children and Adolescents, Leipzig, Germany
| | - Ilka Immisch
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Julia Jacobs
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg i.Br., Germany; Department of Pediatrics and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthias Kieslich
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Karl Martin Klein
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Departments of Clinical Neurosciences, Medical Genetics and Community Health Sciences, Hotchkiss Brain Institute & Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kerstin A Klotz
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg i.Br., Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg i.Br., Germany
| | - Gerhard Kluger
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Clinic Vogtareuth, Germany; Research Institute, Rehabilitation, Transition and Palliation, PMU Salzburg, Salzburg, Austria
| | - Markus Knuf
- Department of Pediatrics, Klinikum Worms, Worms, Germany; Department of Pediatrics, University Medicine Mainz, Mainz, Germany
| | - Thomas Mayer
- Epilepsy Center Kleinwachau, Dresden-Radeberg, Germany
| | - Klaus Marquard
- Department of Pediatric Neurology, Psychosomatics and Pain management, Klinikum Stuttgart, Stuttgart, Germany
| | - Sascha Meyer
- Department of Neuropediatrics, University Children's Hospital of Saarland, Homburg, Germany
| | - Hiltrud Muhle
- Department of Neuropediatrics, Christian-Albrechts-University Kiel & University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Karen Müller-Schlüter
- Epilepsy Center for Children, University Hospital Neuruppin, Brandenburg Medical School, Neuruppin, Germany
| | - Anna H Noda
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Susanne Ruf
- Department of Neuropediatrics, University Hospital Tübingen, Tübingen, Germany
| | - Matthias Sauter
- Klinikum Kempten, Klinikverbund Allgäu, Kempten/Allgäu, Germany
| | - Jan-Ulrich Schlump
- Department of Neuropediatrics, University of Witten/Herdecke, Herdecke, Germany
| | - Steffen Syrbe
- Division of Pediatric Epileptology, Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Charlotte Thiels
- Department of Neuropediatrics and Social Pediatrics, Ruhr University Bochum, Bochum, Germany
| | - Regina Trollmann
- Department of Neuropediatrics, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Bernd Wilken
- Department of Neuropediatrics, Klinikum Kassel, Kassel, Germany
| | - Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg, Germany.
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Ihnen SKZ, Capal JK, Horn PS, Griffith M, Sahin M, Martina Bebin E, Wu JY, Northrup H, Krueger DA. Epilepsy Is Heterogeneous in Early-Life Tuberous Sclerosis Complex. Pediatr Neurol 2021; 123:1-9. [PMID: 34343869 PMCID: PMC8487620 DOI: 10.1016/j.pediatrneurol.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Epilepsy in tuberous sclerosis complex (TSC) typically presents with early onset, multiple seizure types, and intractability. However, variability is observed among individuals. Here, detailed individual data on seizure characteristics collected prospectively during early life were used to define epilepsy profiles in this population. METHODS Children aged zero to 36 months were followed longitudinally. Caregivers kept daily seizure diaries, including onset and daily counts for each seizure type. Patients with >70% seizure diary completion and >365 diary days were included. Developmental outcomes at 36 months were compared between subgroups. RESULTS Epilepsy was seen in 124 of 156 (79%) participants. Seizure onset occurred from zero to 29.5 months; 93% had onset before age 12 months. Focal seizures and epileptic spasms were most common. Number of seizures (for median 897 days) ranged from 1 to 9128. Hierarchical clustering based on six metrics of seizure burden (age of onset, total seizures, ratio of seizure days to nonseizure days, seizures per seizure day, and worst seven- and 30-day stretches) revealed two distinct groups with broadly favorable and unfavorable epilepsy profiles. Subpopulations within each group showed clinically meaningful differences in seizure burden. Groups with higher seizure burden had worse developmental outcomes at 36 months. CONCLUSIONS Although epilepsy is highly prevalent in TSC, not all young children with TSC have the same epilepsy profile. At least two phenotypic subpopulations are discernible based on seizure burden. Early and aggressive treatments for epilepsy in TSC may be best leveraged by targeting specific subgroups based on phenotype severity.
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Affiliation(s)
- S. Katie Z. Ihnen
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jamie K. Capal
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Paul S. Horn
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Molly Griffith
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Mustafa Sahin
- Department of Neurology and F.M Kirby Neurobiology Center, Boston Children’s Hospital, Harvard Medical School, Harvard University, Boston, MA
| | - E. Martina Bebin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Joyce Y. Wu
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Hope Northrup
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Darcy A. Krueger
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Interleukin-6 mediates PSAT1 expression and serine metabolism in TSC2-deficient cells. Proc Natl Acad Sci U S A 2021; 118:2101268118. [PMID: 34544857 DOI: 10.1073/pnas.2101268118] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 01/31/2023] Open
Abstract
Tuberous sclerosis complex (TSC) and lymphangioleiomyomatosis (LAM) are caused by aberrant mechanistic Target of Rapamycin Complex 1 (mTORC1) activation due to loss of either TSC1 or TSC2 Cytokine profiling of TSC2-deficient LAM patient-derived cells revealed striking up-regulation of Interleukin-6 (IL-6). LAM patient plasma contained increased circulating IL-6 compared with healthy controls, and TSC2-deficient cells showed up-regulation of IL-6 transcription and secretion compared to wild-type cells. IL-6 blockade repressed the proliferation and migration of TSC2-deficient cells and reduced oxygen consumption and extracellular acidification. U-13C glucose tracing revealed that IL-6 knockout reduced 3-phosphoserine and serine production in TSC2-deficient cells, implicating IL-6 in de novo serine metabolism. IL-6 knockout reduced expression of phosphoserine aminotransferase 1 (PSAT1), an essential enzyme in serine biosynthesis. Importantly, recombinant IL-6 treatment rescued PSAT1 expression in the TSC2-deficient, IL-6 knockout clones selectively and had no effect on wild-type cells. Treatment with anti-IL-6 (αIL-6) antibody similarly reduced cell proliferation and migration and reduced renal tumors in Tsc2 +/- mice while reducing PSAT1 expression. These data reveal a mechanism through which IL-6 regulates serine biosynthesis, with potential relevance to the therapy of tumors with mTORC1 hyperactivity.
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21
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Kovesdi E, Ripszam R, Postyeni E, Horvath EB, Kelemen A, Fabos B, Farkas V, Hadzsiev K, Sumegi K, Magyari L, Moreno PG, Bauer P, Melegh B. Whole Exome Sequencing in a Series of Patients with a Clinical Diagnosis of Tuberous Sclerosis Not Confirmed by Targeted TSC1/TSC2 Sequencing. Genes (Basel) 2021; 12:genes12091401. [PMID: 34573383 PMCID: PMC8471884 DOI: 10.3390/genes12091401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/05/2021] [Accepted: 09/06/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Approximately fifteen percent of patients with tuberous sclerosis complex (TSC) phenotype do not have any genetic disease-causing mutations which could be responsible for the development of TSC. The lack of a proper diagnosis significantly affects the quality of life for these patients and their families. METHODS The aim of our study was to use Whole Exome Sequencing (WES) in order to identify the genes responsible for the phenotype of nine patients with clinical signs of TSC, but without confirmed tuberous sclerosis complex 1/ tuberous sclerosis complex 2 (TSC1/TSC2) mutations using routine molecular genetic diagnostic tools. RESULTS We found previously overlooked heterozygous nonsense mutations in TSC1, and a heterozygous intronic variant in TSC2. In one patient, two heterozygous missense variants were found in polycystic kidney and hepatic disease 1 (PKHD1), confirming polycystic kidney disease type 4. A heterozygous missense mutation in solute carrier family 12 member 5 (SLC12A5) was found in one patient, which is linked to cause susceptibility to idiopathic generalized epilepsy type 14. Heterozygous nonsense variant ring finger protein 213 (RNF213) was identified in one patient, which is associated with susceptibility to Moyamoya disease type 2. In the remaining three patients WES could not reveal any variants clinically relevant to the described phenotypes. CONCLUSION Patients without appropriate diagnosis due to the lack of sensitivity of the currently used routine diagnostic methods can significantly profit from the wider application of next generation sequencing technologies in order to identify genes and variants responsible for their symptoms.
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Affiliation(s)
- Erzsebet Kovesdi
- Department of Medical Genetics, Medical School, Szentagothai Research Center, University of Pecs, 7624 Pecs, Hungary; (R.R.); (E.P.); (K.H.); (K.S.); (L.M.); (B.M.)
- Molecular Neuroendocrinology Research Group, Institute of Physiology, Center for Neuroscience, Szentagothai Research Center, Medical School, University of Pecs, 7624 Pecs, Hungary
- Correspondence:
| | - Reka Ripszam
- Department of Medical Genetics, Medical School, Szentagothai Research Center, University of Pecs, 7624 Pecs, Hungary; (R.R.); (E.P.); (K.H.); (K.S.); (L.M.); (B.M.)
| | - Etelka Postyeni
- Department of Medical Genetics, Medical School, Szentagothai Research Center, University of Pecs, 7624 Pecs, Hungary; (R.R.); (E.P.); (K.H.); (K.S.); (L.M.); (B.M.)
| | - Emese Beatrix Horvath
- Department of Medical Genetics, Faculty of Medicine, University of Szeged, 6720 Szeged, Hungary;
| | - Anna Kelemen
- National Institute of Clinical Neurosciences, 1145 Budapest, Hungary;
| | - Beata Fabos
- Somogy County Mor Kaposi Teaching Hospital, 7400 Kaposvar, Hungary;
| | - Viktor Farkas
- Department of Pediatrics, Faculty of Medicine, Semmelweis University, 1085-Budapest, Hungary;
| | - Kinga Hadzsiev
- Department of Medical Genetics, Medical School, Szentagothai Research Center, University of Pecs, 7624 Pecs, Hungary; (R.R.); (E.P.); (K.H.); (K.S.); (L.M.); (B.M.)
| | - Katalin Sumegi
- Department of Medical Genetics, Medical School, Szentagothai Research Center, University of Pecs, 7624 Pecs, Hungary; (R.R.); (E.P.); (K.H.); (K.S.); (L.M.); (B.M.)
- Departments of Biochemistry and Medical Chemistry, Medical School, University of Pecs, 7624 Pecs, Hungary
| | - Lili Magyari
- Department of Medical Genetics, Medical School, Szentagothai Research Center, University of Pecs, 7624 Pecs, Hungary; (R.R.); (E.P.); (K.H.); (K.S.); (L.M.); (B.M.)
| | | | - Peter Bauer
- CENTOGENE GmbH, 18055 Rostock, Germany; (P.B.); (P.G.M.)
| | - Bela Melegh
- Department of Medical Genetics, Medical School, Szentagothai Research Center, University of Pecs, 7624 Pecs, Hungary; (R.R.); (E.P.); (K.H.); (K.S.); (L.M.); (B.M.)
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Sato A, Ikeda K. Genetic and Environmental Contributions to Autism Spectrum Disorder Through Mechanistic Target of Rapamycin. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2021; 2:95-105. [PMID: 36325164 PMCID: PMC9616270 DOI: 10.1016/j.bpsgos.2021.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 02/06/2023] Open
Abstract
Autism spectrum disorder (ASD) is a neurodevelopmental disorder that affects an individual’s reciprocal social interaction and communication ability. Numerous genetic and environmental conditions are associated with ASD, including tuberous sclerosis complex, phosphatase and tensin homolog hamartoma tumor syndrome, fragile X syndrome, and neurofibromatosis 1. The pathogenic molecular mechanisms of these diseases are integrated into the hyperactivation of mTORC1 (mechanistic target of rapamycin complex 1). Rodent models of these diseases have shown high mTORC1 activity in the brain and ASD-related behavioral deficits, which were reversed by the mTORC1 inhibitor rapamycin. Environmental stress can also affect this signaling pathway. In utero exposure to valproate caused ASD in offspring and enhanced mTORC1 activity in the brain, which was sensitive to mTORC1 inhibition. mTORC1 is a signaling hub for diverse cellular functions, including protein synthesis, through the phosphorylation of its targets, such as ribosomal protein S6 kinases. Metabotropic glutamate receptor 5–mediated synaptic function is also affected by the dysregulation of mTORC1 activity, such as in fragile X syndrome and tuberous sclerosis complex. Reversing these downstream changes that are associated with mTORC1 activation normalizes behavioral defects in rodents. Despite abundant preclinical evidence, few clinical studies have investigated the treatment of ASD and cognitive deficits. Therapeutics other than mTORC1 inhibitors failed to show efficacy in fragile X syndrome and neurofibromatosis 1. mTORC1 inhibitors have been tested mainly in tuberous sclerosis complex, and their effects on ASD and neuropsychological deficits are promising. mTORC1 is a promising target for the pharmacological treatment of ASD associated with mTORC1 activation.
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23
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A second hit somatic (p.R905W) and a novel germline intron-mutation of TSC2 gene is found in intestinal lymphangioleiomyomatosis: a case report with literature review. Diagn Pathol 2021; 16:83. [PMID: 34465349 PMCID: PMC8406734 DOI: 10.1186/s13000-021-01138-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/11/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by hamartomas in multiple organs associated with germline mutations in TSC1 and TSC2, including exonic, intronic, or mosaic mutations. Gastrointestinal (GI) tract Lymphangioleiomyomatosis (LAM) is an extremely rare manifestation of TSC, with few reported cases. Herein, we aimed to determine the driver mutation, pathogenesis, and relationship of germline and somatic mutations of LAM through whole-genome sequencing (WGS) of the tumor and blood samples and whole transcriptome sequencing (WTS) analysis. CASE PRESENTATION A nine-year-old girl with a full-blown TSC presented with abdominal masses detected during a routine check-up. Resected intestinal masses were diagnosed as LAM by thorough pathological examination. Interestingly, the LAM presented a somatic TSC2 gene mutation in exon 24 (p.R905W, c.C2713T), and the patient had intron retention by a novel germline mutation in the intron region of TSC2 (chr16:2126489, C > G). CONCLUSION Our case suggests that intron retention by a single nucleotide intronic mutation of TSC2 is sufficient to develop severe manifestations of TSC, but the development of LAM requires an additional somatic oncogenic mutation of TSC2.
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24
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Sauter M, Belousova E, Benedik MP, Carter T, Cottin V, Curatolo P, Dahlin M, D'Amato L, d'Augères GB, de Vries PJ, Ferreira JC, Feucht M, Fladrowski C, Hertzberg C, Jozwiak S, Lawson JA, Macaya A, Marques R, Nabbout R, O'Callaghan F, Qin J, Sander V, Shah S, Takahashi Y, Touraine R, Youroukos S, Zonnenberg B, Jansen A, Kingswood JC. Rare manifestations and malignancies in tuberous sclerosis complex: findings from the TuberOus SClerosis registry to increAse disease awareness (TOSCA). Orphanet J Rare Dis 2021; 16:301. [PMID: 34229737 PMCID: PMC8259106 DOI: 10.1186/s13023-021-01917-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare multisystem autosomal dominant disorder caused by pathogenic variants in either the TSC1 or TSC2 gene. Common manifestations of TSC have been grouped into major and minor clinical diagnostic criteria and assessed in clinical routine workup. However, case studies point towards the existence of rare disease manifestations and to the potential association of TSC with malignant tumors. In this study we sought to characterize rare manifestations and malignancies using a large cohort of patients. METHODS TuberOus SClerosis registry to increAse disease awareness (TOSCA) is a multicenter, international disease registry collecting clinical manifestations and characteristics of patients with TSC, both retrospectively and prospectively. We report rates and characteristics of rare manifestations and malignancies in patients with TSC who had enrolled in the TOSCA registry. We also examined these manifestations by age, sex, and genotype (TSC1 or TSC2). RESULTS Overall, 2211 patients with TSC were enrolled in the study. Rare manifestations were reported in 382 (17.3%) study participants and malignancies in 65 (2.9%). Of these rare manifestations, the most frequent were bone sclerotic foci (39.5%), scoliosis (23%), thyroid adenoma (5.5%), adrenal angiomyolipoma (4.5%), hemihypertrophy and pancreatic neuroendocrine tumors (pNET; both 3.1%). These rare manifestations were more commonly observed in adults than children (66.2% vs. 22.7%), in females versus males (58.4% vs. 41.6%; except for scoliosis: 48.9% vs. 51.1%), and in those with TSC2 versus TSC1 (67.0% vs. 21.1%; except for thyroid adenoma: 42.9% vs. 57.1%). In the 65 individuals with reported malignancies, the most common were renal cell carcinoma (47.7%), followed by breast (10.8%) and thyroid cancer (9.2%). Although malignancies were more common in adult patients, 26.1% were reported in children and 63.1% in individuals < 40 years. TSC1 mutations were over-represented in individuals with malignancies compared to the overall TOSCA cohort (32.1% vs. 18.5%). CONCLUSION Rare manifestations were observed in a significant proportion of individuals with TSC. We recommend further examination of rare manifestations in TSC. Collectively, malignancies were infrequent findings in our cohort. However, compared to the general population, malignant tumors occurred earlier in age and some tumor types were more common.
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Affiliation(s)
- Matthias Sauter
- Klinikum Kempten, Klinikverbund Allgäu, Robert-Weixler-Str. 50, 87439, Kempten, Germany.
| | - Elena Belousova
- Research and Clinical Institute of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | | | - Tom Carter
- TSA Tuberous Sclerosis Association, Nottingham, UK
| | - Vincent Cottin
- Hôpital Louis Pradel, Claude Bernard University Lyon 1, Lyon, France
| | | | - Maria Dahlin
- Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | | | - Martha Feucht
- Universitätsklinik Für Kinder-Und Jugendheilkunde (Affiliated Partner of the ERN EpiCARE), Vienna, Austria
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ONLUS, Milan, Italy.,In Den Birken, European Tuberous Sclerosis Complex Association, Dattein, Germany
| | | | - Sergiusz Jozwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland.,Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - John A Lawson
- The Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Alfons Macaya
- Hospital Universitari Vall D'Hebron, Barcelona, Spain
| | - Ruben Marques
- Novartis Farma S.P.A, Origgio, Italy.,Institute of Biomedicine (IBIOMED), University of León, León, Spain
| | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Malades Hospital, Imagine Institute, Paris Descartes University, Paris, France
| | | | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | | | - Seema Shah
- Novartis Healthcare Pvt. Ltd, Hyderabad, India
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Aoi-ku, UrushiyamaShizuoka, Japan
| | - Renaud Touraine
- Department of Genetics, CHU-Hôpital Nord, Saint Etienne, France
| | | | | | - Anna Jansen
- Pediatric Neurology Unit, Department of Pediatrics, UZ Brussel VUB, Brussels, Belgium
| | - J Chris Kingswood
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St Georges University of London, London, UK
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25
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Strzelczyk A, Rosenow F, Zöllner JP, Simon A, Wyatt G, Holland R, Schubert-Bast S. Epidemiology, healthcare resource use, and mortality in patients with tuberous sclerosis complex: A population-based study on German health insurance data. Seizure 2021; 91:287-295. [PMID: 34265583 DOI: 10.1016/j.seizure.2021.06.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/17/2021] [Accepted: 06/19/2021] [Indexed: 01/07/2023] Open
Abstract
PURPOSE 10-year retrospective study to assess burden of illness in individuals with tuberous sclerosis complex (TSC) identified from German healthcare data. METHODS Patients with TSC were identified by International Classification of Diseases code Q85.1. Patients with epilepsy were identified by epilepsy diagnosis or antiseizure medication (ASM) prescription after TSC diagnosis. RESULTS Using data from 2016 (final study year), 100 patients with TSC were identified (mean [range] age: 38 [1-86] years; male: 40%); prevalence: 7.9 per 100,000 (TSC), 2.2 per 100,000 (TSC with epilepsy). During the 10-year study period (2007-2016), 256 patients with TSC were identified and followed up for 1,784 patient-years (epilepsy: 36%, 616 patient-years). TSC manifestations/comorbidities (apart from epilepsy) were identified more frequently in patients with epilepsy than without. Mean annual healthcare costs for patients with TSC were €6,139 per patient-year (PPY), mostly attributable to medication (35%) and inpatient care (29%). Patients with epilepsy incurred costs more than double those without. Mean (standard deviation [SD]) annual hospitalisation rate (AHR) and length of stay (LOS) PPY: 0.5 (1.0) and 5.9 (18.6) days for TSC. AHR and LOS were greater in patients with epilepsy than without. Mean (SD) number of ASMs prescribed (TSC with epilepsy): 3.0 (2.3) over the entire observable time per patient. Mortality rates (vs. control): 5.08% (vs. 1.69%, p<0.001) for TSC, 7.53% (vs. 0.98%, p<0.001) for TSC with epilepsy, 3.68% (vs. 2.03%, p = 0.003) for TSC without epilepsy. CONCLUSION Healthcare costs, resource utilisation, and mortality were greater in patients with TSC and epilepsy than those without epilepsy.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | | | - Geoffrey Wyatt
- Market Access and Health Economics and Outcomes Research, GW Pharma Ltd, London, United Kingdom.
| | - Rowena Holland
- Market Access and Health Economics and Outcomes Research, GW Pharma Ltd, London, United Kingdom.
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt and Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany.
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26
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Zöllner JP, Conradi N, Sauter M, Knuf M, Knake S, Kurlemann G, Mayer T, Hertzberg C, Bertsche A, Immisch I, Klein KM, Marquard K, Meyer S, Noda AH, von Podewils F, Schäfer H, Thiels C, Zukunft B, Schubert-Bast S, Grau J, Willems LM, Rosenow F, Reese JP, Strzelczyk A. Quality of life and its predictors in adults with tuberous sclerosis complex (TSC): a multicentre cohort study from Germany. Neurol Res Pract 2021; 3:35. [PMID: 34176514 PMCID: PMC8237479 DOI: 10.1186/s42466-021-00130-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/10/2021] [Indexed: 12/26/2022] Open
Abstract
Background Tuberous sclerosis complex (TSC) is a monogenetic, multisystemic disease characterised by the formation of benign tumours that can affect almost all organs, caused by pathogenic variations in TSC1 or TSC2. In this multicentre study from Germany, we investigated the influence of sociodemographic, clinical, and therapeutic factors on quality of life (QoL) among individuals with TSC. Methods We assessed sociodemographic and clinical characteristics and QoL among adults with TSC throughout Germany using a validated, three-month, retrospective questionnaire. We examined predictors of health-related QoL (HRQoL) using multiple linear regression analysis and compared the QoL among patients with TSC with QoL among patients with other chronic neurological disorders. Results We enrolled 121 adults with TSC (mean age: 31.0 ± 10.5 years; range: 18–61 years, 45.5% [n = 55] women). Unemployment, a higher grade of disability, a higher number of organ manifestations, the presence of neuropsychiatric manifestations or active epilepsy, and a higher burden of therapy-related adverse events were associated with worse QoL, as measured by two QoL instruments (EuroQoL-5 dimensions [EQ-5D] and Quality of Life in Epilepsy Patients [QOLIE-31]). Neuropsychiatric and structural nervous system manifestations, the number of affected organs, and therapy-related adverse events were also associated with higher depression, as measured by the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). In multiple regression analysis, more severe therapy-related adverse events (large effect, p < 0.001), active epilepsy (large effect, p < 0.001), and neuropsychiatric manifestations (medium effect, p = 0.003) were independently associated with worse HRQoL, explaining 65% of the variance (p < 0.001). The HRQoL among patients with active TSC-associated epilepsy was worse than that among patients with drug-refractory mesial temporal lobe epilepsy (p < 0.001), and the generic QoL among patients with more than three TSC organ manifestations was similar to those of patients with severe migraine and uncontrolled asthma. Conclusions Active epilepsy, neuropsychiatric manifestations (such as anxiety and depression), and therapy-related adverse events are important independent predictors of worse quality of life among adults with TSC. Generic quality of life in TSC with several manifestations is similar to uncontrolled severe chronic diseases and significantly negatively correlates with TSC severity. Trial registration DRKS, DRKS00016045. Registered 01 March 2019.
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Affiliation(s)
- Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Nadine Conradi
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Matthias Sauter
- Klinikum Kempten, Klinikverbund Allgäu, Kempten/Allgäu, Germany
| | - Markus Knuf
- Department of Pediatrics, Klinikum Worms, Worms, Germany.,Department of Pediatrics, University Medicine Mainz, Mainz, Germany
| | - Susanne Knake
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | | | | | | | - Astrid Bertsche
- Department of Neuropediatrics, University Hospital for Children and Adolescents, Rostock, Germany
| | - Ilka Immisch
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Karl Martin Klein
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.,Departments of Clinical Neurosciences, Medical Genetics, and Community Health Sciences, Hotchkiss Brain Institute & Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Klaus Marquard
- Department of Pediatric Neurology, Psychosomatics and Pain Management, Klinikum Stuttgart, Stuttgart, Germany
| | - Sascha Meyer
- Department of Neuropediatrics, University Children's Hospital of Saarland, Homburg, Germany
| | - Anna H Noda
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix von Podewils
- Department of Neurology, Epilepsy Center, University Medicine Greifswald, Greifswald, Germany
| | - Hannah Schäfer
- Division of Nephrology, Medizinische Klinik und Poliklinik IV, Klinikum der LMU München - Innenstadt, Munich, Germany.,Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Charlotte Thiels
- Department of Neuropediatrics and Social Pediatrics, Ruhr University Bochum, Bochum, Germany
| | - Bianca Zukunft
- Department of Nephrology and Internal Intensive Care, Charité - University Medicine Berlin, Berlin, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.,Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Janina Grau
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Jens-Peter Reese
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany. .,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany. .,Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany.
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Grau J, Zöllner JP, Schubert-Bast S, Kurlemann G, Hertzberg C, Wiemer-Kruel A, Bast T, Bertsche A, Bettendorf U, Fiedler B, Hahn A, Hartmann H, Hornemann F, Immisch I, Jacobs J, Kieslich M, Klein KM, Klotz KA, Kluger G, Knuf M, Mayer T, Marquard K, Meyer S, Muhle H, Müller-Schlüter K, Noda AH, Ruf S, Sauter M, Schlump JU, Syrbe S, Thiels C, Trollmann R, Wilken B, Willems LM, Rosenow F, Strzelczyk A. Direct and indirect costs and cost-driving factors of Tuberous sclerosis complex in children, adolescents, and caregivers: a multicenter cohort study. Orphanet J Rare Dis 2021; 16:282. [PMID: 34154622 PMCID: PMC8218507 DOI: 10.1186/s13023-021-01899-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 05/29/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC), a multisystem genetic disorder, affects many organs and systems, characterized by benign growths. This German multicenter study estimated the disease-specific costs and cost-driving factors associated with various organ manifestations in TSC patients. METHODS A validated, three-month, retrospective questionnaire was administered to assess the sociodemographic and clinical characteristics, organ manifestations, direct, indirect, out-of-pocket, and nursing care-level costs, completed by caregivers of patients with TSC throughout Germany. RESULTS The caregivers of 184 patients (mean age 9.8 ± 5.3 years, range 0.7-21.8 years) submitted questionnaires. The reported TSC disease manifestations included epilepsy (92%), skin disorders (86%), structural brain disorders (83%), heart and circulatory system disorders (67%), kidney and urinary tract disorders (53%), and psychiatric disorders (51%). Genetic variations in TSC2 were reported in 46% of patients, whereas 14% were reported in TSC1. Mean total direct health care costs were EUR 4949 [95% confidence interval (95% CI) EUR 4088-5863, median EUR 2062] per patient over three months. Medication costs represented the largest direct cost category (54% of total direct costs, mean EUR 2658), with mechanistic target of rapamycin (mTOR) inhibitors representing the largest share (47%, EUR 2309). The cost of anti-seizure drugs (ASDs) accounted for a mean of only EUR 260 (5%). Inpatient costs (21%, EUR 1027) and ancillary therapy costs (8%, EUR 407) were also important direct cost components. The mean nursing care-level costs were EUR 1163 (95% CI EUR 1027-1314, median EUR 1635) over three months. Total indirect costs totaled a mean of EUR 2813 (95% CI EUR 2221-3394, median EUR 215) for mothers and EUR 372 (95% CI EUR 193-586, median EUR 0) for fathers. Multiple regression analyses revealed polytherapy with two or more ASDs and the use of mTOR inhibitors as independent cost-driving factors of total direct costs. Disability and psychiatric disease were independent cost-driving factors for total indirect costs as well as for nursing care-level costs. CONCLUSIONS This study revealed substantial direct (including medication), nursing care-level, and indirect costs associated with TSC over three months, highlighting the spectrum of organ manifestations and their treatment needs in the German healthcare setting. TRIAL REGISTRATION DRKS, DRKS00016045. Registered 01 March 2019, http://www.drks.de/DRKS00016045.
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Affiliation(s)
- Janina Grau
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | | | | | | | - Thomas Bast
- Epilepsy Center Kork, Clinic for Children and Adolescents, Kehl-Kork, Germany
| | - Astrid Bertsche
- Department of Neuropediatrics, University Hospital for Children and Adolescents, Rostock, Germany
| | | | - Barbara Fiedler
- Department of General Pediatrics, Division of Neuropediatrics, University Hospital Münster, Münster, Germany
| | - Andreas Hahn
- Department of Neuropediatrics, Justus-Liebig-University Gießen, Gießen, Germany
| | - Hans Hartmann
- Department of Neuropediatrics, Clinic for Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Frauke Hornemann
- Department of Neuropediatrics, Leipzig University Hospital for Children and Adolescents, Leipzig, Germany
| | - Ilka Immisch
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Julia Jacobs
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg i.Br., Germany
- Department of Pediatrics and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Matthias Kieslich
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Karl Martin Klein
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Departments of Clinical Neurosciences, Medical Genetics and Community Health Sciences, Hotchkiss Brain Institute & Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kerstin A Klotz
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg i.Br., Germany
- Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg i.Br., Germany
| | - Gerhard Kluger
- Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Schön Clinic Vogtareuth, Vogtareuth, Germany
- Research Institute, Rehabilitation, Transition and Palliation, PMU Salzburg, Salzburg, Austria
| | - Markus Knuf
- Department of Pediatrics, Klinikum Worms, Worms, Germany
- Department of Pediatrics, University Medicine Mainz, Mainz, Germany
| | - Thomas Mayer
- Epilepsy Center Kleinwachau, Dresden-Radeberg, Germany
| | - Klaus Marquard
- Department of Pediatric Neurology, Psychosomatics and Pain Management, Klinikum Stuttgart, Stuttgart, Germany
| | - Sascha Meyer
- Department of Neuropediatrics, Children's Hospital at University Medical Center Homburg, Homburg, Germany
| | - Hiltrud Muhle
- Department of Neuropediatrics, Christian-Albrechts-University Kiel & University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Karen Müller-Schlüter
- Epilepsy Center for Children, Brandenburg Medical School, University Hospital Neuruppin, Neuruppin, Germany
| | - Anna H Noda
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Susanne Ruf
- Department of Neuropediatrics, University Hospital Tübingen, Tübingen, Germany
| | - Matthias Sauter
- Klinikum Kempten, Klinikverbund Allgäu, Kempten (Allgäu), Germany
| | - Jan-Ulrich Schlump
- Department of Neuropediatrics, University of Witten/Herdecke, Herdecke, Germany
| | - Steffen Syrbe
- Division of Pediatric Epileptology, Centre for Paediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Charlotte Thiels
- Department of Neuropediatrics and Socialpediatrics, University Hospital of Ruhr University Bochum, Bochum, Germany
| | - Regina Trollmann
- Department of Neuropediatrics, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Bernd Wilken
- Department of Neuropediatrics, Klinikum Kassel, Kassel, Germany
| | - Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany.
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Zöllner JP, Grau J, Rosenow F, Sauter M, Knuf M, Kurlemann G, Mayer T, Hertzberg C, Bertsche A, Immisch I, Klein KM, Knake S, Marquard K, Meyer S, Noda AH, von Podewils F, Schäfer H, Thiels C, Willems LM, Zukunft B, Schubert-Bast S, Strzelczyk A. Direct and indirect costs and cost-driving factors in adults with tuberous sclerosis complex: a multicenter cohort study and a review of the literature. Orphanet J Rare Dis 2021; 16:250. [PMID: 34078440 PMCID: PMC8170458 DOI: 10.1186/s13023-021-01838-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/22/2021] [Indexed: 02/08/2023] Open
Abstract
Background Tuberous sclerosis complex (TSC) is a monogenetic, multisystem disorder characterized by benign growths due to TSC1 or TSC2 mutations. This German multicenter study estimated the costs and related cost drivers associated with organ manifestations in adults with TSC. Methods A validated, three-month, retrospective questionnaire assessed the sociodemographic and clinical characteristics, organ manifestations, direct, indirect, out-of-pocket (OOP), and nursing care-level costs among adult individuals with TSC throughout Germany from a societal perspective (costing year: 2019). Results We enrolled 192 adults with TSC (mean age: 33.4 ± 12.7 years; range: 18–78 years, 51.6% [n = 99] women). Reported TSC disease manifestations included skin (94.8%) and kidney and urinary tract (74%) disorders, epilepsy (72.9%), structural brain defects (67.2%), psychiatric disorders (50.5%), heart and circulatory system disorders (50.5%), and lymphangioleiomyomatosis (11.5%). TSC1 and TSC2 mutations were reported in 16.7% and 25% of respondents, respectively. Mean direct health care costs totaled EUR 6452 (median EUR 1920; 95% confidence interval [CI] EUR 5533–7422) per patient over three months. Medication costs represented the major direct cost category (77% of total direct costs; mean EUR 4953), and mechanistic target of rapamycin (mTOR) inhibitors represented the largest share (68%, EUR 4358). Mean antiseizure drug (ASD) costs were only EUR 415 (6%). Inpatient costs (8%, EUR 518) and outpatient treatment costs (7%; EUR 467) were important further direct cost components. The mean care grade allowance as an approximator of informal nursing care costs was EUR 929 (median EUR 0; 95% CI EUR 780–1083) over three months. Mean indirect costs totaled EUR 3174 (median EUR 0; 95% CI EUR 2503–3840) among working-age individuals (< 67 years in Germany). Multiple regression analyses revealed mTOR inhibitor use and persistent seizures as independent cost-driving factors for total direct costs. Older age and disability were independent cost-driving factors for total indirect costs, whereas epilepsy, psychiatric disease, and disability were independent cost-driving factors for nursing care costs. Conclusions This three-month study revealed substantial direct healthcare, indirect healthcare, and medication costs associated with TSC in Germany. This study highlights the spectrum of organ manifestations and their associated treatment needs in the German healthcare setting. Trial registration: DRKS, DRKS00016045. Registered 01 March 2019, http://www.drks.de/DRKS00016045. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01838-w.
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Affiliation(s)
- Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Janina Grau
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Matthias Sauter
- Klinikum Kempten, Klinikverbund Allgäu, Kempten/Allgäu, Germany
| | - Markus Knuf
- Department of Pediatrics, Helios Dr. Horst Schmidt Clinic Wiesbaden, Wiesbaden, Germany.,Department of Pediatrics, University Medicine Mainz, Mainz, Germany
| | | | | | | | - Astrid Bertsche
- Department of Neuropediatrics, University Hospital for Children and Adolescents, Rostock, Germany
| | - Ilka Immisch
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Karl Martin Klein
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.,Departments of Clinical Neurosciences, Medical Genetics, and Community Health Sciences, Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Susanne Knake
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Klaus Marquard
- Department of Pediatric Neurology, Psychosomatics and Pain Management, Klinikum Stuttgart, Stuttgart, Germany
| | - Sascha Meyer
- Department of Neuropediatrics, Children's Hospital at University Medical Center Homburg, Homburg, Germany
| | - Anna H Noda
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix von Podewils
- Department of Neurology, Epilepsy Center, University Medicine Greifswald, Greifswald, Germany
| | - Hannah Schäfer
- Division of Nephrology, Medizinische Klinik und Poliklinik IV, Klinikum der LMU München - Innenstadt, München, Germany.,Department of Nephrology, Klinikum Rechts Der Isar, Technische Universität München, München, Germany
| | - Charlotte Thiels
- Department of Neuropediatrics and Socialpediatrics, University Hospital of Ruhr University Bochum, Bochum, Germany
| | - Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Bianca Zukunft
- Department of Nephrology and Internal Intensive Care, Charité - University Medicine Berlin, Berlin, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.,Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany. .,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany. .,Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany.
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29
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De Sautu De Borbón EC, Guerra Vales JM, Lumbreras Bermejo C, Guerrero Ramos F, Buj Padilla MJ, González de la Aleja J, Morales Conejo M. Clinical, genetic and quality-of-life study of a cohort of adult patients with tuberous sclerosis. Orphanet J Rare Dis 2021; 16:243. [PMID: 34059113 PMCID: PMC8165982 DOI: 10.1186/s13023-021-01878-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background and objective Tuberous sclerosis (TS) is a condition whose manifestations in childhood have been extensively described, but whose presentation in adults is less well known. This study describes the clinical and genetic characteristics, therapeutic management and quality of life of a cohort of adult patients with TS. A comparative study of the characteristics of patients diagnosed in childhood and adulthood is also carried out. Material and methods This observational, retrospective, cross-sectional study included a large cohort of adult patients (≥ 16 years old) followed for 5 years in a specific rare diseases unit. Results Fifty-seven patients with a diagnosis of tuberous sclerosis were included, more than 50% of whom were diagnosed as adults. The mean age of the patients was 42 years (20–86). The central nervous system was the main area affected (97%), followed by the skin (80.7%) and kidneys (73%). The most frequent genetic alteration was a mutation in the TSC2 gene (47.7%). Among patients diagnosed in adulthood, there was less neurological involvement, with less frequency of epileptic seizures (30.8% vs 60.79% of patients diagnosed in childhood) and astrocytomas (3.8% vs 53.6%), less intellectual disability (11.5% vs 71.4%) and less expressiveness of the condition. 42% of patients were treated with mTOR pathway inhibitors, and presence of an angiomyolipoma was the main indication. In a quality-of-life analysis, the means of the summary indices were below the scores of the average Spanish population: (47.42 (SD ± 9.82) on the physical health scale, 45.61 (SD ± 7.99) on the mental health scale) versus 50 (SD ± 10) for the general population. Conclusions Up to 50% of adult patients with TS were diagnosed in adulthood, and the condition is less severe with less frequent epileptic seizures and intellectual disability. 42% require treatment with mTOR inhibitors, in most cases due to the presence of AMLs. The quality of life of adult patients with TS is diminished compared to the general population.
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Affiliation(s)
| | - Juan Manuel Guerra Vales
- Department of Internal Medicine, University Hospital, 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain.,Research Institute I+12, University Hospital, 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Carlos Lumbreras Bermejo
- Department of Internal Medicine, University Hospital, 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain.,Research Institute I+12, University Hospital, 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Felix Guerrero Ramos
- Department of Urology, University Hospital, 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - María José Buj Padilla
- Department of Radiology, University Hospital, 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Jesús González de la Aleja
- Department of Neurology, University Hospital, 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Montserrat Morales Conejo
- Department of Internal Medicine, University Hospital, 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain. .,Research Institute I+12, University Hospital, 12 de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain.
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30
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Alsowat D, Whitney R, Hewson S, Jain P, Chan V, Kabir N, Amburgey K, Noone D, Lemaire M, McCoy B, Zak M. The Phenotypic Spectrum of Tuberous Sclerosis Complex: A Canadian Cohort. Child Neurol Open 2021; 8:2329048X211012817. [PMID: 34017900 PMCID: PMC8114745 DOI: 10.1177/2329048x211012817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/15/2021] [Accepted: 03/30/2021] [Indexed: 11/15/2022] Open
Abstract
Objective We aimed to further elucidate the phenotypic spectrum of Tuberous Sclerosis Complex (TSC) depending on genotype. Methods A retrospective review of patients seen in the TSC clinic at the Hospital for Sick Children was conducted and the frequency of TSC manifestations was compared based on genotype. Results Nineteen-patients had TSC1 mutations, 36 had TSC2 mutations and 11 had no mutation identified (NMI). Patients with TSC2 mutations had a higher frequency of early-onset epilepsy and more frequent systemic manifestations. The NMI group had milder neurologic and systemic manifestations. Our data did not demonstrate that intellectual disability and infantile spasms were more common in TSC2 mutations. Conclusions This is the first Canadian pediatric cohort exploring the genotype-phenotype relationship in TSC. We report that some manifestations are more frequent and severe in TSC2 mutations and that NMI may have a milder phenotype. Disease surveillance and counseling should continue regardless of genotype until this is better elucidated.
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Affiliation(s)
- Daad Alsowat
- Epilepsy Program, Division of Pediatric Neurology, Department of Neuroscience, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Robyn Whitney
- Epilepsy Program, Division of Neurology, Department of Pediatrics, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Stacy Hewson
- Department of Genetic Counselling, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Puneet Jain
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Valerie Chan
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nadia Kabir
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kimberly Amburgey
- Department of Genetic Counselling, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Damien Noone
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mathieu Lemaire
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Blathnaid McCoy
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maria Zak
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
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31
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Di Napoli C, Gennaro A, Lupica C, Falsaperla R, Leonardi R, Garozzo MT, Polizzi A, Praticò AD, Zanghì A, Ruggieri M. TSC1 and TSC2: Tuberous Sclerosis Complex and Its Related Epilepsy Phenotype. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1727142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractTuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by a multisystemic involvement. In TSC, reduced function of TSC1 and TSC2 genes products (hamartin and tuberin, respectively) leads to an hyperactivation of the mechanistic target of rapamycin (mTOR) pathway and to a consequent cell growth dysregulation. In TSC patients, neurological and neuropsychiatric manifestations, especially epilepsy and neuropsychiatric comorbidities such as autism or intellectual disability, represent the most disabling features. In particular, epilepsy occurrs up to 80% of patients, is often drug resistant and is frequently associated with neurological impairment. Due to the burden of this morbidity, different treatment strategies have been proposed with the purpose to make patients epilepsy free, such as the use of different antiepileptic drugs like vigabatrin, carbamazepine, valproic acid, and levetiracetam. More recently, a mTOR inhibitor (i.e. everolimus) has showed promising results in terms of seizures reduction.
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Affiliation(s)
- Claudia Di Napoli
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Alessia Gennaro
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Carmelania Lupica
- Postgraduate Training Program in Genetics, Department of Biomedical and Biotechnological Sciences, Section of Genetics, University of Catania, Catania, Italy
| | - Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
- Unit of Neonatal Intenstive Care and Neonatology, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
| | - Roberta Leonardi
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Maria Teresa Garozzo
- Unit of Pediatrics and Pediatric Emergency, Hospital “Cannizzaro,” Catania, Italy
| | - Agata Polizzi
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
| | - Andrea D. Praticò
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Antonio Zanghì
- Department of General Surgery and Medical-Surgical Specialty, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Catania, Italy
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32
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Pfirmann P, Combe C, Rigothier C. [Tuberous sclerosis system: A review]. Rev Med Interne 2021; 42:714-721. [PMID: 33836894 DOI: 10.1016/j.revmed.2021.03.003] [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: 10/20/2020] [Revised: 02/11/2021] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disorder that affects different organs and caused by loss-of-function mutations in one of two genes: TSC1 or TSC2. TSC1 or TSC2 gene mutation lead to dysfunction of hamartin or tuberin, respectively. Hamartin and tuberin form a protein complex that helps regulate cellular proliferation. These proteins form a complex that constitutively inhibits the mammalian target of rapamycin (mTOR) signaling pathway, leading to permanent activation of mTOR signaling within all TSC-associated lesions. Major features of TSC include tumors of the brain, skin, heart, lungs and kidneys, seizures and TSC-associated neuropsychiatric disorders, which can include autism spectrum disorder and cognitive disability. These disorders are usually diagnosed in children and adults. Specific guidelines for diagnosis, surveillance, and management have been proposed by the International Tuberous Sclerosis Complex Consensus Group. Several randomized controlled trials led to regulatory approval of the use of mTOR inhibitors for the treatment of renal angiomyolipomas, brain subependymal giant cell astrocytomas, refractory epilepsy and pulmonary lymphangioleiomyomatosis.
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Affiliation(s)
- P Pfirmann
- Service de néphrologie, transplantation, dialyse et aphérèses, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France; Inserm U1026, BioTis, université de Bordeaux, 33076 Bordeaux, France.
| | - C Combe
- Service de néphrologie, transplantation, dialyse et aphérèses, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France; Inserm U1026, BioTis, université de Bordeaux, 33076 Bordeaux, France
| | - C Rigothier
- Service de néphrologie, transplantation, dialyse et aphérèses, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France; Inserm U1026, BioTis, université de Bordeaux, 33076 Bordeaux, France
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Lattanzi S, Riva A, Striano P. Ganaxolone treatment for epilepsy patients: from pharmacology to place in therapy. Expert Rev Neurother 2021; 21:1317-1332. [PMID: 33724128 DOI: 10.1080/14737175.2021.1904895] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Nonsulfated neurosteroids can provide phasic and tonic inhibition through activation of synaptic and extra-synaptic γ-aminobutyric acid (GABA)A receptors, exhibiting a greater potency for the latter. These actions occur by interacting with modulatory sites that are distinct from those bound by benzodiazepines and barbiturates. Ganaxolone (GNX) is a synthetic analog of the endogenous neurosteroid allopregnanolone and a member of a novel class of neuroactive steroids called epalons.Areas covered: The authors review the pharmacology of GNX, summarize the main clinical evidence about its antiseizure efficacy and tolerability, and suggest implications for clinical practice and future research.Expert opinion: The clinical development of GNX is mainly oriented to target unmet needs and focused on status epilepticus and rare genetic epilepsies that have few or no treatment options.The availability of oral and intravenous formulations allows reaching adult and pediatric patients in acute and chronic care settings. Further evidence will complement the understanding of the potentialities of GNX and possibly lead to indications for use in clinical practice.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Antonella Riva
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, "G. Gaslini" Institute, University of Genoa, Genova, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, "G. Gaslini" Institute, University of Genoa, Genova, Italy
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34
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Bilateral Renal Angiomyolipomas and Subependymal Giant Cell Astrocytoma Associated with Tuberous Sclerosis Complex: a Case Report and Review of The Literature. Balkan J Med Genet 2021; 23:93-98. [PMID: 33816078 PMCID: PMC8009567 DOI: 10.2478/bjmg-2020-0017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal-dominant multi system disorder. The genetic basis of the disorder is mutations in the TSC1 or TSC2 gene, which leads to over activation of the mammalian target of rapamycin (mTOR) protein complex and results in development of benign tumors in different body systems such as brain, skin, lungs and kidney. The mTOR inhibitors are presently the main treatment option for patients with TSC. We here report a 21-year female patient with large bilateral angiomyolipoma (AML) in both kidneys with longest diameter more than 12.3 cm and subependymal giant cell astrocytoma (SEGA). Treatment with everolimus (EVE) was initiated at a dose of 10.0 mg/day and continued during the following 3 years. Magnetic resonance imaging (MRI) was performed before treatment with everolimus was initiated, and consequently at 12 and 36 months for follow-up of the efficacy of the treatment. After 3 years, the total size of largest AML decreased by ~24.0% in the longest diameter. A reduction of the total size of SEGA was also observed. The most common adverse effect of treatment was stomatitis grades 3 to 4 and one febrile episode associated with skin rash that required a reduced dose of EVE. In conclusion, the everolimus treatment improved even such a large renal AML and the effect persisted during the long-term administration with a small number of adverse effects. A positive effect was observed on the brain tumor as well.
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Kingswood JC, Belousova E, Benedik MP, Budde K, Carter T, Cottin V, Curatolo P, Dahlin M, D'Amato L, d'Augères GB, de Vries PJ, Ferreira JC, Feucht M, Fladrowski C, Hertzberg C, Jozwiak S, Lawson JA, Macaya A, Marques R, Nabbout R, O'Callaghan F, Qin J, Sander V, Sauter M, Shah S, Takahashi Y, Touraine R, Youroukos S, Zonnenberg B, Jansen AC. TuberOus SClerosis registry to increAse disease awareness (TOSCA) Post-Authorisation Safety Study of Everolimus in Patients With Tuberous Sclerosis Complex. Front Neurol 2021; 12:630378. [PMID: 33833726 PMCID: PMC8021912 DOI: 10.3389/fneur.2021.630378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/03/2021] [Indexed: 11/20/2022] Open
Abstract
This non-interventional post-authorisation safety study (PASS) assessed the long-term safety of everolimus in patients with tuberous sclerosis complex (TSC) who participated in the TuberOus SClerosis registry to increase disease Awareness (TOSCA) clinical study and received everolimus for the licensed indications in the European Union. The rate of adverse events (AEs), AEs that led to dose adjustments or treatment discontinuation, AEs of potential clinical interest, treatment-related AEs (TRAEs), serious AEs (SAEs), and deaths were documented. One hundred seventy-nine patients were included in the first 5 years of observation; 118 of 179 patients had an AE of any grade, with the most common AEs being stomatitis (7.8%) and headache (7.3%). AEs caused dose adjustments in 56 patients (31.3%) and treatment discontinuation in nine patients (5%). AEs appeared to be more frequent and severe in children. On Tanner staging, all patients displayed signs of age-appropriate sexual maturation. Twenty-two of 106 female (20.8%) patients had menstrual cycle disorders. The most frequent TRAEs were stomatitis (6.7%) and aphthous mouth ulcer (5.6%). SAEs were reported in 54 patients (30.2%); the most frequent SAE was pneumonia (>3% patients; grade 2, 1.1%, and grade 3, 2.8%). Three deaths were reported, all in patients who had discontinued everolimus for more than 28 days, and none were thought to be related to everolimus according to the treating physicians. The PASS sub-study reflects the safety and tolerability of everolimus in the management of TSC in real-world routine clinical practice.
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Affiliation(s)
- J Chris Kingswood
- Genomics Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St George's Hospital, University of London, London, United Kingdom
| | - Elena Belousova
- Research and Clinical Institute of Paediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - Klemens Budde
- Internal Medicine and Nephrology, Hypertensiology DHL, University Medicine Berlin, Berline, Germany
| | - Tom Carter
- Tuberous Sclerosis Association, Nottingham, United Kingdom
| | - Vincent Cottin
- Hôpital Louis Pradel, Claude Bernard University Lyon, Lyon, France
| | | | - Maria Dahlin
- Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | | | - Martha Feucht
- Universitätsklinik für Kinder-und Jugendheilkunde, Vienna, Austria
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ONLUS, Milan, Italy.,European Tuberous Sclerosis Complex Association, In den Birken, Dattein, Neuharlingersiel, Germany
| | | | - Sergiusz Jozwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland.,Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - John A Lawson
- The Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Alfons Macaya
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ruben Marques
- Novartis Farma S.p.A., Origgio, Italy.,Institute of Biomedicine (IBIOMED), University of León, León, Spain
| | - Rima Nabbout
- Department of Paediatric Neurology, Necker Enfants Malades Hospital, Paris Descartes University, Paris, France
| | - Finbar O'Callaghan
- Institute of Child Health, University College London, London, United Kingdom
| | - Jiong Qin
- Department of Paediatrics, Peking University People's Hospital, Beijing, China
| | | | | | - Seema Shah
- Novartis Healthcare Pvt. Ltd, Hyderabad, India
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, NHO, Shizuoka, Japan
| | - Renaud Touraine
- Department of Genetics, CHU-Hôpital Nord, Saint Etienne, France
| | | | | | - Anna C Jansen
- Pediatric Neurology Unit, Department of Paediatrics, UZ Brussel VUB, Brussels, Belgium
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Mühlebner A, van Scheppingen J, de Neef A, Bongaarts A, Zimmer TS, Mills JD, Jansen FE, Spliet WGM, Krsek P, Zamecnik J, Coras R, Blumcke I, Feucht M, Scholl T, Gruber VE, Hainfellner JA, Söylemezoğlu F, Kotulska K, Lagae L, Jansen AC, Kwiatkowski DJ, Jozwiak S, Curatolo P, Aronica E. Myelin Pathology Beyond White Matter in Tuberous Sclerosis Complex (TSC) Cortical Tubers. J Neuropathol Exp Neurol 2021; 79:1054-1064. [PMID: 32954437 PMCID: PMC7559237 DOI: 10.1093/jnen/nlaa090] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a monogenetic disease that arises due to mutations in either the TSC1 or TSC2 gene and affects multiple organ systems. One of the hallmark manifestations of TSC are cortical malformations referred to as cortical tubers. These tubers are frequently associated with treatment-resistant epilepsy. Some of these patients are candidates for epilepsy surgery. White matter abnormalities, such as loss of myelin and oligodendroglia, have been described in a small subset of resected tubers but mechanisms underlying this phenomenon are unclear. Herein, we analyzed a variety of neuropathologic and immunohistochemical features in gray and white matter areas of resected cortical tubers from 46 TSC patients using semi-automated quantitative image analysis. We observed divergent amounts of myelin basic protein as well as numbers of oligodendroglia in both gray and white matter when compared with matched controls. Analyses of clinical data indicated that reduced numbers of oligodendroglia were associated with lower numbers on the intelligence quotient scale and that lower amounts of myelin-associated oligodendrocyte basic protein were associated with the presence of autism-spectrum disorder. In conclusion, myelin pathology in cortical tubers extends beyond the white matter and may be linked to cognitive dysfunction in TSC patients.
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Affiliation(s)
- Angelika Mühlebner
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jackelien van Scheppingen
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Andrew de Neef
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anika Bongaarts
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Till S Zimmer
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - James D Mills
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Floor E Jansen
- Department of Pediatric Neurology, Brain Center University Medical Center
| | - Wim G M Spliet
- Department of Pathology, University Medical Center Utrecht (WGMS) Utrecht, The Netherlands
| | | | | | - Roland Coras
- Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic; Department of Neuropathology, University Hospital Erlangen, Erlangen, Germany
| | - Ingmar Blumcke
- Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic; Department of Neuropathology, University Hospital Erlangen, Erlangen, Germany
| | | | | | | | | | - Figen Söylemezoğlu
- Medical University of Vienna, Vienna, Austria; Department of Pathology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Lieven Lagae
- Department of Development and Regeneration-Section Pediatric Neurology, University Hospitals KU Leuven, Leuven
| | - Anna C Jansen
- Pediatric Neurology Unit-UZ Brussel, Brussels Belgium
| | | | - Sergiusz Jozwiak
- Department of Neurology and Epileptology, The Children's Memorial Health Institute.,Department of Child Neurology, Medical University of Warsaw Warsaw, Poland
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
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Amin S, Mallick AA, Edwards H, Cortina-Borja M, Laugharne M, Likeman M, O'Callaghan FJ. The metformin in tuberous sclerosis (MiTS) study: A randomised double-blind placebo-controlled trial. EClinicalMedicine 2021; 32:100715. [PMID: 33681737 PMCID: PMC7910694 DOI: 10.1016/j.eclinm.2020.100715] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Tuberous Sclerosis Complex (TSC) is a genetic disorder characterised by the development of benign tumours secondary to loss of inhibitory regulation of the mTOR (mechanistic Target of Rapamycin) intracellular growth pathway. Metformin inhibits the mTOR pathway. We investigated whether metformin would reduce growth of hamartomas associated with tuberous sclerosis complex. METHODS In this multicentre randomized, double-blind, placebo-controlled trial, patients with a clinical diagnosis of tuberous sclerosis, aged over 10 years and with at least one renal angiomyolipoma of greater than 1 cm in diameter were enrolled. Participants were randomly allocated (1:1) by a secure website to receive metformin or placebo for 12 months. The primary outcome was percentage volume change of renal angiomyolipomas (AML) at 12 months compared to baseline. Secondary outcomes were percentage change at 12 months from baseline in volume of cerebral Subependymal Giant Cell Astrocytomas (SEGA); appearance of facial and ungual hamartomas; frequency of epileptic seizures; and adaptive behaviour. The trial is registered with The International Standard Randomised Controlled Trial Number (ISRCTN), number 92545532, and the European Union Drug Regulating Authorities Clinical Trials (EUDRACT), number 2011-001319-30. FINDINGS Between 1 November 2012 and 30 September 2015 72 patients were screened and 55 were randomly assigned to metformin (28) or placebo (27). Four participants withdrew between randomisation and starting treatment. All 51 patients who started therapy completed the trial and were assessed for outcome at 12 months. The median percentage change in angiomyolipoma (AML) volume was +7.6% (IQR -1.8% to +42.6%) for the placebo group and +8.9% (IQR 1.3% to 19.5%) for the metformin group (p = 0.28). Twenty-seven patients had SEGAs: 13 received placebo and 14 metformin. The median percentage change in SEGA volume was +3.0% (IQR -22.8% to +27.7%) for the placebo group and - 20.8% (IQR - 47.1% to - 5.0%) for the metformin group (p = 0.03). Twenty-one patients were assessed for seizure frequency: 9 received placebo and 12 received metformin. In the metformin group, a mean reduction of 43.7% from baseline in seizures was observed and in the placebo group a 3.1% mean reduction was observed, with a difference in response of 40.6% (95% CI -3.1% to +84.2%, p = 0.03). There were no significant differences between metformin and placebo groups for the other secondary outcomes. There were no deaths. Three serious adverse events (SAEs) occurred during the trial (all patients on metformin). INTERPRETATION Metformin did not reduce AML volume. Metformin did reduce SEGA volume and seizure frequency compared with placebo. There may be a role for metformin in slowing or reversing growth of some life-threatening hamartomas in TSC and for reducing seizure frequency. Further study is justified. FUNDING This study was funded by the National Institute for Health and Research (NIHR) through the The Research for Patient Benefit Programme (RfPB).
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Affiliation(s)
- Sam Amin
- Clinical Neurosciences Section, Room 41, 4th Floor PUW South, UCL Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, United Kingdom
- Children's Department, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, United Kingdom
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS3 8AE, United Kingdom
| | - Andrew A Mallick
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS3 8AE, United Kingdom
| | - Hannah Edwards
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Mario Cortina-Borja
- Population, Policy and Practice Teaching and Research Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Matthew Laugharne
- Radiology Department, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, United Kingdom
| | - Marcus Likeman
- Department of Paediatric Radiology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS3 8AE, United Kingdom
| | - Finbar J.K. O'Callaghan
- Clinical Neurosciences Section, Room 41, 4th Floor PUW South, UCL Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, United Kingdom
- Department of Paediatric Neurology, Brain Directorate, Great Ormond Street Hospital NHS Trust, London WC1N 3JH, United Kingdom
- Children's Department, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, United Kingdom
- Corresponding author at: Clinical Neurosciences Section, Room 41, 4th Floor PUW South, Institute of Child Health, University College London, London WC1N 1EH, United Kingdom. f.o'
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Delorme J, Bertin C, Delage N, Eschalier A, Ardid D, Authier N, Chenaf C. Prevalence of chronic pain in opioid-maintained patients using the capture-recapture method: a nationwide population-based study. Pain 2021; 162:195-202. [PMID: 32701648 DOI: 10.1097/j.pain.0000000000002011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Few studies all based on classical surveys have provided prevalence estimates of chronic pain (CP) in opioid-maintained patients (OMPs) but often had a limited patient sample size and a great variability in the prevalence estimates. This study sought to assess the prevalence of CP in the exhaustive population of OMPs using the capture-recapture method applied to the French nationwide health care database. Capture-recapture methods are increasingly used to estimate the prevalence of chronic conditions but have never been used in the specific context of CP in OMPs. Three large medical-administrative sources were used: the prescription drug database (A-list), the national hospital discharge database (M-list), and the pain center database (C-list). Between 2015 and 2016, 160,429 OMPs aged 15 years and older were identified and age- and sex-matched with 160,429 non-OMPs. All patients treated with analgesic drugs for ≥6 months (A-list) or diagnosed with CP (M- and C-list) were included. Capture-recapture analyses were performed to yield CP estimates with their 95% confidence intervals using log-linear models. In 2015 to 2016, 12,765 OMPs and 2938 non-OMPs with CP were captured. Most patients were male (67%) in OMPs and non-OMPs; median ages for OMPs and non-OMPs were 46 (interquartile range: 38-51) and 48 (41-53) years, respectively. The CP prevalence estimated in OMPs and non-OMPs ranged from 23.6% (14.9-46.2) to 32.1% (28.6-36.3) and from 7.28% (3.98-18.4) to 9.32% (7.42-12.1), respectively. This first study on CP in the exhaustive population of OMPs using the capture-recapture method demonstrated a high prevalence of CP in OMPs, 3- to 4-fold than in the general population.
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Affiliation(s)
- Jessica Delorme
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, Université Clermont Auvergne-CHU Clermont-Ferrand, F-63001 Clermont-Ferrand, France
| | - Célian Bertin
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, Université Clermont Auvergne-CHU Clermont-Ferrand, F-63001 Clermont-Ferrand, France
| | - Noémie Delage
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
| | - Alain Eschalier
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, Université Clermont Auvergne-CHU Clermont-Ferrand, F-63001 Clermont-Ferrand, France
- Institut Analgesia, Faculté de Médecine, BP38, Clermont-Ferrand, France
| | - Denis Ardid
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
| | - Nicolas Authier
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, Université Clermont Auvergne-CHU Clermont-Ferrand, F-63001 Clermont-Ferrand, France
- Institut Analgesia, Faculté de Médecine, BP38, Clermont-Ferrand, France
| | - Chouki Chenaf
- Université Clermont Auvergne, CHU Clermont-Ferrand, Inserm, Neuro-Dol, Service de Pharmacologie Médicale, Centres Addictovigilance et Pharmacovigilance, Centre Evaluation et Traitement de la Douleur, Clermont-Ferrand, France
- Observatoire Français des Médicaments Antalgiques (OFMA)/French Monitoring Centre for Analgesic Drugs, Université Clermont Auvergne-CHU Clermont-Ferrand, F-63001 Clermont-Ferrand, France
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Fetal rhabdomyoma with maternal tuberous sclerosis that almost completely filled the left ventricle at an early gestational week. Turk Arch Pediatr 2021; 56:94-96. [PMID: 34013241 DOI: 10.14744/turkpediatriars.2020.70457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/25/2020] [Indexed: 11/20/2022]
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Sidira C, Vargiami E, Dragoumi P, Zafeiriou DI. Hemimegalencephaly and tuberous sclerosis complex: A rare yet challenging association. Eur J Paediatr Neurol 2021; 30:58-65. [PMID: 33387903 DOI: 10.1016/j.ejpn.2020.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/20/2020] [Accepted: 12/17/2020] [Indexed: 12/18/2022]
Abstract
Hemimegalencephaly is a rare malformation of cortical development characterised by enlargement of one cerebral hemisphere. The association between hemimegalencephaly and tuberous sclerosis complex, an autosomal dominant genetic disorder, is uncommon and has so far been reported only in a few cases. Intractable epilepsy and severe developmental delay are typical clinical manifestations. Aberrant activation of the mTOR signalling pathway is considered to be the hallmark of the pathogenesis of these two disorders. Thus, mTOR inhibitors such as everolimus represent a promising therapeutic approach to mTOR-associated manifestations. We present a thorough literature review of the association between hemimegaloencephaly and tuberous sclerosis complex.
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Affiliation(s)
- Christina Sidira
- 1st Paediatric Department, Developmental Centre "A. Fokas", Aristotle University of Thessaloniki, "Hippokration" General Hospital, Thessaloniki, Greece
| | - Efthymia Vargiami
- 1st Paediatric Department, Developmental Centre "A. Fokas", Aristotle University of Thessaloniki, "Hippokration" General Hospital, Thessaloniki, Greece
| | - Pinelopi Dragoumi
- 1st Paediatric Department, Developmental Centre "A. Fokas", Aristotle University of Thessaloniki, "Hippokration" General Hospital, Thessaloniki, Greece
| | - Dimitrios I Zafeiriou
- 1st Paediatric Department, Developmental Centre "A. Fokas", Aristotle University of Thessaloniki, "Hippokration" General Hospital, Thessaloniki, Greece.
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Bouvarel H, Rodier-Bonifas C, Burillon C. Cataracte congénitale et sclérose tubéreuse de Bourneville : à propos de deux cas. J Fr Ophtalmol 2020; 43:e337-e339. [DOI: 10.1016/j.jfo.2019.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/24/2019] [Accepted: 12/10/2019] [Indexed: 10/23/2022]
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Uematsu M, Numata-Uematsu Y, Aihara Y, Kobayashi T, Fujikawa M, Togashi N, Shiihara T, Ohashi K, Hattori A, Saitoh S, Kure S. Behavioral problems and family distress in tuberous sclerosis complex. Epilepsy Behav 2020; 111:107321. [PMID: 32698109 DOI: 10.1016/j.yebeh.2020.107321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC)-associated neuropsychiatric disorders (TAND) have a large impact on patients and their families. Improving intellectual ability outcomes using preventive vigabatrin (VGB) treatment has recently been reported. AIM The aim of this study was to investigate the severity of behavioral problems and degree of distress among families of patients with TSC with and without a history of VGB treatment. METHOD The study enrolled 21 children and adolescents who were patients with TSC from four hospitals: 14 in the VGB group and 7 in the no-VGB group. To evaluate patients' psychiatric and neurological symptoms, we used the TAND Checklist, Aberrant Behavior Checklist (ABC), Social Communication Questionnaire (SCQ), and Social Responsive Scale-2nd edition (SRS-2). RESULTS All VGB-group patients were administered VGB after the onset of epileptic seizures. No obvious differences were observed between the VGB and no-VGB groups in behavioral problem scores on the TAND Checklist, or on the ABC, SCQ, and SRS-2 total scores. Behavioral problem scores were lower in patients with normal intelligence than in those with mild intellectual disability (ID; P = 0.042). Degrees of family distress assessed with the TAND Checklist were not correlated with the intelligence quotient/developmental quotient (IQ/DQ) or seizure frequency but were correlated with the total SRS-2 scores (P = 0.022). For several patients, there were large discrepancies between familial and physician ratings of the TAND impact score. CONCLUSION Children and adolescents with TSC may present with significant behavioral difficulties and family distress, regardless of whether they were treated with VGB or not after the onset of seizures. Difficulties in social communication may have the strongest "TAND impact" on families.
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Affiliation(s)
- Mitsugu Uematsu
- Department of Pediatrics, Tohoku University School of Medicine, 980-8574, Japan.
| | | | - Yu Aihara
- Department of Pediatrics, Tohoku University School of Medicine, 980-8574, Japan
| | - Tomoko Kobayashi
- Department of Pediatrics, Tohoku University School of Medicine, 980-8574, Japan
| | - Mayu Fujikawa
- Department of Neuropsychiatry, Keio University School of Medicine, 160-8582, Japan; Department of Epileptology, Tohoku University School of Medicine, 980-8574, Japan
| | - Noriko Togashi
- Department of Pediatric Neurology, Miyagi Children's Hospital, 989-3126, Japan
| | - Takashi Shiihara
- Department of Neurology, Gunma Children's Medical Center, 377-8577, Japan
| | - Kei Ohashi
- Department of Neonatology and Pediatrics, Nagoya City University Graduate School of Medical Sciences, 467-8602, Japan
| | - Ayako Hattori
- Department of Neonatology and Pediatrics, Nagoya City University Graduate School of Medical Sciences, 467-8602, Japan
| | - Shinji Saitoh
- Department of Neonatology and Pediatrics, Nagoya City University Graduate School of Medical Sciences, 467-8602, Japan
| | - Shigeo Kure
- Department of Pediatrics, Tohoku University School of Medicine, 980-8574, Japan
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Jansen AC, Vanclooster S, de Vries PJ, Fladrowski C, Beaure d'Augères G, Carter T, Belousova E, Benedik MP, Cottin V, Curatolo P, Dahlin M, D'Amato L, Ferreira JC, Feucht M, Hertzberg C, Jozwiak S, Lawson JA, Macaya A, Marques R, Nabbout R, O'Callaghan F, Qin J, Sander V, Sauter M, Shah S, Takahashi Y, Touraine R, Youroukos S, Zonnenberg B, Kingswood JC. Burden of Illness and Quality of Life in Tuberous Sclerosis Complex: Findings From the TOSCA Study. Front Neurol 2020; 11:904. [PMID: 32982929 PMCID: PMC7485558 DOI: 10.3389/fneur.2020.00904] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/14/2020] [Indexed: 12/16/2022] Open
Abstract
Research on tuberous sclerosis complex (TSC) to date has focused mainly on the physical manifestations of the disease. In contrast, the psychosocial impact of TSC has received far less attention. The aim of this study was therefore to examine the impact of TSC on health, quality of life (QoL), and psychosocial well-being of individuals with TSC and their families. Questionnaires with disease-specific questions on burden of illness (BOI) and validated QoL questionnaires were used. After completion of additional informed consent, we included 143 individuals who participated in the TOSCA (TuberOus SClerosis registry to increase disease Awareness) study. Our results highlighted the substantial burden of TSC on the personal lives of individuals with TSC and their families. Nearly half of the patients experienced negative progress in their education or career due to TSC (42.1%), as well as many of their caregivers (17.6% employed; 58.8% unemployed). Most caregivers (76.5%) indicated that TSC affected family life, and social and working relationships. Further, well-coordinated care was lacking: a smooth transition from pediatric to adult care was mentioned by only 36.8% of adult patients, and financial, social, and psychological support in 21.1, 0, and 7.9%, respectively. In addition, the moderate rates of pain/discomfort (35%) and anxiety/depression (43.4%) reported across all ages and levels of disease demonstrate the high BOI and low QoL in this vulnerable population.
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Affiliation(s)
- Anna C Jansen
- Pediatric Neurology Unit, Department of Pediatrics, UZ Brussel VUB, Brussels, Belgium.,Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Petrus J de Vries
- Division of Child and Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Carla Fladrowski
- Associazione Sclerosi Tuberosa ONLUS, Milan, Italy.,European Tuberous Sclerosis Complex Association, In den Birken, Dattein, Germany
| | | | - Tom Carter
- TSA Tuberous Sclerosis Association, Nottingham, United Kingdom
| | - Elena Belousova
- Research and Clinical Institute of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - Vincent Cottin
- Hôpital Louis Pradel, Claude Bernard University Lyon 1, Lyon, France
| | | | - Maria Dahlin
- Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Martha Feucht
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Affiliated Partner of the ERN EpiCARE, Vienna, Austria
| | | | - Sergiusz Jozwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland.,Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - John A Lawson
- The Tuberous Sclerosis Multidisciplinary Management Clinic, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Alfons Macaya
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ruben Marques
- Novartis Farma S.p.A., Origgio, Italy.,Institute of Biomedicine (IBIOMED), University of Leon, León, Spain
| | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Malades Hospital, Paris Descartes University, Paris, France
| | - Finbar O'Callaghan
- Institute of Child Health, University College London, London, United Kingdom
| | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital (PKUPH), Beijing, China
| | | | | | - Seema Shah
- Novartis Healthcare Pvt Ltd, Hyderabad, India
| | - Yukitoshi Takahashi
- National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
| | - Renaud Touraine
- Department of Genetics, CHU-Hôpital Nord, Saint Etienne, France
| | | | | | - J Chris Kingswood
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St Georges University of London, London, United Kingdom
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Specchio N, Pietrafusa N, Trivisano M, Moavero R, De Palma L, Ferretti A, Vigevano F, Curatolo P. Autism and Epilepsy in Patients With Tuberous Sclerosis Complex. Front Neurol 2020; 11:639. [PMID: 32849171 PMCID: PMC7431762 DOI: 10.3389/fneur.2020.00639] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/29/2020] [Indexed: 12/27/2022] Open
Abstract
Introduction: Individuals with Tuberous Sclerosis Complex (TSC) are at increased risk of developing both epilepsy and autism spectrum disorder (ASD), but the relationship between these conditions is little understood. We reviewed published reports to elucidate the relationship between ASD, epilepsy, and TSC, and to define the genetic and neurological risk factors. Methods: Articles (January 2004-May 2019) were identified via PubMed, EMBASE, and CENTRAL databases. Article inclusion required report on individuals with TSC-associated ASD and epilepsy with prevalence, odds ratio, or rate report on the comorbidity of ASD in epileptic patients due to TSC. Results: A total of 841 abstracts were identified in the original search. Thirty-six articles were included, which identified study populations, ASD measures used, and study confounders as bias factors. This review included 2,666 TSC patients, with a mean age of 15.9 years (range 1.94-30.3 years). The percentage of TSC patients with epilepsy and autism was 33.7%. Patients with TSC and autism showed more frequent seizures and earlier epilepsy onset than TSC patients without autism. ASD and intractable epilepsy were both predicted by a higher number of areas with dysplastic features revealed in brain MR scans. ASD, the onset of seizures in children <2 years of age, and >3 tubers have all been associated with an increased risk of refractory epilepsy in TSC patients. However, the direction of the relationship is not clear because a history of epilepsy, or infantile spasms in patients with TSC is also associated with an increased likelihood of ASD. Overall, 73.2% of patients carried TSC2 genetic variant and, among patients with TSC and autism, the percentage of TSC2 individuals was 85.6%. Conclusions: The complex interrelationship between TSC, autism, and epilepsy, coupled with limited knowledge on the neurobiological basis for the interrelationship, limits overall understanding and opportunities for management. The results of this review highlight the need for early identification and management to optimize favorable outcomes in the most vulnerable individuals with TSC. Regardless of whether studies are considered individually or collectively, interpretation is made difficult due to the differences between the studies, most notably between methods and diagnostic criteria used to assess intellectual ability.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Member of European Reference Network EpiCARE
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Luca De Palma
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandro Ferretti
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Federico Vigevano
- Member of European Reference Network EpiCARE
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
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Ahmed M, Hassan K, Mustafa ME. Cutaneous Lesions as the Sole Presentation of Tuberous Sclerosis. Cureus 2020; 12:e9528. [PMID: 32905242 PMCID: PMC7465932 DOI: 10.7759/cureus.9528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare genetic, neurocutaneous condition characterized by hamartomas in different organs, including the brain, skin, heart, kidney, and lungs. Fibromas are the typical presentation, but rare symptoms may present as well. We present the case of a 26-year-old woman who presented to our clinic with long-standing cutaneous manifestations of TSC and lacked the typical neurological and intellectual signs of the condition.
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Samanta D. An Updated Review of Tuberous Sclerosis Complex-Associated Autism Spectrum Disorder. Pediatr Neurol 2020; 109:4-11. [PMID: 32563542 DOI: 10.1016/j.pediatrneurol.2020.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 03/01/2020] [Accepted: 03/03/2020] [Indexed: 01/30/2023]
Abstract
Tuberous sclerosis complex (TSC) is a neurocutaneous disorder caused by mutations of either the TSC1 or TSC2 gene. Various neuropsychiatric features, including autism, are prevalent in TSC. Recently, significant progress has been possible with the prospective calculation of the prevalence of autism in TSC, identification of early clinical and neurophysiological biomarkers to predict autism, and investigation of different therapies to prevent autism in this high-risk population. The author provides a narrative review of recent findings related to biomarkers for diagnosis of autism in TSC, as well as recent studies related to the management of TSC-associated autism. Further sophisticated modeling and analysis are required to understand the role of different models-tuber models, seizures and related neurophysiological factors models, genotype models, and brain connectivity models-to unravel the neurobiological basis of autism in TSC. Early neuropsychologic assessments may be beneficial in this high-risk group. Targeted intervention to improve visual skill, cognition, and fine motor skills with later addition of social skill training can be helpful. Multicenter, prospective studies are ongoing to identify if presymptomatic treatment with vigabatrin in patients with TSC can improve outcomes, including autism. Several studies indicated reasonable safety of everolimus in young children, and its potential application in high-risk infants with TSC, before the closure of the temporal window of permanent changes, maybe undertaken shortly.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Section, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
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Fang Y, Li F, Qi C, Mao X, Wang F, Zhao Z, Chen JK, Zhang Z, Wu H. Metformin effectively treats Tsc1 deletion-caused kidney pathology by upregulating AMPK phosphorylation. Cell Death Discov 2020; 6:52. [PMID: 32566257 PMCID: PMC7295815 DOI: 10.1038/s41420-020-0285-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/18/2020] [Accepted: 05/28/2020] [Indexed: 12/25/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is characterized by hamartomatous lesions in multiple organs, with most patients developing polycystic kidney disease and leading to a decline of renal function. TSC is caused by loss-of-function mutations in either Tsc1 or Tsc2 gene, but currently, there is no effective treatment for aberrant kidney growth in TSC patients. By generating a renal proximal tubule-specific Tsc1 gene-knockout (Tsc1 ptKO) mouse model, we observed that Tsc1 ptKO mice developed aberrantly enlarged kidneys primarily due to hypertrophy and proliferation of proximal tubule cells, along with some cystogenesis, interstitial inflammation, and fibrosis. Mechanistic studies revealed inhibition of AMP-activated protein kinase (AMPK) phosphorylation at Thr-172 and activation of Akt phosphorylation at Ser-473 and Thr-308. We therefore treated Tsc1 ptKO mice with the AMPK activator, metformin, by daily intraperitoneal injection. Our results indicated that metformin increased the AMPK phosphorylation, but decreased the Akt phosphorylation. These signaling modulations resulted in inhibition of proliferation and induction of apoptosis in the renal proximal tubule cells of Tsc1 ptKO mice. Importantly, metformin treatment effectively prevented aberrant kidney enlargement and cyst growth, inhibited inflammatory response, attenuated interstitial fibrosis, and protected renal function. The effects of metformin were further confirmed by in vitro experiments. In conclusion, this study indicates a potential therapeutic effect of metformin on Tsc1 deletion-induced kidney pathology, although currently metformin is primarily prescribed to treat patients with type 2 diabetes.
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Affiliation(s)
- Yili Fang
- Department of Pathology, School of Basic Medical Science, Fudan University, Shanghai, 200032 PR China
| | - Fang Li
- Department of Pathology, School of Basic Medical Science, Fudan University, Shanghai, 200032 PR China
| | - Chenyang Qi
- Department of Pathology, School of Basic Medical Science, Fudan University, Shanghai, 200032 PR China
| | - Xing Mao
- Department of Pathology, School of Basic Medical Science, Fudan University, Shanghai, 200032 PR China
| | - Feng Wang
- Department of Nephrology, Shanghai 6th People’s Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200032 PR China
| | - Zhonghua Zhao
- Department of Pathology, School of Basic Medical Science, Fudan University, Shanghai, 200032 PR China
| | - Jian-Kang Chen
- Department of Cellular Biology & Anatomy, Medical College of Georgia, Augusta University, Augusta, GA 30912 USA
| | - Zhigang Zhang
- Department of Pathology, School of Basic Medical Science, Fudan University, Shanghai, 200032 PR China
| | - Huijuan Wu
- Department of Pathology, School of Basic Medical Science, Fudan University, Shanghai, 200032 PR China
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Pfirmann P, Aupy J, Jambon E, Idier L, Prezelin-Reydit M, Fermis M, Devillard R, Grenier N, Combe C, Rigothier C. Description of a multidisciplinary model of care in a French cohort of adult patients with tuberous sclerosis complex. J Med Genet 2020; 58:25-31. [PMID: 32409510 DOI: 10.1136/jmedgenet-2019-106607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/07/2020] [Accepted: 03/29/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare autosomal dominant genetic disorder. Due to the various manifestations of TSC and their potential complications, a multidisciplinary care approach is recommended by consensus guidelines. OBJECTIVES Our study aimed to give a complete description of our TSC adult cohort and to evaluate the multidisciplinary and interdisciplinary management model. METHODS Data on each adult patient diagnosed with TSC, including disease manifestations, interventions and outcomes, were collected at baseline and updated annually. A multidisciplinary TSC approach with all the recommended explorations was carried out annually. RESULTS 90 patients were enrolled in Centre Hospitalier Universitaire de Bordeaux, between January 2000 and September 2018. Median age of patients at inclusion was 37 years (range, 27-47) and 20 years old at diagnosis of TSC. Regarding the occurrence of TSC manifestations, 97% of the patients had cutaneous lesions, 89% had neurological manifestations, 83% had renal manifestations and 100% had dental lesions with pits. More than half the patients had sclerotic bone lesions (68%), TSC-associated neuropsychiatric disorders (64%) and lymphangioleiomyomatosis (59%). A TSC multidisciplinary approach was developed including a global follow-up and an evaluation of TSC targeting organs, according to the recommendations. A satisfaction survey revealed global and entire satisfaction of patients with TSC. CONCLUSION We obtained an accurate description of a cohort of adult patients with TSC. Our multidisciplinary approach model allowed us to provide optimal management of patients with TSC with a high level of patient satisfaction.
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Affiliation(s)
- Pierre Pfirmann
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France .,Tissue Bioengineering, BioTis, U1026, INSERM DR Aquitaine Poitou-Charentes, Bordeaux, France
| | - Jerome Aupy
- Service de Neurologie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Eva Jambon
- Service d'Imagerie Médicale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Laetitia Idier
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Association pour l'Utilisation du Rein Artificiel a Domicile en Aquitaine, Gradignan, France
| | - Mathilde Prezelin-Reydit
- Association pour l'Utilisation du Rein Artificiel a Domicile en Aquitaine, Gradignan, France.,ISPED, INSERM, Bordeaux Population Health Research Center, Bordeaux, France
| | - Marine Fermis
- Service de Médecine Bucco-Dentaire, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Raphael Devillard
- Tissue Bioengineering, BioTis, U1026, INSERM DR Aquitaine Poitou-Charentes, Bordeaux, France.,Service de Médecine Bucco-Dentaire, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Nicolas Grenier
- Service d'Imagerie Médicale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Christian Combe
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Tissue Bioengineering, BioTis, U1026, INSERM DR Aquitaine Poitou-Charentes, Bordeaux, France
| | - Claire Rigothier
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Tissue Bioengineering, BioTis, U1026, INSERM DR Aquitaine Poitou-Charentes, Bordeaux, France
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Deep learning in rare disease. Detection of tubers in tuberous sclerosis complex. PLoS One 2020; 15:e0232376. [PMID: 32348367 PMCID: PMC7190137 DOI: 10.1371/journal.pone.0232376] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/13/2020] [Indexed: 01/09/2023] Open
Abstract
Objective To develop and test a deep learning algorithm to automatically detect cortical tubers in magnetic resonance imaging (MRI), to explore the utility of deep learning in rare disorders with limited data, and to generate an open-access deep learning standalone application. Methods T2 and FLAIR axial images with and without tubers were extracted from MRIs of patients with tuberous sclerosis complex (TSC) and controls, respectively. We trained three different convolutional neural network (CNN) architectures on a training dataset and selected the one with the lowest binary cross-entropy loss in the validation dataset, which was evaluated on the testing dataset. We visualized image regions most relevant for classification with gradient-weighted class activation maps (Grad-CAM) and saliency maps. Results 114 patients with TSC and 114 controls were divided into a training set, a validation set, and a testing set. The InceptionV3 CNN architecture performed best in the validation set and was evaluated in the testing set with the following results: sensitivity: 0.95, specificity: 0.95, positive predictive value: 0.94, negative predictive value: 0.95, F1-score: 0.95, accuracy: 0.95, and area under the curve: 0.99. Grad-CAM and saliency maps showed that tubers resided in regions most relevant for image classification within each image. A stand-alone trained deep learning App was able to classify images using local computers with various operating systems. Conclusion This study shows that deep learning algorithms are able to detect tubers in selected MRI images, and deep learning can be prudently applied clinically to manually selected data in a rare neurological disorder.
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50
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Geffrey AL, Geenen KR, Abati E, Greenstein SH, VanderVeen DK, Levy RL, Davidson SL, McGarrey MP, Thiele EA, Aronow ME. Juvenile cataract in association with tuberous sclerosis complex. Ophthalmic Genet 2020; 41:345-349. [PMID: 32340510 DOI: 10.1080/13816810.2020.1755989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disorder characterized by benign hamartomas occurring in multiple organ systems including the brain, kidneys, heart, lungs, liver, skin, and the eyes. Typical retinal findings associated with TSC include astrocytic hamartoma and achromic patch. While rare cases of cataract occurring in the setting of TSC have been reported, this is the first analysis of a large series of individuals with TSC that aims to quantify the frequency of this finding and to describe its clinical and genetic associations. MATERIALS AND METHODS This is a retrospective chart review of 244 patients from the Herscot Center for Tuberous Sclerosis Complex at the Massachusetts General Hospital who underwent complete ophthalmic examination. We describe the clinical and genetic findings in five individuals with TSC and juvenile cataract. RESULTS Four of five cases (80%) were unilateral. The cataract was described as having an anterior subcapsular component in 3 of 5 cases (60%). Three individuals (60%) underwent lensectomy with intraocular lens (IOL) implant and two individuals (40%) were observed. Genetic testing revealed a known disease-causing mutation in TSC2 in 100% of cases. CONCLUSIONS Recent evidence suggests that mTOR signaling may play a role in cataract formation which could explain the relatively high incidence of juvenile cataract in this population. Juvenile cataract is a potentially under-recognized ocular manifestation of TSC.
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Affiliation(s)
- A L Geffrey
- Herscot Center for Tuberous Sclerosis Complex, Massachusetts General Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - K R Geenen
- Herscot Center for Tuberous Sclerosis Complex, Massachusetts General Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - E Abati
- Neurology Unit, Department of Pathophysiology and Transplantation, University of Milan, IRCCS Policlinico Ca'Granda Foundation , Milan, Italy
| | - S H Greenstein
- Massachusetts Eye and Ear, Harvard Medical School , Boston, Massachusetts, USA
| | - D K VanderVeen
- Department of Ophthalmology, Boston Children's Hospital , Boston, Massachusetts, USA
| | - R L Levy
- Department of Ophthalmology, Weill Cornell Medical College , New York, New York, USA
| | - S L Davidson
- Department of Ophthalmology, Children's Hospital of Philadelphia , Philadelphia, Pennsylvania, USA
| | - M P McGarrey
- Massachusetts Eye and Ear, Harvard Medical School , Boston, Massachusetts, USA
| | - E A Thiele
- Herscot Center for Tuberous Sclerosis Complex, Massachusetts General Hospital, Harvard Medical School , Boston, Massachusetts, USA
| | - M E Aronow
- Massachusetts Eye and Ear, Harvard Medical School , Boston, Massachusetts, USA
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