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Brima T, Freedman EG, Prinsloo KD, Augustine EF, Adams HR, Wang KH, Mink JW, Shaw LH, Mantel EP, Foxe JJ. Assessing the integrity of auditory sensory memory processing in CLN3 disease (Juvenile Neuronal Ceroid Lipofuscinosis (Batten disease)): an auditory evoked potential study of the duration-evoked mismatch negativity (MMN). J Neurodev Disord 2024; 16:3. [PMID: 38183037 PMCID: PMC10770910 DOI: 10.1186/s11689-023-09515-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/12/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND We interrogated auditory sensory memory capabilities in individuals with CLN3 disease (juvenile neuronal ceroid lipofuscinosis), specifically for the feature of "duration" processing. Given decrements in auditory processing abilities associated with later-stage CLN3 disease, we hypothesized that the duration-evoked mismatch negativity (MMN) of the event related potential (ERP) would be a marker of progressively atypical cortical processing in this population, with potential applicability as a brain-based biomarker in clinical trials. METHODS We employed three stimulation rates (fast: 450 ms, medium: 900 ms, slow: 1800 ms), allowing for assessment of the sustainability of the auditory sensory memory trace. The robustness of MMN directly relates to the rate at which the regularly occurring stimulus stream is presented. As presentation rate slows, robustness of the sensory memory trace diminishes. By manipulating presentation rate, the strength of the sensory memory trace is parametrically varied, providing greater sensitivity to detect auditory cortical dysfunction. A secondary hypothesis was that duration-evoked MMN abnormalities in CLN3 disease would be more severe at slower presentation rates, resulting from greater demand on the sensory memory system. RESULTS Data from individuals with CLN3 disease (N = 21; range 6-28 years of age) showed robust MMN responses (i.e., intact auditory sensory memory processes) at the medium stimulation rate. However, at the fastest rate, MMN was significantly reduced, and at the slowest rate, MMN was not detectable in CLN3 disease relative to neurotypical controls (N = 41; ages 6-26 years). CONCLUSIONS Results reveal emerging insufficiencies in this critical auditory perceptual system in individuals with CLN3 disease.
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Affiliation(s)
- Tufikameni Brima
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
| | - Edward G Freedman
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kevin D Prinsloo
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Erika F Augustine
- University of Rochester Batten Center (URBC), Department of Neurology and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Heather R Adams
- University of Rochester Batten Center (URBC), Department of Neurology and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kuan Hong Wang
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Jonathan W Mink
- University of Rochester Batten Center (URBC), Department of Neurology and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Luke H Shaw
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Emma P Mantel
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - John J Foxe
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
- University of Rochester Batten Center (URBC), Department of Neurology and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
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Brima T, Freedman EG, Prinsloo KD, Augustine EF, Adams HR, Wang KH, Mink JW, Shaw LH, Mantel EP, Foxe JJ. Assessing the integrity of auditory sensory memory processing in CLN 3 disease (Juvenile Neuronal Ceroid Lipofuscinosis (Batten disease)): An auditory evoked potential study of the duration-evoked mismatch negativity (MMN). RESEARCH SQUARE 2023:rs.3.rs-3203894. [PMID: 37645970 PMCID: PMC10462191 DOI: 10.21203/rs.3.rs-3203894/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Background We interrogated auditory sensory memory capabilities in individuals with CLN3 disease (juvenile neuronal ceroid lipofuscinosis), specifically for the feature of "duration" processing, a critical cue in speech perception. Given decrements in speech and language skills associated with later-stage CLN3 disease, we hypothesized that the duration-evoked mismatch negativity (MMN) of the event related potential (ERP) would be a marker of progressively atypical cortical processing in this population, with potential applicability as a brain-based biomarker in clinical trials. Methods We employed three stimulation rates (fast: 450 ms, medium: 900 ms, slow: 1800 ms), allowing for assessment of the sustainability of the auditory sensory memory trace. The robustness of MMN directly relates to the rate at which the regularly occurring stimulus stream is presented. As presentation rate slows, robustness of the sensory memory trace diminishes. By manipulating presentation rate, the strength of the sensory memory trace is parametrically varied, providing greater sensitivity to detect auditory cortical dysfunction. A secondary hypothesis was that duration-evoked MMN abnormalities in CLN3 disease would be more severe at slower presentation rates, resulting from greater demand on the sensory memory system. Results Data from individuals with CLN3 disease (N=21; range 6-28 years of age) showed robust MMN responses (i.e., intact auditory sensory memory processes) at the medium stimulation rate. However, at the fastest rate, MMN was significantly reduced, and at the slowest rate, MMN was not detectable in CLN3 disease relative to neurotypical controls (N=41; ages 6-26 years). Conclusions Results reveal emerging insufficiencies in this critical auditory perceptual system in individuals with CLN3 disease.
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Affiliation(s)
- Tufikameni Brima
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Edward G. Freedman
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kevin D. Prinsloo
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Erika F. Augustine
- University of Rochester Batten Center (URBC), Department of Neurology and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Heather R. Adams
- University of Rochester Batten Center (URBC), Department of Neurology and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Kuan Hong Wang
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Jonathan W. Mink
- University of Rochester Batten Center (URBC), Department of Neurology and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Luke H. Shaw
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Emma P. Mantel
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - John J. Foxe
- The Frederick J. and Marion A. Schindler Cognitive Neurophysiology Laboratory, Department of Neuroscience and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- University of Rochester Batten Center (URBC), Department of Neurology and The Ernest J. Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Dang Do AN, Baker EH, Farmer CA, Soldatos AG, Thurm AE, Porter FD. Brain proton MR spectroscopy measurements in CLN3 disease. Mol Genet Metab 2023; 139:107584. [PMID: 37086568 PMCID: PMC10202445 DOI: 10.1016/j.ymgme.2023.107584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/22/2023] [Accepted: 04/14/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND CLN3 is an autosomal recessive lysosomal disorder with intracellular accumulation of ceroid-lipofuscins. CLN3 classically has onset around 4-6 years of age involving vision loss, followed by developmental regression and seizures. Symptoms are progressive and result in premature death. Because treatments are under development, here we explore magnetic resonance spectroscopy (MRS) measurements of metabolite levels in the brain as a potential objective outcome measures. METHODS Individuals with genetically confirmed CLN3 were enrolled from October 2017-November 2021 in a prospective natural history study (NCT033007304). Baseline concentrations of brain metabolites measured by MRS were compared to concurrently collected dimensional assessment measures: Vineland-3 Adaptive Behavior Composite (ABC) score, verbal intelligence quotient (VIQ), and the Physical, Capability with actual vision, and Clinical global impression of change sub-domains of the Unified Batten Disease Rating Scale (UBDRS). RESULTS 27 participants with typical CLN3 presentation (15F:12M; ages 6.0-20.7 years) completed MRS, ABC, and UBDRS; 20 (12F:8M; ages 6.5-20.7 years) also completed the VIQ assessment. N-acetyl aspartate [B(95% CI) = -0.61(-0.78;-0.45)] and glutamine/glutamate/GABA [B(95% CI) = -0.82(-1.04;-0.6)] in the parietal gray matter (PGM) decreased across the ages. The strongest correlations between MRS metabolite measurements and the clinical severity assessments were found with N-acetyl aspartate [VIQ (ρ = 0.58), Vineland-3 ABC (ρ = 0.59), UBDRS |ρ| range = (0.57;0.7)] and glutamine/glutamate/GABA [VIQ (ρ = 0.57), Vineland-3 ABC (ρ = 0.60), UBDRS |ρ| range = (0.59;0.77)] measured in the midline PGM. These correlations were accounted for when age was considered. CONCLUSIONS Based on their correlations to established assessments, NAA and glutamine/glutamate/GABA measured in the midline parietal gray matter may be useful indicators of CLN3 disease state. In a clinical trial, divergence of the MRS measurements and clinical severity markers from age may be useful as surrogate measures for treatment responses.
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Affiliation(s)
- An N Dang Do
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, USA.
| | - Eva H Baker
- Radiology and Imaging Sciences Department, Clinical Center, NIH, Bethesda, MD, USA
| | | | - Ariane G Soldatos
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA
| | - Audrey E Thurm
- National Institute of Mental Health, NIH, Bethesda, MD, USA
| | - Forbes D Porter
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, USA
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Sakti DH, Cornish EE, Fraser CL, Nash BM, Sandercoe TM, Jones MM, Rowe NA, Jamieson RV, Johnson AM, Grigg JR. Early recognition of CLN3 disease facilitated by visual electrophysiology and multimodal imaging. Doc Ophthalmol 2023:10.1007/s10633-023-09930-1. [PMID: 36964447 DOI: 10.1007/s10633-023-09930-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/07/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Neuronal ceroid lipofuscinosis is a group of neurodegenerative disorders with varying visual dysfunction. CLN3 is a subtype which commonly presents with visual decline. Visual symptomatology can be indistinct making early diagnosis difficult. This study reports ocular biomarkers of CLN3 patients to assist clinicians in early diagnosis, disease monitoring, and future therapy. METHODS Retrospective review of 5 confirmed CLN3 patients in our eye clinic. Best corrected visual acuity (BCVA), electroretinogram (ERG), ultra-widefield (UWF) fundus photography and fundus autofluorescence (FAF), and optical coherence tomography (OCT) studies were undertaken. RESULTS Five unrelated children, 4 females and 1 male, with median age of 6.2 years (4.6-11.7) at first assessment were investigated at the clinic from 2016 to 2021. Four homozygous and one heterozygous pathogenic CLN3 variants were found. Best corrected visual acuities (BCVAs) ranged from 0.18 to 0.88 logMAR at first presentation. Electronegative ERGs were identified in all patients. Bull's eye maculopathies found in all patients. Hyper-autofluorescence ring surrounding hypo-autofluorescence fovea on FAF was found. Foveal ellipsoid zone (EZ) disruptions were found in all patients with additional inner and outer retinal microcystic changes in one patient. Neurological problems noted included autism, anxiety, motor dyspraxia, behavioural issue, and psychomotor regression. CONCLUSIONS CLN3 patients presented at median age 6.2 years with visual decline. Early onset maculopathy with an electronegative ERG and variable cognitive and motor decline should prompt further investigations including neuropaediatric evaluation and genetic assessment for CLN3 disease. The structural parameters such as EZ and FAF will facilitate ocular monitoring.
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Affiliation(s)
- Dhimas H Sakti
- Save Sight Institute, Speciality of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney, Sydney Eye Hospital Campus, 8 Macquarie St, Sydney, NSW, 2001, Australia
- Department of Ophthalmology, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Elisa E Cornish
- Save Sight Institute, Speciality of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney, Sydney Eye Hospital Campus, 8 Macquarie St, Sydney, NSW, 2001, Australia
- Eye Genetics Research Unit, The Children's Hospital at Westmead, Save Sight Institute, Children's Medical Research Institute, The University of Sydney, Sydney, NSW, Australia
| | - Clare L Fraser
- Save Sight Institute, Speciality of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney, Sydney Eye Hospital Campus, 8 Macquarie St, Sydney, NSW, 2001, Australia
| | - Benjamin M Nash
- Eye Genetics Research Unit, The Children's Hospital at Westmead, Save Sight Institute, Children's Medical Research Institute, The University of Sydney, Sydney, NSW, Australia
- Sydney Genome Diagnostics, Sydney Children's Hospital Network (Westmead), Sydney, Australia
| | - Trent M Sandercoe
- Department of Ophthalmology, Sydney Children's Hospital Network (Westmead), Sydney, Australia
| | - Michael M Jones
- Department of Ophthalmology, Sydney Children's Hospital Network (Westmead), Sydney, Australia
| | - Neil A Rowe
- Department of Ophthalmology, Sydney Children's Hospital Network (Westmead), Sydney, Australia
| | - Robyn V Jamieson
- Save Sight Institute, Speciality of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney, Sydney Eye Hospital Campus, 8 Macquarie St, Sydney, NSW, 2001, Australia
- Eye Genetics Research Unit, The Children's Hospital at Westmead, Save Sight Institute, Children's Medical Research Institute, The University of Sydney, Sydney, NSW, Australia
| | - Alexandra M Johnson
- Department of Neurology, Sydney Children's Hospital, University of New South Wales, Sydney, Australia
| | - John R Grigg
- Save Sight Institute, Speciality of Clinical Ophthalmology and Eye Health, Faculty of Medicine and Health, The University of Sydney, Sydney Eye Hospital Campus, 8 Macquarie St, Sydney, NSW, 2001, Australia.
- Eye Genetics Research Unit, The Children's Hospital at Westmead, Save Sight Institute, Children's Medical Research Institute, The University of Sydney, Sydney, NSW, Australia.
- Department of Ophthalmology, Sydney Children's Hospital Network (Westmead), Sydney, Australia.
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Munesue Y, Ageyama N, Kimura N, Takahashi I, Nakayama S, Okabayashi S, Katakai Y, Koie H, Yagami KI, Ishii K, Tamaoka A, Yasutomi Y, Shimozawa N. Cynomolgus macaque model of neuronal ceroid lipofuscinosis type 2 disease. Exp Neurol 2023; 363:114381. [PMID: 36918063 DOI: 10.1016/j.expneurol.2023.114381] [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: 07/04/2022] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023]
Abstract
Neuronal ceroid lipofuscinoses (NCLs) are autosomal-recessive fatal neurodegenerative diseases that occur in children and young adults, with symptoms including ataxia, seizures and visual impairment. We report the discovery of cynomolgus macaques carrying the CLN2/TPP1 variant and our analysis of whether the macaques could be a new non-human primate model for NCL type 2 (CLN2) disease. Three cynomolgus macaques presented progressive neuronal clinical symptoms such as limb tremors and gait disturbance after about 2 years of age. Morphological analyses using brain MRI at the endpoint of approximately 3 years of age revealed marked cerebellar and cerebral atrophy of the gray matter, with sulcus dilation, gyrus thinning, and ventricular enlargement. Histopathological analyses of three affected macaques revealed severe neuronal loss and degeneration in the cerebellar and cerebral cortices, accompanied by glial activation and/or changes in axonal morphology. Neurons observed throughout the central nervous system contained autofluorescent cytoplasmic pigments, which were identified as ceroid-lipofuscin based on staining properties, and the cerebral cortex examined by transmission electron microscopy had curvilinear profiles, the typical ultrastructural pattern of CLN2. These findings are commonly observed in all forms of NCL. DNA sequencing analysis identified a homozygous single-base deletion (c.42delC) of the CLN2/TPP1 gene, resulting in a frameshifted premature stop codon. Immunohistochemical analysis showed that tissue from the affected macaques lacked a detectable signal against TPP1, the product of the CLN2/TPP1 gene. Analysis for transmission of the CLN2/TPP1 mutated gene revealed that 47 (49.5%) and 48 (50.5%) of the 95 individuals genotyped in the CLN2-affected macaque family were heterozygous carriers and homozygous wild-type individuals, respectively. Thus, we identified cynomolgus macaques as a non-human primate model of CLN2 disease. The CLN2 macaques reported here could become a useful resource for research and the development of drugs and methods for treating CLN2 disease, which involves severe symptoms in humans.
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Affiliation(s)
- Yoshiko Munesue
- Division of Clinical Medicine, Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Naohide Ageyama
- Tsukuba Primate Research Center, National Institutes of Biomedical Innovation, Health and Nutrition, 1-1 Hachimandai, Tsukuba, Ibaraki 305-0843, Japan
| | - Nobuyuki Kimura
- Tsukuba Primate Research Center, National Institutes of Biomedical Innovation, Health and Nutrition, 1-1 Hachimandai, Tsukuba, Ibaraki 305-0843, Japan; Department of Veterinary Associated Science, Faculty of Veterinary Medicine, Okayama University of Science, 1-3 Ikoinooka, Imabari, Ehime 794-8555, Japan
| | - Ichiro Takahashi
- Tsukuba Primate Research Center, National Institutes of Biomedical Innovation, Health and Nutrition, 1-1 Hachimandai, Tsukuba, Ibaraki 305-0843, Japan
| | - Shunya Nakayama
- Tsukuba Primate Research Center, National Institutes of Biomedical Innovation, Health and Nutrition, 1-1 Hachimandai, Tsukuba, Ibaraki 305-0843, Japan; Laboratory of Veterinary Physiology/Pathophysiology, Nihon University, College of Bioresource Science, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
| | - Sachi Okabayashi
- The Corporation for Production and Research of Laboratory Primates, 1-16-2 Sakura, Tsukuba, Ibaraki 305-0843, Japan
| | - Yuko Katakai
- The Corporation for Production and Research of Laboratory Primates, 1-16-2 Sakura, Tsukuba, Ibaraki 305-0843, Japan
| | - Hiroshi Koie
- Laboratory of Veterinary Physiology/Pathophysiology, Nihon University, College of Bioresource Science, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
| | - Ken-Ichi Yagami
- Laboratory Animal Resource Center, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Kazuhiro Ishii
- Division of Clinical Medicine, Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Akira Tamaoka
- Division of Clinical Medicine, Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Yasuhiro Yasutomi
- Tsukuba Primate Research Center, National Institutes of Biomedical Innovation, Health and Nutrition, 1-1 Hachimandai, Tsukuba, Ibaraki 305-0843, Japan; Department of Molecular and Experimental Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Nobuhiro Shimozawa
- Tsukuba Primate Research Center, National Institutes of Biomedical Innovation, Health and Nutrition, 1-1 Hachimandai, Tsukuba, Ibaraki 305-0843, Japan.
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Brudvig JJ, Swier VJ, Johnson TB, Cain JC, Pratt M, Rechtzigel M, Leppert H, Dang Do AN, Porter FD, Weimer JM. Glycerophosphoinositol is Elevated in Blood Samples From CLN3Δex7-8 pigs, Cln3Δex7-8 Mice, and CLN3-Affected Individuals. Biomark Insights 2022; 17:11772719221107765. [PMID: 36212622 PMCID: PMC9535353 DOI: 10.1177/11772719221107765] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/01/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction: CLN3 Batten disease is a rare pediatric neurodegenerative lysosomal disorder
caused by biallelic disease-associated variants in CLN3.
Despite decades of intense research, specific biofluid biomarkers of disease
status have not been reported, hindering clinical development of therapies.
Thus, we sought to determine whether individuals with CLN3 Batten disease
have elevated levels of specific metabolites in blood. Methods: We performed an exhaustive metabolomic screen using serum samples from a
novel minipig model of CLN3 Batten disease and validated findings in
CLN3 pig serum and CSF and Cln3 mouse
serum. We further validate biomarker candidates with a retrospective
analysis of plasma and CSF samples collected from participants in a natural
history study. Plasma samples were evaluated from 22 phenotyped individuals
with CLN3 disease, 15 heterozygous carriers, and 6 non-affected non-carriers
(NANC). Results: CLN3 pig serum samples from 4 ages exhibited large elevations in 4
glycerophosphodiester species: glycerophosphoinositol (GPI),
glycerophosphoethanolamine (GPE), glycerophosphocholine (GPC), and
glycerophosphoserine (GPS). GPI and GPE exhibited the largest elevations,
with similar elevations found in CLN3 pig CSF and
Cln3 mouse serum. In plasma samples from individuals
with CLN3 disease, glycerophosphoethanolamine and glycerophosphoinositol
were significantly elevated with glycerophosphoinositol exhibiting the
clearest separation (mean 0.1338 vs 0.04401 nmol/mL for non-affected
non-carriers). Glycerophosphoinositol demonstrated excellent sensitivity and
specificity as a biomarker, with a receiver operating characteristic area
under the curve of 0.9848 (P = .0003). Conclusions: GPE and GPI could have utility as biomarkers of CLN3 disease status. GPI, in
particular, shows consistent elevations across a diverse cohort of
individuals with CLN3. This raises the potential to use these biomarkers as
a blood-based diagnostic test or as an efficacy measure for
disease-modifying therapies.
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Affiliation(s)
- Jon J Brudvig
- Pediatrics & Rare Diseases, Sanford Research, Sioux Falls, SD, USA
- Pediatrics, University of South Dakota Sanford School of Medicine, Vermillion, SD, USA
- Discovery Science, Amicus Therapeutics, Philadelphia, PA, USA
| | - Vicki J Swier
- Pediatrics & Rare Diseases, Sanford Research, Sioux Falls, SD, USA
| | - Tyler B Johnson
- Pediatrics & Rare Diseases, Sanford Research, Sioux Falls, SD, USA
- Discovery Science, Amicus Therapeutics, Philadelphia, PA, USA
| | - Jacob C Cain
- Pediatrics & Rare Diseases, Sanford Research, Sioux Falls, SD, USA
- Discovery Science, Amicus Therapeutics, Philadelphia, PA, USA
| | - Melissa Pratt
- Pediatrics & Rare Diseases, Sanford Research, Sioux Falls, SD, USA
| | - Mitch Rechtzigel
- Pediatrics & Rare Diseases, Sanford Research, Sioux Falls, SD, USA
| | - Hannah Leppert
- Pediatrics & Rare Diseases, Sanford Research, Sioux Falls, SD, USA
| | - An N Dang Do
- Division of Translational Medicine, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Forbes D Porter
- Division of Translational Medicine, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Jill M Weimer
- Pediatrics & Rare Diseases, Sanford Research, Sioux Falls, SD, USA
- Pediatrics, University of South Dakota Sanford School of Medicine, Vermillion, SD, USA
- Discovery Science, Amicus Therapeutics, Philadelphia, PA, USA
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7
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Natural history of MRI brain volumes in patients with neuronal ceroid lipofuscinosis 3: a sensitive imaging biomarker. Neuroradiology 2022; 64:2059-2067. [PMID: 35699772 PMCID: PMC9474504 DOI: 10.1007/s00234-022-02988-9] [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: 05/25/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Grey matter (GM) atrophy due to neuronal loss is a striking feature of patients with CLN3 disease. A precise and quantitative description of disease progression is needed in order to establish an evaluation tool for current and future experimental treatments. In order to develop a quantitative marker to measure brain volume outcome, we analysed the longitudinal volumetric development of GM, white matter (WM) and lateral ventricles and correlated those with the clinical course. METHODS One hundred twenty-two MRI scans of 35 patients (21 females; 14 males; age 15.3 ± 4.8 years) with genetically confirmed CLN3 disease were performed. A three-dimensional T1-weighted sequence was acquired with whole brain coverage. Volumetric segmentation of the brain was performed with the FreeSurfer image analysis suite. The clinical severity was assessed by the Hamburg jNCL score, a disease-specific scoring system. RESULTS The volumes of supratentorial cortical GM and supratentorial WM, cerebellar GM, basal ganglia/thalamus and hippocampus significantly (r = - 0.86 to - 0.69, p < 0.0001) decreased with age, while the lateral ventricle volume increased (r = 0.68, p < 0.0001). Supratentorial WM volume correlated poorer with age (r = - 0.56, p = 0.0001). Supratentorial cortical GM volume showed the steepest (4.6% (± 0.2%)) and most uniform decrease with strongest correlation with age (r = - 0.86, p < 0.0001). In addition, a strong correlation with disease specific clinical scoring existed for the supratentorial cortical GM volume (r = 0.85, p = < 0.0001). CONCLUSION Supratentorial cortical GM volume is a sensitive parameter for assessment of disease progression even in early and late disease stages and represents a potential reliable outcome measure for evaluation of experimental therapies.
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Balagura G, Xian J, Riva A, Marchese F, Ben Zeev B, Rios L, Sirsi D, Accorsi P, Amadori E, Astrea G, Baldassari S, Beccaria F, Boni A, Budetta M, Cantalupo G, Capovilla G, Cesaroni E, Chiesa V, Coppola A, Dilena R, Faggioli R, Ferrari A, Fiorini E, Madia F, Gennaro E, Giacomini T, Giordano L, Iacomino M, Lattanzi S, Marini C, Mancardi MM, Mastrangelo M, Messana T, Minetti C, Nobili L, Papa A, Parmeggiani A, Pisano T, Russo A, Salpietro V, Savasta S, Scala M, Accogli A, Scelsa B, Scudieri P, Spalice A, Specchio N, Trivisano M, Tzadok M, Valeriani M, Vari MS, Verrotti A, Vigevano F, Vignoli A, Toonen R, Zara F, Helbig I, Striano P. Epilepsy Course and Developmental Trajectories in STXBP1-DEE. Neurol Genet 2022; 8:e676. [PMID: 35655584 PMCID: PMC9157582 DOI: 10.1212/nxg.0000000000000676] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 03/14/2022] [Indexed: 01/18/2023]
Abstract
Background and Objectives Clinical manifestations in STXBP1 developmental and epileptic encephalopathy (DEE) vary in severity and outcome, and the genotypic spectrum is diverse. We aim to trace the neurodevelopmental trajectories in individuals with STXBP1-DEE and dissect the relationship between neurodevelopment and epilepsy. Methods Retrospective standardized clinical data were collected through international collaboration. A composite neurodevelopmental score system compared the developmental trajectories in STXBP1-DEE. Results Forty-eight patients with de novo STXBP1 variants and a history of epilepsy were included (age range at the time of the study: 10 months to 35 years, mean 8.5 years). At the time of inclusion, 65% of individuals (31/48) had active epilepsy, whereas 35% (17/48) were seizure free, and 76% of those (13/17) achieved remission within the first year of life. Twenty-two individuals (46%) showed signs of developmental impairment and/or neurologic abnormalities before epilepsy onset. Age at seizure onset correlated with severity of developmental outcome and the developmental milestones achieved, with a later seizure onset associated with better developmental outcome. In contrast, age at seizure remission and epilepsy duration did not affect neurodevelopmental outcomes. Overall, we did not observe a clear genotype-phenotype correlation, but monozygotic twins with de novo STXBP1 variant showed similar phenotype and parallel disease course. Discussion The disease course in STXBP1-DEE presents with 2 main trajectories, with either early seizure remission or drug-resistant epilepsy, and a range of neurodevelopmental outcomes from mild to profound intellectual disability. Age at seizure onset is the only epilepsy-related feature associated with neurodevelopment outcome. These findings can inform future dedicated natural history studies and trial design.
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Honingh AK, Kruithof YL, Kuper WFE, van Hasselt PM, Sterkenburg PS. Towards Understanding Behaviour and Emotions of Children with CLN3 Disease (Batten Disease): Patterns, Problems and Support for Child and Family. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19105895. [PMID: 35627432 PMCID: PMC9141744 DOI: 10.3390/ijerph19105895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 02/04/2023]
Abstract
The juvenile variant of Neuronal Ceroid Lipofuscinosis (CLN3 disease/Batten disease) is a rare progressive brain disease in children and young adults, characterized by vision loss, decline in cognitive and motor capacities and epilepsy. Children with CLN3 disease often show disturbed behaviour and emotions. The aim of this study is to gain a better understanding of the behaviour and emotions of children with CLN3 disease and to examine the support that the children and their parents are receiving. A combination of qualitative and quantitative analysis was used to analyse patient files and parent interviews. Using a framework analysis approach a codebook was developed, the sources were coded and the data were analysed. The analysis resulted in overviews of (1) typical behaviour and emotions of children as a consequence of CLN3 disease, (2) the support children with CLN3 disease receive, (3) the support parents of these children receive, and (4) the problems these parents face. For a few children their visual, physical or cognitive deterioration was found to lead to specific emotions and behaviour. The quantitative analysis showed that anxiety was reported for all children. The presented overviews on support contain tacit knowledge of health care professionals that has been made explicit by this study. The overviews may provide a lead to adaptable support-modules for children with CLN3 disease and their parents.
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Affiliation(s)
- Aline K. Honingh
- Faculty of Behavioural and Movement Science, Vrije Universiteit Amsterdam, 1081 BT Amsterdam, The Netherlands;
- Correspondence:
| | - Yvonne L. Kruithof
- Special Education Visually Impaired Children, Bartiméus, 3703 AJ Zeist, The Netherlands;
| | - Willemijn F. E. Kuper
- Department of Metabolic Diseases, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Utrecht University, 3508 AB Utrecht, The Netherlands; (W.F.E.K.); (P.M.v.H.)
| | - Peter M. van Hasselt
- Department of Metabolic Diseases, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Utrecht University, 3508 AB Utrecht, The Netherlands; (W.F.E.K.); (P.M.v.H.)
| | - Paula S. Sterkenburg
- Faculty of Behavioural and Movement Science, Vrije Universiteit Amsterdam, 1081 BT Amsterdam, The Netherlands;
- Special Education Visually Impaired Children, Bartiméus, 3703 AJ Zeist, The Netherlands;
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10
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Wibbeler E, Nickel M, Schwering C, Schulz A, Mink JW. The Unified Batten Disease Rating Scale (UBDRS): Validation and reliability in an independent CLN3 disease sample. Eur J Paediatr Neurol 2022; 38:62-65. [PMID: 35427884 PMCID: PMC9879304 DOI: 10.1016/j.ejpn.2022.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/03/2022] [Accepted: 03/14/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The neuronal ceroid lipofuscinoses (NCLs) are a group of disorders characterized by neurodegeneration and intracellular accumulation of an auto-fluorescent lipopigment. Together, NCLs represent the most common cause of cerebral neurodegenerative disease in children. CLN3 disease, the classic juvenile-onset form (JNCL) due to mutations in CLN3, is characterized by progressive vision loss, epilepsy, dementia, behavioral difficulties, and motor impairment. The Unified Batten Disease Rating Scale (UBDRS) is a disease-specific rating scale that was developed to assess disease severity in 4 domains: physical, behavior, seizures, and functional capability. Validity and reliability of the UBDRS has been established in a large North American cohort of over 130 individuals. The purpose of this study was to determine whether the UBDRS is valid and reliable when tested in an independent sample. METHODS Over the course of one week, 13 individuals with genetically confirmed CLN3 disease were evaluated with the UBDRS by 5 examiners at the University Medical Center Hamburg Eppendorf (UKE). One rater (JWM), one of the developers of the UBDRS, served as the reference standard. The other 4 raters were physicians with expertise in various forms of Batten Disease. After a formal training session, 13 individuals (age 16.5 ± 5.6 yrs) were evaluated simultaneous in parallel by the 5 raters. Inter-rater reliability of the Physical subscale was assessed with Intra-class Correlation (ICC) analysis. The relationship between age and severity was assessed and compared to previously published data from the North American cohort. FINDINGS The ICC among the 5 independent raters was 0.92, demonstrating excellent inter-rater reliability. The individual correlations of each UKE rater compared to the reference standard rater were all >0.95. The average UBDRS Physical Subscale score in this sample was 28 ± 21 (mean ± SD) with a range from 1 to 61. When evaluated as a function of participant age, the slope was 3.06 points/year (R2 = 0.66). INTERPRETATION We have shown excellent interrater reliability for the UBDRS as a clinical rating scale for CLN3 disease in a sample independent from previous work. The results of this study are comparable to those published by Kwon et al., 2011 in a North American cohort showing a slope of 2.86 points per year with a 95% CI of 2.27-3.45 (N = 82). Our results demonstrate excellence inter-rater reliability after training a new group of raters and provide additional evidence for construct validity of the UBDRS. The UBDRS is a valid and reliable rating scale that can used by trained raters to assess the severity and rate of progression of CLN3 disease.
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Affiliation(s)
- Eva Wibbeler
- University Medical Center Hamburg Eppendorf (UKE), Hamburg, Germany.
| | - Miriam Nickel
- University Medical Center Hamburg Eppendorf (UKE), Hamburg, Germany
| | | | - Angela Schulz
- University Medical Center Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Jonathan W Mink
- Department of Neurology, University of Rochester, 601 Elmwood Avenue, Rochester, NY, 14642, USA
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11
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Simonati A, Williams RE. Neuronal Ceroid Lipofuscinosis: The Multifaceted Approach to the Clinical Issues, an Overview. Front Neurol 2022; 13:811686. [PMID: 35359645 PMCID: PMC8961688 DOI: 10.3389/fneur.2022.811686] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/11/2022] [Indexed: 01/04/2023] Open
Abstract
The main aim of this review is to summarize the current state-of-art in the field of childhood Neuronal Ceroid Lipofuscinosis (NCL), a group of rare neurodegenerative disorders. These are genetic diseases associated with the formation of toxic endo-lysosomal storage. Following a brief historical review of the evolution of NCL definition, a clinically-oriented approach is used describing how the early symptoms and signs affecting motor, visual, cognitive domains, and including seizures, may lead clinicians to a rapid molecular diagnosis, avoiding the long diagnostic odyssey commonly observed. We go on to focus on recent advances in NCL research and summarize contributions to knowledge of the pathogenic mechanisms underlying NCL. We describe the large variety of experimental models which have aided this research, as well as the most recent technological developments which have shed light on the main mechanisms involved in the cellular pathology, such as apoptosis and autophagy. The search for innovative therapies is described. Translation of experimental data into therapeutic approaches is being established for several of the NCLs, and one drug is now commercially available. Lastly, we show the importance of palliative care and symptomatic treatments which are still the main therapeutic interventions.
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Affiliation(s)
- Alessandro Simonati
- Departments of Surgery, Dentistry, Paediatrics, and Gynaecology, School of Medicine, University of Verona, Verona, Italy
- Department of Clinical Neuroscience, AOUI-VR, Verona, Italy
- *Correspondence: Alessandro Simonati
| | - Ruth E. Williams
- Department of Children's Neuroscience, Evelina London Children's Hospital, London, United Kingdom
- Ruth E. Williams
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Misko AL, Wood LB, DeBono M, Oberman R, Raas-Rothschild A, Grishchuk Y, Eichler F. Cross-sectional Observations on the Natural History of Mucolipidosis Type IV. Neurol Genet 2022; 8:e662. [PMID: 35425852 PMCID: PMC9005048 DOI: 10.1212/nxg.0000000000000662] [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: 09/10/2021] [Accepted: 01/04/2022] [Indexed: 11/18/2022]
Abstract
Background and Objectives Mucolipidosis type IV (MLIV) is an ultra-rare lysosomal disorder initially described as a static neurodevelopmental condition. However, patient caregivers frequently report progressive muscular hypertonicity and functional decline. We evaluated a cohort of patients with MLIV to determine whether neurologic disability correlates with age. Methods We performed a cross-sectional, observational study of 26 patients with MLIV in the United States and Israel ranging in age from 2 to 40 years. Medical history was obtained from caregivers, and patients underwent a full neurologic examination. The Brief Assessment of Motor Function (BAMF), Gross Motor Function Classification System, and modified Ashworth scales were applied. Caregivers identified developmental skills on the Oregon Project for Visually Impaired and Blind Children checklist that their child had lost the ability to perform. Results Three patients were clinically classified as mildly affected and the remaining 23 patients as typical, severely affected cases. Timing of first symptom onset ranged from 1.5 months to 8 years of age (median 7.25 months). Across typical patients, modified Ashworth scores demonstrated a positive age dependence illustrating worsening spasticity across the lifespan. Signs of extrapyramidal motor dysfunction were also qualitatively observed. In parallel, gross and fine motor function assessed with the BAMF and Gross Motor Function Classification System scales declined across age. All typical patients had restricted tongue mobility and lacked rotary jaw movement when chewing, but BAMF scores for deglutition declined only in the oldest patients. In contrast, scores for articulation were low in all patients and did not correlate with age. Finally, loss of developmental skills frequently occurred in early adolescence. Discussion This cross-sectional natural history study of MLIV demonstrates worse motor function in older patients. These data support a neurodegenerative component of MLIV that manifests as developmental regression in the second decade of life. Whether the emergence of functional decline results from the cumulative, nonlinear interactions of steadily progressive neurodegenerative processes or reflects an inflection from impaired CNS development to degeneration is uncertain. However, understanding the relationship between CNS pathology and clinical course of disease will be imperative to guiding future interventional trials and optimizing patient care.
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13
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Rare diseases - rare outcomes: Assessing communication abilities for the developmental and epileptic encephalopathies. Epilepsy Behav 2022; 128:108586. [PMID: 35158285 DOI: 10.1016/j.yebeh.2022.108586] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Developmental and epileptic encephalopathies (DEE) entail moderate to profound communication and other impairments that are poorly measured by typical clinical outcomes assessments (COA). We examined the potential of alternative approaches, specifically, the use of raw scores and COAs outside of their intended age ranges. METHODS In a cross-sectional survey, 120 parents of children with Dravet Syndrome, Lennox-Gastaut syndrome, KCNQ2-DEE, KCNB1-DEE, and SCN2A-DEE (ages 1-35 years) completed the Adaptive Behavior Assessment System-3 for ages 0-5 years, modified checklist for autism (mCHAT), communication and social behavior scales (CSBS), communication matrix (CM), and several parent-reported classifiers of communication. Adaptive Behavior Assessment System communication and social raw scores were the primary and adjunctive outcomes. Floor and ceiling effects, dispersion and convergence with related measures were assessed with appropriate parametric and nonparametric statistical techniques. RESULTS Median chronological age (CA) was 8.7 years (Interquartile range (IQR): 5.3-13.5). Adaptive Behavior Assessment Systemcommunication and social age equivalents were 12.5 months (IQR 7.5-28) and 16.5 months (IQR 9-31). Most raw scores corresponded to standardized scores indicating performance <3 standard deviations below the general population mean. Adaptive Behavior Assessment System raw scores demonstrated minimal floor and ceiling effects (<1-2.5%). In linear regression models, scores correlated with age under 6 years (communication, p = 0.001; social, p = 0.003) but significantly flattened out thereafter. Scores varied substantially by DEE group (both p < 0.001) and decreased with higher convulsive seizure frequency (communication, p = 0.01, social, p = 0.02). There was good convergence with mCHAT, CSBS, and CM scores (all r > 0.8). SIGNIFICANCE Raw scores and out-of-range COAs may provide measures that are sensitive at the very limited levels of functioning typical of profoundly impaired, older patients with DEEs. To ensure that targeted trial outcomes are responsive to meaningful change, development of these approaches will be essential to clinical trial readiness for novel therapies for rare DEEs.
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14
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Nickel M, Schulz A. Natural History Studies in NCL and Their Expanding Role in Drug Development: Experiences From CLN2 Disease and Relevance for Clinical Trials. Front Neurol 2022; 13:785841. [PMID: 35211079 PMCID: PMC8861081 DOI: 10.3389/fneur.2022.785841] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/10/2022] [Indexed: 11/18/2022] Open
Abstract
Conducting clinical trials in rare diseases is challenging. In trials that aim to use natural history control cohorts for evaluation of efficacy, lack of data on natural history of disease prolongs development of future therapies significantly. Therefore, collection of valid natural history data in clinical settings is needed to advance drug development. These data need to fulfill requirements on type of collection, quantifiable measures on the course of disease, verification and monitoring as well as compliance to strict data protection and sharing policies. Disease registries can be a source for patient data. Late-infantile CLN2 disease is characterized by rapid psychomotor decline and epilepsy. Natural-history data of 140 genotype-confirmed CLN2 patients from two independent, international cohorts were analyzed in a natural history study. Both datasets included quantitative ratings with disease-specific clinical scores. Among 41 patients for whom longitudinal assessments spanning an extended disease course were available within the DEM-CHILD DB (an international NCL disease patient database, NCT04613089), a rapid loss of motor and language abilities was documented in quantitative detail. Data showed that the course of disease in late-infantile CLN2 disease is highly predictable with regard to the loss of language and motor function and that the results were homogeneous across multiple and international sites. These data were accepted by EMA and FDA as valid natural-history controls for the evaluation of efficacy in experimental therapies for CLN2 disease and led to an expedited approval of intracerebroventricular enzyme replacement therapy with cerliponase alpha in May 2017.
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Affiliation(s)
- Miriam Nickel
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Angela Schulz
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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15
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Dang Do AN, Thurm AE, Farmer CA, Soldatos AG, Chlebowski CE, O'Reilly JK, Porter FD. Use of the Vineland-3, a measure of adaptive functioning, in CLN3. Am J Med Genet A 2021; 188:1056-1064. [PMID: 34913584 DOI: 10.1002/ajmg.a.62607] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/19/2021] [Accepted: 11/30/2021] [Indexed: 11/10/2022]
Abstract
Progressive vision loss and neurocognitive impairment are early and frequent presentations in CLN3 disease. This highlights neurodevelopmental functioning as critical to the disease, but limits the neuropsychological test repertoire. We evaluated the convergent validity of the Vineland Adaptive Behavior Scales as a potential outcome measure. In a prospective observational study of 22 individuals (female:male 11:11; 6-20 years-old) with a molecular diagnosis of CLN3, we used generalized linear models and Spearman correlations to quantify the relationship of the adaptive behavior composite (ABC) standard score with established outcomes of verbal IQ (VIQ) and disease severity (Unified Batten Disease Rating Scale, UBDRS) scores. We analyzed ABC changes in 1-year follow-up data in a subset of the same cohort (n = 17). The ABC and VIQ, both standard scores, exhibited a strong positive correlation in cross-sectional data (r = 0.81). ABC and UBDRS scores were strongly and positively correlated in cross-sectional data (rrange = 0.87-0.93). Participants' ABC scores decreased slightly over the 1-year follow-up period (mean change, 95% CI: -5.23, -2.16). The convergent validity of the Vineland-3 for use in CLN3 is supported by its relationships with the established outcomes of VIQ and UBDRS. Future longitudinal research, including replication in other cohorts and evaluation of sensitivity to change, will be important to establish utility of the Vineland-3 for monitoring change in CLN3.
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Affiliation(s)
- An N Dang Do
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - Audrey E Thurm
- National Institute of Mental Health, NIH, Bethesda, Maryland, USA
| | - Cristan A Farmer
- National Institute of Mental Health, NIH, Bethesda, Maryland, USA
| | - Ariane G Soldatos
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland, USA
| | | | - Julie K O'Reilly
- National Institute of Mental Health, NIH, Bethesda, Maryland, USA
| | - Forbes D Porter
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
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16
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Gardner E, Mole SE. The Genetic Basis of Phenotypic Heterogeneity in the Neuronal Ceroid Lipofuscinoses. Front Neurol 2021; 12:754045. [PMID: 34733232 PMCID: PMC8558747 DOI: 10.3389/fneur.2021.754045] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/20/2021] [Indexed: 12/12/2022] Open
Abstract
The neuronal ceroid lipofuscinoses (NCLs) are a group of inherited neurodegenerative disorders that affect children and adults. They share some similar clinical features and the accumulation of autofluorescent storage material. Since the discovery of the first causative genes, more than 530 mutations have been identified across 13 genes in cases diagnosed with NCL. These genes encode a variety of proteins whose functions have not been fully defined; most are lysosomal enzymes, or transmembrane proteins of the lysosome or other organelles. Many mutations in these genes are associated with a typical NCL disease phenotype. However, increasing numbers of variant disease phenotypes are being described, affecting age of onset, severity or progression, and including some distinct clinical phenotypes. This data is collated by the NCL Mutation Database which allows analysis from many perspectives. This article will summarise and interpret current knowledge and understanding of their genetic basis and phenotypic heterogeneity.
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Affiliation(s)
- Emily Gardner
- MRC Laboratory for Molecular Cell Biology and Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Sara E Mole
- MRC Laboratory for Molecular Cell Biology and Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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17
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Masten MC, Corre C, Paciorkowski AR, Vierhile A, Adams HR, Vermilion J, Zimmerman GA, Augustine EF, Mink JW. A diagnostic confidence scheme for CLN3 disease. J Inherit Metab Dis 2021; 44:1453-1462. [PMID: 34453334 PMCID: PMC9248362 DOI: 10.1002/jimd.12429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/05/2021] [Accepted: 08/25/2021] [Indexed: 11/09/2022]
Abstract
Over the past 20 years, diagnostic testing for genetic diseases has evolved, leading to variable diagnostic certainty for individuals included in long-term natural history studies. Using genotype and phenotype data from an ongoing natural history study of CLN3 disease, we developed a hierarchical diagnostic confidence scheme with three major classes: Definite, Probable, or Possible CLN3 disease. An additional level, CLN3 Disease PLUS, includes individuals with CLN3 disease plus an additional disorder with a separate etiology that substantially affects the phenotype. Within the Definite and Probable CLN3 disease classes, we further divided individuals into subclasses based on phenotype. After assigning participants to classes, we performed a blinded reclassification to assess the reliability of this scheme. A total of 134 individuals with suspected CLN3 disease were classified: 100 as Definite, 21 as Probable, and 7 as Possible. Six individuals were classified as CLN3-PLUS. Phenotypes included the classical juvenile-onset syndromic phenotype, a "vision loss only" phenotype, and an atypical syndromic phenotype. Some individuals were too young to fully classify phenotype. Test-retest reliability showed 96% agreement. We created a reliable diagnostic confidence scheme for CLN3 disease that has excellent face validity. This scheme has implications for clinical research in CLN3 and other rare genetic neurodegenerative disorders.
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Affiliation(s)
- Margaux C. Masten
- Department of Neurology, University of Rochester, Rochester, New York, USA
| | - Camille Corre
- Department of Neurology, University of Rochester, Rochester, New York, USA
| | | | - Amy Vierhile
- Department of Neurology, University of Rochester, Rochester, New York, USA
| | - Heather R. Adams
- Department of Neurology, University of Rochester, Rochester, New York, USA
| | - Jennifer Vermilion
- Department of Neurology, University of Rochester, Rochester, New York, USA
| | - Grace A. Zimmerman
- Department of Neurology, University of Rochester, Rochester, New York, USA
| | - Erika F. Augustine
- Department of Neurology, University of Rochester, Rochester, New York, USA
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Jonathan W. Mink
- Department of Neurology, University of Rochester, Rochester, New York, USA
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18
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Cotman SL, Lefrancois S. CLN3, at the crossroads of endocytic trafficking. Neurosci Lett 2021; 762:136117. [PMID: 34274435 DOI: 10.1016/j.neulet.2021.136117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/15/2021] [Accepted: 07/13/2021] [Indexed: 12/29/2022]
Abstract
The CLN3 gene was identified over two decades ago, but the primary function of the CLN3 protein remains unknown. Recessive inheritance of loss of function mutations in CLN3 are responsible for juvenile neuronal ceroid lipofuscinosis (Batten disease, or CLN3 disease), a fatal childhood onset neurodegenerative disease causing vision loss, seizures, progressive dementia, motor function loss and premature death. CLN3 is a multipass transmembrane protein that primarily localizes to endosomes and lysosomes. Defects in endocytosis, autophagy, and lysosomal function are common findings in CLN3-deficiency model systems. However, the molecular mechanisms underlying these defects have not yet been fully elucidated. In this mini-review, we will summarize the current understanding of the CLN3 protein interaction network and discuss how this knowledge is starting to delineate the molecular pathogenesis of CLN3 disease. Accumulating evidence strongly points towards CLN3 playing a role in regulation of the cytoskeleton and cytoskeletal associated proteins to tether cellular membranes, regulation of membrane complexes such as channels/transporters, and modulating the function of small GTPases to effectively mediate vesicular movement and membrane dynamics.
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Affiliation(s)
- Susan L Cotman
- Center for Genomic Medicine, Department of Neurology, Mass General Research Institute, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, United States.
| | - Stéphane Lefrancois
- Centre Armand-Frappier Santé Biotechnologie, Institut national de la recherche scientifique, Laval H7V 1B7, Canada; Department of Anatomy and Cell Biology, McGill University, Montreal H3A 0C7, Canada; Centre d'Excellence en Recherche sur les Maladies Orphelines - Fondation Courtois (CERMO-FC), Université du Québec à Montréal (UQAM), Montréal H2X 3Y7, Canada.
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Abdennadher M, Inati S, Soldatos A, Norato G, Baker EH, Thurm A, Bartolini L, Masvekar R, Theodore W, Bielekova B, Porter FD, Dang Do AN. Seizure phenotype in CLN3 disease and its relation to other neurologic outcome measures. J Inherit Metab Dis 2021; 44:1013-1020. [PMID: 33550636 PMCID: PMC9437865 DOI: 10.1002/jimd.12366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 11/12/2022]
Abstract
CLN3 disease is a pediatric neurodegenerative condition wherein seizures are common. The most common disease-causing variant is an ~1-kb deletion in CLN3. We investigated seizure phenotype in relation to genotype and to adaptive behavior, MR spectroscopy and CSF biochemical markers in a CLN3 cohort. We performed seizure phenotyping using clinical history, EEG, and the Unified Batten Disease Rating Scale (UBDRS) seizure score. We assessed correlations of seizure severity with disease severity (UBDRS capability), adaptive behavior composite score (ABC; Vineland-3), glutamate+glutamine+GABA and N-acetylaspartate+N-acetylaspartyl glutamate (MR spectroscopy), and CSF neurofilament light chain (NEFL) levels. In 20 participants, median age was 10.7 years (IQR = 7.8). Eighteen completed baseline EEG; 12 had a 1-year follow-up. Seizures were reported in 14 (8 1-kb deletion homozygotes), with median age at onset of 10.0 (IQR = 6.8). Epileptiform discharges were noted in 15 (9 homozygotes). Bilateral tonic clonic (n = 11) and nonmotor seizures (n = 7) were most common. UBDRS seizure score correlated with age (rp = 0.50; [0.08,0.77]; P = .02), UBDRS capability (rp = -0.57; [-0.81,-0.17]; P = .009) and ABC (rp = -0.66; [-0.85,-0.31]; P = .001) scores, glutamate+glutamine+GABA (rp = -0.54; [-0.80,-0.11]; P = .02) and N-acetylaspartate+N-acetylaspartyl glutamate (rp = -0.54; [-0.80,-0.11]; P = .02), and CSF NEFL (rp = 0.65; [0.29,0.85]; P = .002) levels. After controlling for age, correlations with ABC and CSF NEFL remained significant. In our CLN3 cohort, seizures and epileptiform discharges were frequent and often started by age 10 years without significant difference between genotypes. ABC and CSF NEFL correlate with UBDRS seizure score, reflecting the role of seizures in the neurodegenerative process. Longitudinal evaluations in a larger cohort are needed to confirm these findings.
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Affiliation(s)
- Myriam Abdennadher
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland, USA
- Department of Neurology, Boston Medical Center; Boston University School of Medicine, Boston, MA, USA
| | - Sara Inati
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland, USA
| | - Ariane Soldatos
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland, USA
| | - Gina Norato
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland, USA
| | - Eva H. Baker
- Radiology and Imaging Sciences Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Audrey Thurm
- National Institute of Mental Health, NIH, Bethesda, Maryland, USA
| | - Luca Bartolini
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland, USA
- Division of Pediatric Neurology, Hasbro Children’s Hospital; The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ruturaj Masvekar
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
| | - William Theodore
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland, USA
| | - Bibiana Bielekova
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland, USA
| | - Forbes D. Porter
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
| | - An N. Dang Do
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland, USA
- Correspondence: An Ngoc Dang Do, MD PhD, 10 Center Drive, MSC 1103. Bethesda, MD 20892, Phone: 301.496.8849, Fax: 301.402.0574,
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Hildenbrand H, Wickstrom J, Parks R, Zampieri C, Nguyen TT, Thurm A, Jenkins K, Alter KE, Matsubara J, Hammond D, Soldatos A, Porter FD, Dang Do AN. Characterizing upper limb function in the context of activities of daily living in CLN3 disease. Am J Med Genet A 2021; 185:1399-1413. [PMID: 33559393 DOI: 10.1002/ajmg.a.62114] [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: 10/23/2020] [Revised: 01/15/2021] [Accepted: 01/23/2021] [Indexed: 11/06/2022]
Abstract
In CLN3 disease, impairments in motor function are frequently reported to have later onset compared to visual and cognitive decline, but upper limb motor function has yet to be explored in this population. In a cohort of 22 individuals with CLN3, we used a novel application of multiple measures to (1) characterize motor function, particularly of the upper limbs, in activities of daily living (ADLs), and (2) explore associations between motor function and age as well as visual ability, disease severity, and cognitive function, as evaluated by the Unified Batten Disease Rating Scale (UBDRS), a validated CLN3 disease measure. ADLs that required coordination, speed, and fine motor control were particularly challenging for children with CLN3 based on item-level performance across direct assessments (Jebsen-Taylor Hand Function Test [JTHFT] and MyoSet Tools) and caregiver reports (Pediatric Evaluation of Disability Inventory-Computer Adaptive Testing [PEDI-CAT] and Patient-Reported Outcomes Measurement Information System [PROMIS] Pediatric Upper Extremity). Poorer visual ability, disease severity, and cognitive function were associated with worse performance on these measures, whereas age had limited impact. These findings support the need for children with CLN3 to receive skilled clinical evaluation and treatment tailored to their individual needs, particularly in the context of ADLs, as their symptom profile progresses.
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Affiliation(s)
- Hanna Hildenbrand
- Department of Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Jordan Wickstrom
- Department of Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Rebecca Parks
- Department of Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Cris Zampieri
- Department of Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Thuy-Tien Nguyen
- Department of Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Audrey Thurm
- Neurodevelopmental and Behavioral Phenotyping Service, National Institutes of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Kisha Jenkins
- Office of the Clinical Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Katharine E Alter
- Department of Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Jesse Matsubara
- Department of Rehabilitation Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Dylan Hammond
- Office of the Clinical Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Ariane Soldatos
- Pediatric Neurology Consultation Service, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Forbes D Porter
- Office of the Clinical Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - An N Dang Do
- Office of the Clinical Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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21
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Spitz MA, Severac F, Obringer C, Baer S, Le May N, Calmels N, Laugel V. Diagnostic and severity scores for Cockayne syndrome. Orphanet J Rare Dis 2021; 16:63. [PMID: 33536051 PMCID: PMC7860636 DOI: 10.1186/s13023-021-01686-8] [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: 10/21/2020] [Accepted: 01/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background Cockayne syndrome is a progressive multisystem genetic disorder linked to defective DNA repair and transcription. This rare condition encompasses a very wide spectrum of clinical severity levels ranging from severe prenatal onset to mild adult-onset subtypes. The rarity, complexity and variability of the disease make early diagnosis and severity assessment difficult. Based on similar approaches in other neurodegenerative disorders, we propose to validate diagnostic and severity scores for Cockayne syndrome. Methods Clinical, imaging and genetic data were retrospectively collected from 69 molecularly confirmed CS patients. A clinical diagnostic score and a clinical-radiological diagnostic score for CS were built using a multivariable logistic regression model with a stepwise variable selection procedure. A severity score for CS was designed on five items (head circumference, growth failure, neurosensorial signs, motor autonomy, communication skills) and validated by comparison with classical predefined severity subtypes of CS. Results Short stature, enophtalmos, hearing loss, cataracts, cutaneous photosensitivity, frequent dental caries, enamel hypoplasia, morphological abnormalities of the teeth, areflexia and spasticity were included in the clinical diagnostic score as being the most statistically relevant criteria. Appropriate weights and thresholds were assigned to obtain optimal sensitivity and specificity (95.7% and 86.4% respectively). The severity score was shown to be able to quantitatively differentiate classical predefined subtypes of CS and confirmed the continuous distribution of the clinical presentations in CS. Longitudinal follow-up of the severity score was able to reflect the natural course of the disease. Conclusion The diagnostic and severity scores for CS will facilitate early diagnosis and longitudinal evaluation of future therapeutic interventions. Prospective studies will be needed to confirm these findings.
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Affiliation(s)
- M A Spitz
- Service de Pédiatrie Spécialisée et Générale, Unité de Neurologie Pédiatrique, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - F Severac
- Groupe Méthode en Recherche Clinique, Service de Santé Publique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Laboratoire de Biostatistique et d'Informatique Médicale, ICube, UMR 7357, Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - C Obringer
- Laboratoire de Génétique Médicale, Institut de Génétique Médicale d'Alsace, Faculté de Médecine de Strasbourg, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - S Baer
- Service de Pédiatrie Spécialisée et Générale, Unité de Neurologie Pédiatrique, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - N Le May
- Laboratoire de Génétique Médicale, Institut de Génétique Médicale d'Alsace, Faculté de Médecine de Strasbourg, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - N Calmels
- Laboratoire de Diagnostic Génétique, Institut de Génétique Médicale d'Alsace, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - V Laugel
- Service de Pédiatrie Spécialisée et Générale, Unité de Neurologie Pédiatrique, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France. .,Laboratoire de Génétique Médicale, Institut de Génétique Médicale d'Alsace, Faculté de Médecine de Strasbourg, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
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Aylward SC, Pindrik J, Abreu NJ, Cherny WB, O’Neal M, de Los Reyes E. Cerliponase alfa for CLN2 disease, a promising therapy. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1856654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Shawn C. Aylward
- Department of Pediatrics and Neurology, Nationwide Children‘s Hospital, Columbus, OH, USA
| | - Jonathan Pindrik
- Division of Pediatric Neurosurgery, Nationwide Children‘s Hospital, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University, Columbus, OH, USA
| | - Nicolas J. Abreu
- Department of Pediatrics and Neurology, Nationwide Children‘s Hospital, Columbus, OH, USA
| | - W. Bruce Cherny
- Department of Pediatric Neurosurgery, St. Luke‘s Children‘s Hospital, Boise, ID, USA
| | - Matthew O’Neal
- Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Emily de Los Reyes
- Department of Pediatrics and Neurology, Nationwide Children‘s Hospital, Columbus, OH, USA
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23
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Dulz S, Atiskova Y, Wibbeler E, Wildner J, Wagenfeld L, Schwering C, Nickel M, Bartsch U, Spitzer MS, Schulz A. An Ophthalmic Rating Scale to Assess Ocular Involvement in Juvenile CLN3 Disease. Am J Ophthalmol 2020; 220:64-71. [PMID: 32707205 DOI: 10.1016/j.ajo.2020.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE Juvenile CLN3 disease, the most prevalent form of Batten disease, is a progressive neurodegenerative disorder resulting from mutations in the CLN3 gene. The objective of this study was to design an ophthalmic rating scale for CLN3 disease in order to quantify disease progression. DESIGN Retrospective, cross-sectional study. METHODS Patients underwent ophthalmic evaluations including visual testing, optical coherence tomography and fundus imaging. Patients were also assessed using the Hamburg Juvenile Neuronal Ceroid Lipofuscinosis (JNCL) scoring system. Ophthalmic findings were divided into grades of severity ranging from 0 to 3, and the association between the extent of ocular disease and neurological function and age was assessed. RESULTS Forty-two eyes of 21 patients were included. The mean age at the time of examination was 13.2 years (range, 5.3-21.9 years). The mean ophthalmic severity grade was 2.4 (range, 0-3). The mean neurological severity score was 9.9 (range, 4-14). Ophthalmic manifestations increased in severity with increasing age of the patients (r = -0.84; P < .001), and a strong correlation was found between the CLN3 ophthalmic rating scale score and the Hamburg JNCL score (r = 0.83; P < .001). CONCLUSIONS Ophthalmic manifestations of CLN3 disease correlate closely with the severity of neurological symptoms and age of the patient. The newly established Hamburg CLN3 ophthalmic rating scale may serve as an objective marker of ocular disease severity and progression and may be valuable tool for the evaluation of novel therapeutic strategies for CLN3 disease.
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Affiliation(s)
- Simon Dulz
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Yevgeniya Atiskova
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eva Wibbeler
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Wildner
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lars Wagenfeld
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Schwering
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miriam Nickel
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Udo Bartsch
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Stephan Spitzer
- Department of Ophthalmology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Angela Schulz
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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24
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Abstract
Neuronal ceroid lipofuscinosis (NCLs) is a group of inherited neurodegenerative lysosomal storage diseases that together represent the most common cause of dementia in children. Phenotypically, patients have visual impairment, cognitive and motor decline, epilepsy, and premature death. A primary challenge is to halt and/or reverse these diseases, towards which developments in potential effective therapies are encouraging. Many treatments, including enzyme replacement therapy (for CLN1 and CLN2 diseases), stem-cell therapy (for CLN1, CLN2, and CLN8 diseases), gene therapy vector (for CLN1, CLN2, CLN3, CLN5, CLN6, CLN7, CLN10, and CLN11 diseases), and pharmacological drugs (for CLN1, CLN2, CLN3, and CLN6 diseases) have been evaluated for safety and efficacy in pre-clinical and clinical studies. Currently, cerliponase alpha for CLN2 disease is the only approved therapy for NCL. Lacking is any study of potential treatments for CLN4, CLN9, CLN12, CLN13 or CLN14 diseases. This review provides an overview of genetics for each CLN disease, and we discuss the current understanding from pre-clinical and clinical study of potential therapeutics. Various therapeutic interventions have been studied in many experimental animal models. Combination of treatments may be useful to slow or even halt disease progression; however, few therapies are unlikely to even partially reverse the disease and a complete reversal is currently improbable. Early diagnosis to allow initiation of therapy, when indicated, during asymptomatic stages is more important than ever.
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Shematorova EK, Shpakovski GV. Current Insights in Elucidation of Possible Molecular Mechanisms of the Juvenile Form of Batten Disease. Int J Mol Sci 2020; 21:ijms21218055. [PMID: 33137890 PMCID: PMC7663513 DOI: 10.3390/ijms21218055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 12/14/2022] Open
Abstract
The neuronal ceroid lipofuscinoses (NCLs) collectively constitute one of the most common forms of inherited childhood-onset neurodegenerative disorders. They form a heterogeneous group of incurable lysosomal storage diseases that lead to blindness, motor deterioration, epilepsy, and dementia. Traditionally the NCL diseases were classified according to the age of disease onset (infantile, late-infantile, juvenile, and adult forms), with at least 13 different NCL varieties having been described at present. The current review focuses on classic juvenile NCL (JNCL) or the so-called Batten (Batten-Spielmeyer-Vogt; Spielmeyer-Sjogren) disease, which represents the most common and the most studied form of NCL, and is caused by mutations in the CLN3 gene located on human chromosome 16. Most JNCL patients carry the same 1.02-kb deletion in this gene, encoding an unusual transmembrane protein, CLN3, or battenin. Accordingly, the names CLN3-related neuronal ceroid lipofuscinosis or CLN3-disease sometimes have been used for this malady. Despite excessive in vitro and in vivo studies, the precise functions of the CLN3 protein and the JNCL disease mechanisms remain elusive and are the main subject of this review. Although the CLN3 gene is highly conserved in evolution of all mammalian species, detailed analysis of recent genomic and transcriptomic data indicates the presence of human-specific features of its expression, which are also under discussion. The main recorded to date changes in cell metabolism, to some extent contributing to the emergence and progression of JNCL disease, and human-specific molecular features of CLN3 gene expression are summarized and critically discussed with an emphasis on the possible molecular mechanisms of the malady appearance and progression.
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Affiliation(s)
- Elena K. Shematorova
- Laboratory of Mechanisms of Gene Expression, Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya 16/10, 117997 Moscow, Russia;
- National Research Center “Kurchatov Institute”, 1, Academika Kurchatova pl., 123182 Moscow, Russia
| | - George V. Shpakovski
- Laboratory of Mechanisms of Gene Expression, Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya 16/10, 117997 Moscow, Russia;
- National Research Center “Kurchatov Institute”, 1, Academika Kurchatova pl., 123182 Moscow, Russia
- Correspondence: ; Tel.: +7-(495)-330-4953; Fax: +7-(495)-335-7103
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Adang LA, Gavazzi F, Jawad AF, Cusack SV, Kopin K, Peer K, Besnier C, De Simone M, De Giorgis V, Orcesi S, Fazzi E, Galli J, Shults J, Vanderver A. Development of a neurologic severity scale for Aicardi Goutières Syndrome. Mol Genet Metab 2020; 130:153-160. [PMID: 32279991 PMCID: PMC7366613 DOI: 10.1016/j.ymgme.2020.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Aicardi Goutières Syndrome (AGS) is a severe, autoinflammatory leukodystrophy characterized by global neurologic dysfunction. Our goal was to create an easy-to-apply scale relevant to the unique developmental challenges associated with AGS. METHODS All individuals were recruited through our natural history study. Individuals were classified by AGS severity as mild, moderate, or severe, and clinical encounters were assigned a composite score for neurologic function calculated from the sum of three functional classification scales. Through expert consensus, we identified 11 key items to reflect the severity of AGS across gross motor, fine motor, and cognitive skills to create the AGS Scale. There was strong interrater reliability. The AGS scale was applied across available medical records to evaluate neurologic function over time. The AGS scale was compared to performance on a standard measure of gross motor function (Gross Motor Function Measure-88, GMFM-88) and a putative diagnostic biomarker of disease, the interferon signaling gene expression score (ISG). RESULTS The AGS scale score correlated with severity classifications and the composite neurologic function scores. When retrospectively applied across our natural history study, the majority of individuals demonstrated an initial decline in function followed by stable scores. Within the first 6 months of disease, the AGS score was the most dynamic. The AGS scale correlated with performance by the GMFM-88, but did not correlate with ISG levels. CONCLUSIONS This study demonstrates the utility of the AGS scale as a multimodal tool for the assessment of neurologic function in AGS. The AGS scale correlates with clinical severity and with a more labor-intensive tool, GMFM-88. This study underscores the limitations of the ISG score as a marker of disease severity. With the AGS scale, we found that AGS neurologic severity is the most dynamic early in disease. This novel AGS scale is a promising tool to longitudinally follow neurologic function in this unique population.
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Affiliation(s)
- Laura A Adang
- Division of Neurology, Children's Hospital of Philadelphia, United States.
| | - Francesco Gavazzi
- Division of Neurology, Children's Hospital of Philadelphia, United States
| | - Abbas F Jawad
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, United States
| | - Stacy V Cusack
- Division of Occupational Therapy, Children's Hospital of Philadelphia, United States
| | - Kimberly Kopin
- Division of Physical Therapy, Children's Hospital of Philadelphia, United States
| | - Kyle Peer
- Division of Neurology, Children's Hospital of Philadelphia, United States
| | - Constance Besnier
- Division of Neurology, Children's Hospital of Philadelphia, United States
| | - Micaela De Simone
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Italy
| | - Valentina De Giorgis
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
| | - Simona Orcesi
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Pavia, Italy
| | - Elisa Fazzi
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Italy
| | - Jessica Galli
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Italy
| | - Justine Shults
- Department of Biostatistics, Perelman School of Medicine at University of Pennsylvania, United States
| | - Adeline Vanderver
- Division of Neurology, Children's Hospital of Philadelphia, United States
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Masten MC, Williams JD, Vermilion J, Adams HR, Vierhile A, Collins A, Marshall FJ, Augustine EF, Mink JW. The CLN3 Disease Staging System: A new tool for clinical research in Batten disease. Neurology 2020; 94:e2436-e2440. [PMID: 32300063 DOI: 10.1212/wnl.0000000000009454] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/03/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To develop a disease-specific staging system for CLN3 disease and to test the hypothesis that salient and discrete clinical features of CLN3 disease may be used to define disease stages by analyzed data from an 18-year-long natural history study. METHODS A proposed staging system, the CLN3 Staging System (CLN3SS), was based on salient and clinically meaningful endpoints. The relationships between stage and age, stage and Unified Batten Disease Rating Scale (UBDRS) physical severity score, and stage and UBDRS capability impairment subscale scores were determined. We used t tests to determine whether the stages were significantly different from each other on the basis of age and scores. RESULTS Data were analyzed from 322 evaluations in 108 individuals. There were significant differences among the stages based on age and severity scores. For individuals with longitudinal data, no individual reverted to a less severe stage over time. CONCLUSION The CLN3SS is a disease-specific staging system that can be used to classify individuals into specific strata based on age and disease severity. The CLN3SS has potential applications in clinical trials for cohort stratification.
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Affiliation(s)
- Margaux C Masten
- From the Departments of Neurology (M.C.M., J.D.W., J.V., H.R.A., A.V., A.C., F.J.M., E.F.A., J.W.M.), Neuroscience (J.W.M.), and Pediatrics (J.V., H.R.A., E.F.A., J.W.M.) and Center for Health and Technology (E.F.A.), University of Rochester School of Medicine and Dentistry; and University of Rochester School of Nursing (A.V.), NY.
| | - Justin D Williams
- From the Departments of Neurology (M.C.M., J.D.W., J.V., H.R.A., A.V., A.C., F.J.M., E.F.A., J.W.M.), Neuroscience (J.W.M.), and Pediatrics (J.V., H.R.A., E.F.A., J.W.M.) and Center for Health and Technology (E.F.A.), University of Rochester School of Medicine and Dentistry; and University of Rochester School of Nursing (A.V.), NY
| | - Jennifer Vermilion
- From the Departments of Neurology (M.C.M., J.D.W., J.V., H.R.A., A.V., A.C., F.J.M., E.F.A., J.W.M.), Neuroscience (J.W.M.), and Pediatrics (J.V., H.R.A., E.F.A., J.W.M.) and Center for Health and Technology (E.F.A.), University of Rochester School of Medicine and Dentistry; and University of Rochester School of Nursing (A.V.), NY
| | - Heather R Adams
- From the Departments of Neurology (M.C.M., J.D.W., J.V., H.R.A., A.V., A.C., F.J.M., E.F.A., J.W.M.), Neuroscience (J.W.M.), and Pediatrics (J.V., H.R.A., E.F.A., J.W.M.) and Center for Health and Technology (E.F.A.), University of Rochester School of Medicine and Dentistry; and University of Rochester School of Nursing (A.V.), NY
| | - Amy Vierhile
- From the Departments of Neurology (M.C.M., J.D.W., J.V., H.R.A., A.V., A.C., F.J.M., E.F.A., J.W.M.), Neuroscience (J.W.M.), and Pediatrics (J.V., H.R.A., E.F.A., J.W.M.) and Center for Health and Technology (E.F.A.), University of Rochester School of Medicine and Dentistry; and University of Rochester School of Nursing (A.V.), NY
| | - Alyssa Collins
- From the Departments of Neurology (M.C.M., J.D.W., J.V., H.R.A., A.V., A.C., F.J.M., E.F.A., J.W.M.), Neuroscience (J.W.M.), and Pediatrics (J.V., H.R.A., E.F.A., J.W.M.) and Center for Health and Technology (E.F.A.), University of Rochester School of Medicine and Dentistry; and University of Rochester School of Nursing (A.V.), NY
| | - Frederick J Marshall
- From the Departments of Neurology (M.C.M., J.D.W., J.V., H.R.A., A.V., A.C., F.J.M., E.F.A., J.W.M.), Neuroscience (J.W.M.), and Pediatrics (J.V., H.R.A., E.F.A., J.W.M.) and Center for Health and Technology (E.F.A.), University of Rochester School of Medicine and Dentistry; and University of Rochester School of Nursing (A.V.), NY
| | - Erika F Augustine
- From the Departments of Neurology (M.C.M., J.D.W., J.V., H.R.A., A.V., A.C., F.J.M., E.F.A., J.W.M.), Neuroscience (J.W.M.), and Pediatrics (J.V., H.R.A., E.F.A., J.W.M.) and Center for Health and Technology (E.F.A.), University of Rochester School of Medicine and Dentistry; and University of Rochester School of Nursing (A.V.), NY
| | - Jonathan W Mink
- From the Departments of Neurology (M.C.M., J.D.W., J.V., H.R.A., A.V., A.C., F.J.M., E.F.A., J.W.M.), Neuroscience (J.W.M.), and Pediatrics (J.V., H.R.A., E.F.A., J.W.M.) and Center for Health and Technology (E.F.A.), University of Rochester School of Medicine and Dentistry; and University of Rochester School of Nursing (A.V.), NY
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Johnson TB, Brudvig JJ, Lehtimäki KK, Cain JT, White KA, Bragge T, Rytkönen J, Huhtala T, Timm D, Vihma M, Puoliväli JT, Poutiainen P, Nurmi A, Weimer JM. A multimodal approach to identify clinically relevant biomarkers to comprehensively monitor disease progression in a mouse model of pediatric neurodegenerative disease. Prog Neurobiol 2020; 189:101789. [PMID: 32198061 DOI: 10.1016/j.pneurobio.2020.101789] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 01/21/2020] [Accepted: 03/13/2020] [Indexed: 12/24/2022]
Abstract
While research has accelerated the development of new treatments for pediatric neurodegenerative disorders, the ability to demonstrate the long-term efficacy of these therapies has been hindered by the lack of convincing, noninvasive methods for tracking disease progression both in animal models and in human clinical trials. Here, we unveil a new translational platform for tracking disease progression in an animal model of a pediatric neurodegenerative disorder, CLN6-Batten disease. Instead of looking at a handful of parameters or a single "needle in a haystack", we embrace the idea that disease progression, in mice and patients alike, is a diverse phenomenon best characterized by a combination of relevant biomarkers. Thus, we employed a multi-modal quantitative approach where 144 parameters were longitudinally monitored to allow for individual variability. We use a range of noninvasive neuroimaging modalities and kinematic gait analysis, all methods that parallel those commonly used in the clinic, followed by a powerful statistical platform to identify key progressive anatomical and metabolic changes that correlate strongly with the progression of pathological and behavioral deficits. This innovative, highly sensitive platform can be used as a powerful tool for preclinical studies on neurodegenerative diseases, and provides proof-of-principle for use as a potentially translatable tool for clinicians in the future.
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Affiliation(s)
- Tyler B Johnson
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, SD, USA
| | - Jon J Brudvig
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, SD, USA
| | | | - Jacob T Cain
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, SD, USA
| | - Katherine A White
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, SD, USA
| | - Timo Bragge
- Discovery Research Services, Charles River, Kuopio, Finland
| | - Jussi Rytkönen
- Discovery Research Services, Charles River, Kuopio, Finland
| | - Tuulia Huhtala
- Discovery Research Services, Charles River, Kuopio, Finland
| | - Derek Timm
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, SD, USA
| | - Maria Vihma
- Discovery Research Services, Charles River, Kuopio, Finland
| | | | - Pekka Poutiainen
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Antti Nurmi
- Discovery Research Services, Charles River, Kuopio, Finland.
| | - Jill M Weimer
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, SD, USA; Department of Pediatrics, Sanford School of Medicine at the University of South Dakota, Sioux Falls, SD, USA.
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29
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Rosenberg JB, Chen A, Kaminsky SM, Crystal RG, Sondhi D. Advances in the Treatment of Neuronal Ceroid Lipofuscinosis. Expert Opin Orphan Drugs 2019; 7:473-500. [PMID: 33365208 PMCID: PMC7755158 DOI: 10.1080/21678707.2019.1684258] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/21/2019] [Indexed: 12/27/2022]
Abstract
Neuronal ceroid lipofuscinoses (NCL) represent a class of neurodegenerative disorders involving defective lysosomal processing enzymes or receptors, leading to lysosomal storage disorders, typically characterized by observation of cognitive and visual impairments, epileptic seizures, ataxia, and deterioration of motor skills. Recent success of a biologic (Brineura®) for the treatment of neurologic manifestations of the central nervous system (CNS) has led to renewed interest in therapeutics for NCL, with the goal of ablating or reversing the impact of these devastating disorders. Despite complex challenges associated with CNS therapy, many treatment modalities have been evaluated, including enzyme replacement therapy, gene therapy, stem cell therapy, and small molecule pharmacotherapy. Because the clinical endpoints for the evaluation of candidate therapies are complex and often reliant on subjective clinical scales, the development of quantitative biomarkers for NCLs has become an apparent necessity for the validation of potential treatments. We will discuss the latest findings in the search for relevant biomarkers for assessing disease progression. For this review, we will focus primarily on recent pre-clinical and clinical developments for treatments to halt or cure these NCL diseases. Continued development of current therapies and discovery of newer modalities will be essential for successful therapeutics for NCL. AREAS COVERED The reader will be introduced to the NCL subtypes, natural histories, experimental animal models, and biomarkers for NCL progression; challenges and different therapeutic approaches, and the latest pre-clinical and clinical research for therapeutic development for the various NCLs. This review corresponds to the literatures covering the years from 1968 to mid-2019, but primarily addresses pre-clinical and clinical developments for the treatment of NCL disease in the last decade and as a follow-up to our 2013 review of the same topic in this journal. EXPERT OPINION Much progress has been made in the treatment of neurologic diseases, such as the NCLs, including better animal models and improved therapeutics with better survival outcomes. Encouraging results are being reported at symposiums and in the literature, with multiple therapeutics reaching the clinical trial stage for the NCLs. The potential for a cure could be at hand after many years of trial and error in the preclinical studies. The clinical development of enzyme replacement therapy (Brineura® for CLN2), immunosuppression (CellCept® for CLN3), and gene therapy vectors (for CLN1, CLN2, CLN3, and CLN6) are providing encouragement to families that have a child afflicted with NCL. We believe that successful therapies in the future may involve the combination of two or more therapeutic modalities to provide therapeutic benefit especially as the patients grow older.
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Affiliation(s)
- Jonathan B Rosenberg
- Department of Genetic Medicine, Weill Cornell Medical College, New York, New York
| | - Alvin Chen
- Department of Genetic Medicine, Weill Cornell Medical College, New York, New York
| | - Stephen M Kaminsky
- Department of Genetic Medicine, Weill Cornell Medical College, New York, New York
| | - Ronald G Crystal
- Department of Genetic Medicine, Weill Cornell Medical College, New York, New York
| | - Dolan Sondhi
- Department of Genetic Medicine, Weill Cornell Medical College, New York, New York
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30
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Wright GA, Georgiou M, Robson AG, Ali N, Kalhoro A, Holthaus SK, Pontikos N, Oluonye N, de Carvalho ER, Neveu MM, Weleber RG, Michaelides M. Juvenile Batten Disease (CLN3): Detailed Ocular Phenotype, Novel Observations, Delayed Diagnosis, Masquerades, and Prospects for Therapy. Ophthalmol Retina 2019; 4:433-445. [PMID: 31926949 PMCID: PMC7479512 DOI: 10.1016/j.oret.2019.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 12/31/2022]
Abstract
Purpose To characterize the retinal phenotype of juvenile neuronal ceroid lipofuscinosis (JNCL), highlight delayed and mistaken diagnosis, and propose an algorithm for early identification. Design Retrospective case series. Participants Eight children (5 female) with JNCL. Methods Review of clinical notes, retinal imaging including fundus autofluorescence and OCT, electroretinography (ERG), and both microscopy and molecular genetic testing. Main Outcome Measurements Demographic data, signs and symptoms, visual acuity (VA), fundus autofluorescence and OCT findings, ERG phenotype, and microscopy/molecular genetics. Results Participants presented with rapid bilateral vision loss over 1 to 18 months, with mean VA deteriorating from 0.44 logarithm of the minimum angle of resolution (logMAR) (range, 0.20–1.78 logMAR) at baseline to 1.34 logMAR (0.30 logMAR - light perception) at last follow-up. Age of onset ranged from 3 to 7 years (mean, 5.3 years). The age at diagnosis of JNCL ranged from 7 to 10 years (mean, 8.3 years). Six children displayed eccentric fixation, and 6 children had cognitive or neurologic signs at the time of diagnosis (75%). Seven patients had bilateral bull’s-eye maculopathy at presentation. Coats-like exudative vasculopathy, not previously reported in JNCL, was observed in 1 patient. OCT imaging revealed near complete loss of outer retinal layers and marked atrophy of the nerve fiber and ganglion cell layers at the central macula. An electronegative ERG was present in 4 patients (50%), but with additional a-wave reduction, there was an undetectable ERG in the remaining 4 patients. Blood film microscopy revealed vacuolated lymphocytes, and electron microscopy showed lysosomal (fingerprint) inclusions in all 8 patients. Conclusions In a young child with bilateral rapidly progressive vision loss and macular disturbance, blood film microscopy to detect vacuolated lymphocytes is a rapid, readily accessible, and sensitive screening test for JNCL. Early suspicion of JNCL can be aided by detailed directed history and high-resolution retinal imaging, with subsequent targeted microscopy/genetic testing. Early diagnosis is critical to ensure appropriate management, counseling, support, and social care for children and their families. Furthermore, although potential therapies for this group of disorders are in early-phase clinical trial, realistic expectations are that successful intervention will be most effective when initiated at the earliest stage of disease.
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Affiliation(s)
- Genevieve A Wright
- UCL Institute of Ophthalmology, University College London, London, United Kingdom; Moorfields Eye Hospital, London, United Kingdom
| | - Michalis Georgiou
- UCL Institute of Ophthalmology, University College London, London, United Kingdom; Moorfields Eye Hospital, London, United Kingdom
| | - Anthony G Robson
- UCL Institute of Ophthalmology, University College London, London, United Kingdom; Moorfields Eye Hospital, London, United Kingdom
| | - Naser Ali
- UCL Institute of Ophthalmology, University College London, London, United Kingdom; Moorfields Eye Hospital, London, United Kingdom
| | | | - Sm Kleine Holthaus
- UCL Institute of Ophthalmology, University College London, London, United Kingdom
| | - Nikolas Pontikos
- UCL Institute of Ophthalmology, University College London, London, United Kingdom; Moorfields Eye Hospital, London, United Kingdom
| | | | | | - Magella M Neveu
- UCL Institute of Ophthalmology, University College London, London, United Kingdom; Moorfields Eye Hospital, London, United Kingdom
| | - Richard G Weleber
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - Michel Michaelides
- UCL Institute of Ophthalmology, University College London, London, United Kingdom; Moorfields Eye Hospital, London, United Kingdom.
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Sleat DE, Wiseman JA, El-Banna M, Zheng H, Zhao C, Soherwardy A, Moore DF, Lobel P. Analysis of Brain and Cerebrospinal Fluid from Mouse Models of the Three Major Forms of Neuronal Ceroid Lipofuscinosis Reveals Changes in the Lysosomal Proteome. Mol Cell Proteomics 2019; 18:2244-2261. [PMID: 31501224 PMCID: PMC6823856 DOI: 10.1074/mcp.ra119.001587] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/06/2019] [Indexed: 01/06/2023] Open
Abstract
Treatments are emerging for the neuronal ceroid lipofuscinoses (NCLs), a group of similar but genetically distinct lysosomal storage diseases. Clinical ratings scales measure long-term disease progression and response to treatment but clinically useful biomarkers have yet to be identified in these diseases. We have conducted proteomic analyses of brain and cerebrospinal fluid (CSF) from mouse models of the most frequently diagnosed NCL diseases: CLN1 (infantile NCL), CLN2 (classical late infantile NCL) and CLN3 (juvenile NCL). Samples were obtained at different stages of disease progression and proteins quantified using isobaric labeling. In total, 8303 and 4905 proteins were identified from brain and CSF, respectively. We also conduced label-free analyses of brain proteins that contained the mannose 6-phosphate lysosomal targeting modification. In general, we detect few changes at presymptomatic timepoints but later in disease, we detect multiple proteins whose expression is significantly altered in both brain and CSF of CLN1 and CLN2 animals. Many of these proteins are lysosomal in origin or are markers of neuroinflammation, potentially providing clues to underlying pathogenesis and providing promising candidates for further validation.
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Affiliation(s)
- David E Sleat
- Center for Advanced Biotechnology and Medicine, Piscataway, NJ 08854; Department of Biochemistry and Molecular Biology, Robert-Wood Johnson Medical School, Rutgers Biomedical Health Sciences, Piscataway, NJ 08854.
| | | | - Mukarram El-Banna
- Center for Advanced Biotechnology and Medicine, Piscataway, NJ 08854
| | - Haiyan Zheng
- Center for Advanced Biotechnology and Medicine, Piscataway, NJ 08854
| | - Caifeng Zhao
- Center for Advanced Biotechnology and Medicine, Piscataway, NJ 08854
| | - Amenah Soherwardy
- Center for Advanced Biotechnology and Medicine, Piscataway, NJ 08854
| | - Dirk F Moore
- Department of Biostatistics, School of Public Health, Rutgers - The State University of New Jersey, Piscataway, NJ 08854
| | - Peter Lobel
- Center for Advanced Biotechnology and Medicine, Piscataway, NJ 08854; Department of Biochemistry and Molecular Biology, Robert-Wood Johnson Medical School, Rutgers Biomedical Health Sciences, Piscataway, NJ 08854.
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Adams HR, Defendorf S, Vierhile A, Mink JW, Marshall FJ, Augustine EF. A novel, hybrid, single- and multi-site clinical trial design for CLN3 disease, an ultra-rare lysosomal storage disorder. Clin Trials 2019; 16:555-560. [PMID: 31184505 DOI: 10.1177/1740774519855715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Travel burden often substantially limits the ability of individuals to participate in clinical trials. Wide geographic dispersion of individuals with rare diseases poses an additional key challenge in the conduct of clinical trials for rare diseases. Novel technologies and methods can improve access to research by connecting participants in their homes and local communities to a distant research site. For clinical trials, however, understanding of factors important for transition from traditional multi-center trial models to local participation models is limited. We sought to test a novel, hybrid, single- and multi-site clinical trial design in the context of a trial for Juvenile Neuronal Ceroid Lipofuscinosis (CLN3 disease), a very rare pediatric neurodegenerative disorder. METHODS We created a "hub and spoke" model for implementing a 22-week crossover clinical trial of mycophenolate compared with placebo, with two 8-week study arms. A single central site, the "hub," conducted screening, consent, drug dispensing, and tolerability and efficacy assessments. Each participant identified a clinician to serve as a collaborating "spoke" site to perform local safety monitoring. Study participants traveled to the hub at the beginning and end of each study arm, and to their individual spoke site in the intervening weeks. RESULTS A total of 18 spoke sites were established for 19 enrolled study participants. One potential participant was unable to identify a collaborating local site and was thus unable to participate. Study start-up required a median 6.7 months (interquartile range = 4.6-9.2 months). Only 33.3% (n = 6 of 18) of spoke site investigators had prior clinical trial experience, thus close collaboration with respect to study startup, training, and oversight was an important requirement. All but one participant completed all study visits; no study visits were missed due to travel requirements. CONCLUSIONS This study represents a step toward local trial participation for patients with rare diseases. Even in the context of close oversight, local participation models may be best suited for studies of compounds with well-understood side-effect profiles, for those with straightforward modes of administration, or for studies requiring extended follow-up periods.
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Affiliation(s)
- Heather R Adams
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA.,Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Sara Defendorf
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Amy Vierhile
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA.,Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Jonathan W Mink
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA.,Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA.,Department of Neuroscience, University of Rochester Medical Center, Rochester, NY, USA
| | - Frederick J Marshall
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Erika F Augustine
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA.,Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA.,Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
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Kuper WF, van Alfen C, van Eck L, Huijgen BC, Nieuwenhuis EE, van Brussel M, van Hasselt PM. Motor function impairment is an early sign of CLN3 disease. Neurology 2019; 93:e293-e297. [DOI: 10.1212/wnl.0000000000007773] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 03/04/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo delineate timing of motor decline in CLN3 disease.MethodsMotor function, assessed by the 6-Minute Walk Test (6MWT), was evaluated repeatedly in 15 patients with CLN3 disease, resulting in 65 test results and during one occasion in 2 control cohorts. One control cohort (n = 14) had isolated visual impairment; a second cohort (n = 12) exhibited visual impairment in combination with neurologic impairments. Based on 6MWT reference values in healthy sighted children, z scores of 6MWT results in patients with CLN3 disease and control cohort individuals were calculated. 6MWT results were correlated with age—including multilevel modeling analysis allowing assessment of imbalanced repeated measurements—and with Unified Batten Disease Rating Scale (UBDRS) scores.ResultsIn CLN3 disease, 6MWT scores were already impaired from first testing near diagnosis (mean z scores of −3.6 and −4.7 at 7 and 8 years of age, respectively). Afterwards, 6MWT scores continuously declined with age (r = −0.64, p < 0.0001) and with increasing UBDRS scores (r = −0.60, p = 0.0001), confirming correlation with disease progression. The decrease was more pronounced at a later age, as shown by the nonlinear multilevel model for 6MWT results in CLN3 disease (y = 409.18 − [0.52 × age2]). In contrast, an upward trend of 6MWT scores with age was observed in the control cohort with isolated visual impairment (r = 0.56; p = 0.04) similar to healthy, sighted children. The control cohort with additional neurologic impairments displayed a slightly decreased 6MWT walking distance independent of age.ConclusionsThe 6MWT unveils early onset of motor decline in CLN3 disease.
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Johnson TB, Cain JT, White KA, Ramirez-Montealegre D, Pearce DA, Weimer JM. Therapeutic landscape for Batten disease: current treatments and future prospects. Nat Rev Neurol 2019; 15:161-178. [PMID: 30783219 PMCID: PMC6681450 DOI: 10.1038/s41582-019-0138-8] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Batten disease (also known as neuronal ceroid lipofuscinoses) constitutes a family of devastating lysosomal storage disorders that collectively represent the most common inherited paediatric neurodegenerative disorders worldwide. Batten disease can result from mutations in 1 of 13 genes. These mutations lead to a group of diseases with loosely overlapping symptoms and pathology. Phenotypically, patients with Batten disease have visual impairment and blindness, cognitive and motor decline, seizures and premature death. Pathologically, Batten disease is characterized by lysosomal accumulation of autofluorescent storage material, glial reactivity and neuronal loss. Substantial progress has been made towards the development of effective therapies and treatments for the multiple forms of Batten disease. In 2017, cerliponase alfa (Brineura), a tripeptidyl peptidase enzyme replacement therapy, became the first globally approved treatment for CLN2 Batten disease. Here, we provide an overview of the promising therapeutic avenues for Batten disease, highlighting current FDA-approved clinical trials and prospective future treatments.
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Affiliation(s)
- Tyler B Johnson
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, SD, USA
| | - Jacob T Cain
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, SD, USA
| | - Katherine A White
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, SD, USA
| | | | - David A Pearce
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, SD, USA.
- Department of Pediatrics, Sanford School of Medicine at the University of South Dakota, Sioux Falls, SD, USA.
| | - Jill M Weimer
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, SD, USA.
- Department of Pediatrics, Sanford School of Medicine at the University of South Dakota, Sioux Falls, SD, USA.
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35
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Mitchell NL, Russell KN, Wellby MP, Wicky HE, Schoderboeck L, Barrell GK, Melzer TR, Gray SJ, Hughes SM, Palmer DN. Longitudinal In Vivo Monitoring of the CNS Demonstrates the Efficacy of Gene Therapy in a Sheep Model of CLN5 Batten Disease. Mol Ther 2018; 26:2366-2378. [PMID: 30078766 PMCID: PMC6171082 DOI: 10.1016/j.ymthe.2018.07.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 07/08/2018] [Accepted: 07/12/2018] [Indexed: 02/03/2023] Open
Abstract
Neuronal ceroid lipofuscinoses (NCLs; Batten disease) are neurodegenerative lysosomal storage diseases predominantly affecting children. Single administration of brain-directed lentiviral or recombinant single-stranded adeno-associated virus 9 (ssAAV9) vectors expressing ovine CLN5 into six pre-clinically affected sheep with a naturally occurring CLN5 NCL resulted in long-term disease attenuation. Treatment efficacy was demonstrated by non-invasive longitudinal in vivo monitoring developed to align with assessments used in human medicine. The treated sheep retained neurological and cognitive function, and one ssAAV9-treated animal has been retained and is now 57 months old, almost triple the lifespan of untreated CLN5-affected sheep. The onset of visual deficits was much delayed. Computed tomography and MRI showed that brain structures and volumes remained stable. Because gene therapy in humans is more likely to begin after clinical diagnosis, self-complementary AAV9-CLN5 was injected into the brain ventricles of four 7-month-old affected sheep already showing early clinical signs in a second trial. This also halted disease progression beyond their natural lifespan. These findings demonstrate the efficacy of CLN5 gene therapy, using three different vector platforms, in a large animal model and, thus, the prognosis for human translation.
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Affiliation(s)
- Nadia L Mitchell
- Department of Molecular Biosciences, Faculty of Agriculture and Life Sciences, Lincoln University, Lincoln 7647, New Zealand; Department of Radiology, University of Otago, Christchurch 8140, New Zealand
| | - Katharina N Russell
- Department of Molecular Biosciences, Faculty of Agriculture and Life Sciences, Lincoln University, Lincoln 7647, New Zealand
| | - Martin P Wellby
- Department of Molecular Biosciences, Faculty of Agriculture and Life Sciences, Lincoln University, Lincoln 7647, New Zealand
| | - Hollie E Wicky
- Department of Biochemistry, Brain Health Research Centre, University of Otago, Dunedin 9054, New Zealand
| | - Lucia Schoderboeck
- Department of Biochemistry, Brain Health Research Centre, University of Otago, Dunedin 9054, New Zealand
| | - Graham K Barrell
- Department of Molecular Biosciences, Faculty of Agriculture and Life Sciences, Lincoln University, Lincoln 7647, New Zealand
| | - Tracy R Melzer
- Department of Medicine, University of Otago, Christchurch 8140, New Zealand
| | - Steven J Gray
- Gene Therapy Center and Department of Ophthalmology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Stephanie M Hughes
- Department of Biochemistry, Brain Health Research Centre, University of Otago, Dunedin 9054, New Zealand
| | - David N Palmer
- Department of Molecular Biosciences, Faculty of Agriculture and Life Sciences, Lincoln University, Lincoln 7647, New Zealand; Department of Radiology, University of Otago, Christchurch 8140, New Zealand.
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Timm D, Cain JT, Geraets RD, White KA, Koh SY, Kielian T, Pearce DA, Hastings ML, Weimer JM. Searching for novel biomarkers using a mouse model of CLN3-Batten disease. PLoS One 2018; 13:e0201470. [PMID: 30086172 PMCID: PMC6080763 DOI: 10.1371/journal.pone.0201470] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 07/16/2018] [Indexed: 12/11/2022] Open
Abstract
CLN3-Batten disease is a rare, autosomal recessive disorder involving seizures, visual, motor and cognitive decline, and premature death. The Cln3Δex7/8 mouse model recapitulates several phenotypic characteristics of the most common 1.02kb disease-associated deletion. Identification of reproducible biomarker(s) to facilitate longitudinal monitoring of disease progression and provide readouts for therapeutic response has remained elusive. One factor that has complicated the identification of suitable biomarkers in this mouse model has been that variations in animal husbandry appear to significantly influence readouts. In the current study, we cross-compared a number of biological parameters in blood from Cln3Δex7/8 mice and control, non-disease mice on the same genetic background from multiple animal facilities in an attempt to better define a surrogate marker of CLN3-Batten disease. Interestingly, we found that significant differences between Batten and non-disease mice found at one site were generally not maintained across different facilities. Our results suggest that colony variation in the Cln3Δex7/8 mouse model of CLN3-Batten disease can influence potential biomarkers of the disease.
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Affiliation(s)
- Derek Timm
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Jacob T. Cain
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Ryan D. Geraets
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, South Dakota, United States of America
- The University of South Dakota, Sioux Falls, South Dakota, United States of America
| | - Katherine A. White
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Seung yon Koh
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, South Dakota, United States of America
| | - Tammy Kielian
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - David A. Pearce
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, South Dakota, United States of America
- The University of South Dakota, Sioux Falls, South Dakota, United States of America
| | - Michelle L. Hastings
- Center for Genetic Disease, Department of Cell Biology and Anatomy, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, United States of America
| | - Jill M. Weimer
- Pediatrics and Rare Diseases Group, Sanford Research, Sioux Falls, South Dakota, United States of America
- The University of South Dakota, Sioux Falls, South Dakota, United States of America
- * E-mail:
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Mink JW. Natural history data for childhood neurodegenerative disease. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:547-548. [PMID: 30119709 DOI: 10.1016/s2352-4642(18)30210-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 06/25/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Jonathan W Mink
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, USA.
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Short-Term Administration of Mycophenolate Is Well-Tolerated in CLN3 Disease (Juvenile Neuronal Ceroid Lipofuscinosis). JIMD Rep 2018; 43:117-124. [PMID: 29923092 DOI: 10.1007/8904_2018_113] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/09/2018] [Accepted: 05/08/2018] [Indexed: 12/13/2022] Open
Abstract
Mycophenolate, an immunosuppressant, is commonly used off-label for autoimmune neurological conditions. In CLN3 disease, a neurodegenerative disorder of childhood, preclinical and clinical data suggest secondary autoimmunity and inflammation throughout the central nervous system are key components of pathogenesis. We tested the short-term tolerability of mycophenolate in individuals with CLN3 disease, in preparation for possible long-term efficacy trials of this drug. We conducted a randomized, double-blind, placebo-controlled, crossover study of mycophenolate in 19 ambulatory individuals with CLN3 disease to determine the safety and tolerability of short-term administration (NCT01399047). The study included two 8-week treatment periods with a 4-week intervening washout. Mycophenolate was well tolerated. 89.5% of participants completed the mycophenolate arm, on the assigned study dose (95% CI: 66.9-98.7%), and there were no significant differences in tolerability rates between mycophenolate and placebo arms (10.5%; 95% CI: -3.3-24.3%, p = 0.21). All reported adverse events were mild in severity; the most common adverse events on mycophenolate were vomiting (31.6%; 95% CI: 12.6-56.6%), diarrhea (15.8%; 95% CI: 3.4-39.6%), and cough (15.8%; 95% CI: 3.4-39.6%). These did not occur at a significantly increased frequency above placebo. There were no definite effects on measured autoimmunity or clinical outcomes in the setting of short-term administration. Study of long-term exposure is needed to test the impact of mycophenolate on key clinical features and CLN3 disease trajectory.
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Cavalca E, Cesani M, Gifford JC, Sena-Esteves M, Terreni MR, Leoncini G, Peviani M, Biffi A. Metallothioneins are neuroprotective agents in lysosomal storage disorders. Ann Neurol 2018; 83:418-432. [DOI: 10.1002/ana.25161] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 11/07/2017] [Accepted: 01/24/2018] [Indexed: 12/23/2022]
Affiliation(s)
- Eleonora Cavalca
- Gene Therapy Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center; Boston MA
- Vita Salute San Raffaele University; Milan Italy
- San Raffaele Telethon Institute for Gene Therapy; San Raffaele Scientific Institute; Milan Italy
| | - Martina Cesani
- San Raffaele Telethon Institute for Gene Therapy; San Raffaele Scientific Institute; Milan Italy
| | - Jennifer C. Gifford
- Department of Neurology and Horae Gene Therapy Center; University of Massachusetts Medical School; Worcester MA
| | - Miguel Sena-Esteves
- Department of Neurology and Horae Gene Therapy Center; University of Massachusetts Medical School; Worcester MA
| | | | - Giuseppe Leoncini
- Pathology Department; San Raffaele Scientific Institute; Milan Italy
| | - Marco Peviani
- Gene Therapy Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center; Boston MA
| | - Alessandra Biffi
- Gene Therapy Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center; Boston MA
- San Raffaele Telethon Institute for Gene Therapy; San Raffaele Scientific Institute; Milan Italy
- Harvard Medical School; Boston MA
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40
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Cox GF. The art and science of choosing efficacy endpoints for rare disease clinical trials. Am J Med Genet A 2018; 176:759-772. [PMID: 29423972 DOI: 10.1002/ajmg.a.38629] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 01/17/2018] [Indexed: 12/17/2022]
Abstract
An important challenge in rare disease clinical trials is to demonstrate a clinically meaningful and statistically significant response to treatment. Selecting the most appropriate and sensitive efficacy endpoints for a treatment trial is part art and part science. The types of endpoints should align with the stage of development (e.g., proof of concept vs. confirmation of clinical efficacy). The patient characteristics and disease stage should reflect the treatment goal of improving disease manifestations or preventing disease progression. For rare diseases, regulatory approval requires demonstration of clinical benefit, defined as how a patient, feels, functions, or survives, in at least one adequate and well-controlled pivotal study conducted according to Good Clinical Practice. In some cases, full regulatory approval can occur using a validated surrogate biomarker, while accelerated, or provisional, approval can occur using a biomarker that is likely to predict clinical benefit. Rare disease studies are small by necessity and require the use of endpoints with large effect sizes to demonstrate statistical significance. Understanding the quantitative factors that determine effect size and its impact on powering the study with an adequate sample size is key to the successful choice of endpoints. Interpreting the clinical meaningfulness of an observed change in an efficacy endpoint can be justified by statistical methods, regulatory precedence, and clinical context. Heterogeneous diseases that affect multiple organ systems may be better accommodated by endpoints that assess mean change across multiple endpoints within the same patient rather than mean change in an individual endpoint across all patients.
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Affiliation(s)
- Gerald F Cox
- Editas Medicine, Cambridge, Massachusetts.,Division of Genetics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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41
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Sleat DE, Tannous A, Sohar I, Wiseman JA, Zheng H, Qian M, Zhao C, Xin W, Barone R, Sims KB, Moore DF, Lobel P. Proteomic Analysis of Brain and Cerebrospinal Fluid from the Three Major Forms of Neuronal Ceroid Lipofuscinosis Reveals Potential Biomarkers. J Proteome Res 2017; 16:3787-3804. [PMID: 28792770 DOI: 10.1021/acs.jproteome.7b00460] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Clinical trials have been conducted for the neuronal ceroid lipofuscinoses (NCLs), a group of neurodegenerative lysosomal diseases that primarily affect children. Whereas clinical rating systems will evaluate long-term efficacy, biomarkers to measure short-term response to treatment would be extremely valuable. To identify candidate biomarkers, we analyzed autopsy brain and matching CSF samples from controls and three genetically distinct NCLs due to deficiencies in palmitoyl protein thioesterase 1 (CLN1 disease), tripeptidyl peptidase 1 (CLN2 disease), and CLN3 protein (CLN3 disease). Proteomic and biochemical methods were used to analyze lysosomal proteins, and, in general, we find that changes in protein expression compared with control were most similar between CLN2 disease and CLN3 disease. This is consistent with previous observations of biochemical similarities between these diseases. We also conducted unbiased proteomic analyses of CSF and brain using isobaric labeling/quantitative mass spectrometry. Significant alterations in protein expression were identified in each NCL, including reduced STXBP1 in CLN1 disease brain. Given the confounding variable of post-mortem changes, additional validation is required, but this study provides a useful starting set of candidate NCL biomarkers for further evaluation.
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Affiliation(s)
- David E Sleat
- Center for Advanced Biotechnology and Medicine , Piscataway, New Jersey 08854, United States.,Department of Biochemistry and Molecular Biology, Robert-Wood Johnson Medical School, Rutgers Biomedical Health Sciences , Piscataway, New Jersey 08854, United States
| | - Abla Tannous
- Center for Advanced Biotechnology and Medicine , Piscataway, New Jersey 08854, United States
| | - Istvan Sohar
- Center for Advanced Biotechnology and Medicine , Piscataway, New Jersey 08854, United States
| | - Jennifer A Wiseman
- Center for Advanced Biotechnology and Medicine , Piscataway, New Jersey 08854, United States
| | - Haiyan Zheng
- Center for Advanced Biotechnology and Medicine , Piscataway, New Jersey 08854, United States
| | - Meiqian Qian
- Center for Advanced Biotechnology and Medicine , Piscataway, New Jersey 08854, United States
| | - Caifeng Zhao
- Center for Advanced Biotechnology and Medicine , Piscataway, New Jersey 08854, United States
| | - Winnie Xin
- Neurogenetics DNA Diagnostic Laboratory, Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, Massachusetts 02115, United States
| | - Rosemary Barone
- Neurogenetics DNA Diagnostic Laboratory, Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, Massachusetts 02115, United States
| | - Katherine B Sims
- Neurogenetics DNA Diagnostic Laboratory, Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, Massachusetts 02115, United States
| | - Dirk F Moore
- Department of Biostatistics, School of Public Health, Rutgers - The State University of New Jersey , Piscataway, New Jersey 08854, United States
| | - Peter Lobel
- Center for Advanced Biotechnology and Medicine , Piscataway, New Jersey 08854, United States.,Department of Biochemistry and Molecular Biology, Robert-Wood Johnson Medical School, Rutgers Biomedical Health Sciences , Piscataway, New Jersey 08854, United States
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42
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Nelvagal HR, Cooper JD. Translating preclinical models of neuronal ceroid lipofuscinosis: progress and prospects. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1360182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Hemanth R. Nelvagal
- Pediatric Storage Disorders Laboratory, Division of Medical Genetics, Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine, UCLA, Torrance, CA, USA
| | - Jonathan D. Cooper
- Pediatric Storage Disorders Laboratory, Division of Medical Genetics, Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine, UCLA, Torrance, CA, USA
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43
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Mole SE. The value of a comprehensive natural history in late infantile CLN5 disease. Dev Med Child Neurol 2017; 59:777-778. [PMID: 28556060 DOI: 10.1111/dmcn.13472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sara E Mole
- MRC Laboratory for Molecular Cell Biology, Department of Genetics, Evolution and Environment & UCL GOSH Institute of Child Health, University College London, London, UK
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44
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Ostergaard JR. Juvenile neuronal ceroid lipofuscinosis (Batten disease): current insights. Degener Neurol Neuromuscul Dis 2016; 6:73-83. [PMID: 30050370 PMCID: PMC6053093 DOI: 10.2147/dnnd.s111967] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The present review is focused on juvenile neuronal ceroid lipofuscinosis (JNCL; Batten disease) due to a mutation in CLN3. Functional vision impairment occurring around 5-6 years of age is the first symptom in more than 80% of patients. Approximately 2 years later (though sometimes simultaneously), obvious signs of cognitive impairment appear. Behavior problems can occur in advance, especially in boys. These include anxious and depressed mood, aggressive behavior, and hallucinations, and even psychotic symptoms. Following the teens, severe dementia is present, including loss of memory, attention, and general reasoning abilities, as well as loss of independent adaptive skills such as mobility, feeding, and communicating. Sleep abnormalities, such as settling problems, nocturnal awakenings, and nightmares, are reported in more than half of patients. The vast majority, if not all, patients develop seizures, starting at approximately 10 years of age. Generalized tonic-clonic seizure occurs as the only type of seizure in approximately half of patients, and in combination with partial seizures in a third of patients. There seems to be no difference in seizure severity according to sex or genotype, and there is great variation in seizure activity among patients. Soon after diagnosis, patients begin to have slight ataxic symptoms, and at adolescence extrapyramidal symptoms (rigidity, bradykinesia, slow steps with flexion in hips and knees) occur with increasing frequency. Chewing and swallowing difficulties emerge as well, and food intake is hampered in the late teens. Disabling periodically involuntary movements may occur as well. A progressive cardiac involvement with repolarization disturbances, ventricular hypertrophy, and sinus-node dysfunction, ultimately leading to severe bradycardia and/or other conduction abnormalities, starts in the mid-teens. Patients are usually bedridden at 20 years of age, and death usually occurs in the third decade of life.
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Affiliation(s)
- John R Ostergaard
- Department of Paediatrics, Aarhus University Hospital, Centre for Rare Diseases, Aarhus, Denmark,
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45
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Shapiro E, Bernstein J, Adams HR, Barbier AJ, Buracchio T, Como P, Delaney KA, Eichler F, Goldsmith JC, Hogan M, Kovacs S, Mink JW, Odenkirchen J, Parisi MA, Skrinar A, Waisbren SE, Mulberg AE. Neurocognitive clinical outcome assessments for inborn errors of metabolism and other rare conditions. Mol Genet Metab 2016; 118:65-9. [PMID: 27132782 PMCID: PMC4895194 DOI: 10.1016/j.ymgme.2016.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 01/03/2023]
Abstract
Well-defined and reliable clinical outcome assessments are essential for determining whether a drug provides clinically meaningful treatment benefit for patients. In 2015, FDA convened a workshop, "Assessing Neurocognitive Outcomes in Inborn Errors of Metabolism." Topics covered included special challenges of clinical studies of inborn errors of metabolism (IEMs) and other rare diseases; complexities of identifying treatment effects in the context of the dynamic processes of child development and disease progression; and the importance of natural history studies. Clinicians, parents/caregivers, and participants from industry, academia, and government discussed factors to consider when developing measures to assess treatment outcomes, as well as tools and methods that may contribute to standardizing measures. Many issues examined are relevant to the broader field of rare diseases in addition to specifics of IEMs.
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Affiliation(s)
- Elsa Shapiro
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA; Shapiro & Delaney, LLC, Mendota Heights, MN, USA.
| | - Jessica Bernstein
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.
| | - Heather R Adams
- Department of Neurology, Division of Child Neurology, University of Rochester Medical Center, Rochester, NY, USA.
| | | | - Teresa Buracchio
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.
| | - Peter Como
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, USA.
| | - Kathleen A Delaney
- Shapiro & Delaney, LLC, Mendota Heights, MN, USA; Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA.
| | - Florian Eichler
- Department of Neurology, Center for Rare Neurological Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Jonathan C Goldsmith
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.
| | - Melissa Hogan
- Saving Case & Friends, Inc., Thompson's Station, TN, USA.
| | - Sarrit Kovacs
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.
| | - Jonathan W Mink
- Department of Neurology, Division of Child Neurology, University of Rochester Medical Center, Rochester, NY, USA.
| | - Joanne Odenkirchen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Melissa A Parisi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
| | - Alison Skrinar
- Clinical Outcomes Research and Evaluation, Ultragenyx Pharmaceutical Inc., Novato, CA, USA.
| | - Susan E Waisbren
- Metabolism Program, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Andrew E Mulberg
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA.
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Hersrud SL, Geraets RD, Weber KL, Chan CH, Pearce DA. Plasma biomarkers for neuronal ceroid lipofuscinosis. FEBS J 2016; 283:459-71. [PMID: 26565144 PMCID: PMC4744155 DOI: 10.1111/febs.13593] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 10/27/2015] [Accepted: 11/06/2015] [Indexed: 12/11/2022]
Abstract
The neuronal ceroid lipofuscinoses (NCLs) are a group of neurodegenerative genetic diseases that primarily affect children and have no known cure. A unified clinical rating scale for the juvenile form of NCL has been developed, although it has not been validated in other subtypes and does not give a true measure of the pathophysiological changes occurring during disease progression. In the present study, we have identified candidate biomarkers in blood plasma of NCL disease using multiple proteomic approaches, with the aim of developing a panel of biomarkers that could serve as a metric for therapeutic response. Candidate biomarkers were identified as proteins with levels that significantly differed between patients and controls in both sample sets. The seven candidates identified have previously been associated with neurodegenerative and inflammatory diseases. Multiplex immunoassay based testing was the most efficient and effective evaluation technique and could be employed on a broad scale to track patient response to treatment.
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Affiliation(s)
- Samantha L. Hersrud
- Sanford Children’s Health Research Center, Sanford Research, Sioux Falls, SD 57104, United States
- Sanford School of Medicine, University of South Dakota, Vermillion, SD 57105, United States
| | - Ryan D. Geraets
- Sanford Children’s Health Research Center, Sanford Research, Sioux Falls, SD 57104, United States
- Sanford School of Medicine, University of South Dakota, Vermillion, SD 57105, United States
| | - Krystal L. Weber
- Sanford Children’s Health Research Center, Sanford Research, Sioux Falls, SD 57104, United States
| | - Chun-Hung Chan
- Sanford Children’s Health Research Center, Sanford Research, Sioux Falls, SD 57104, United States
| | - David A. Pearce
- Sanford Children’s Health Research Center, Sanford Research, Sioux Falls, SD 57104, United States
- Sanford School of Medicine, University of South Dakota, Vermillion, SD 57105, United States
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47
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48
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Augustine EF, Adams HR, Beck CA, Vierhile A, Kwon J, Rothberg PG, Marshall F, Block R, Dolan J, Mink JW. Standardized assessment of seizures in patients with juvenile neuronal ceroid lipofuscinosis. Dev Med Child Neurol 2015; 57:366-71. [PMID: 25387857 PMCID: PMC4610252 DOI: 10.1111/dmcn.12634] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2014] [Indexed: 11/30/2022]
Abstract
AIM To evaluate seizure phenomenology, treatment, and course in individuals with juvenile neuronal ceroid lipofuscinosis (JNCL). METHOD Data from an ongoing natural history study of JNCL were analyzed using cross-sectional and longitudinal methods. Seizures were evaluated with the Unified Batten Disease Rating Scale, a disease-specific quantitative assessment tool. RESULTS Eighty-six children (44 males, 42 females) with JNCL were assessed at an average of three annual visits (range 1-11). Eighty-six percent (n=74) experienced at least one seizure, most commonly generalized tonic-clonic, with mean age at onset of 9 years 7 months (SD 2y 10mo). Seizures were infrequent, typically occurring less often than once every 3 months, and were managed with one to two medications for most participants. Valproate (49%, n=36) and levetiracetam (41%, n=30) were the most commonly used seizure medications. Myoclonic seizures occurred infrequently (16%, n=14). Seizure severity did not vary by sex or genotype. Seizures showed mild worsening with increasing age. INTERPRETATION The neuronal ceroid lipofuscinoses (NCLs) represent a group of disorders unified by neurodegeneration and symptoms of blindness, seizures, motor impairment, and dementia. While NCLs are considered in the differential diagnosis of progressive myoclonus epilepsy, we show that myoclonic seizures are infrequent in JNCL. This highlights the NCLs as consisting of genetically distinct disorders with differing natural history.
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Affiliation(s)
- Erika F Augustine
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Heather R Adams
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Christopher A Beck
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Amy Vierhile
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Jennifer Kwon
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Paul G Rothberg
- Department of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Frederick Marshall
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Robert Block
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - James Dolan
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Jonathan W Mink
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York
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49
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Sondhi D, Rosenberg JB, Van de Graaf BG, Kaminsky SM, Crystal RG. Advances in the treatment of neuronal ceroid lipofuscinosis. Expert Opin Orphan Drugs 2013. [DOI: 10.1517/21678707.2013.852081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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50
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Abstract
The neuronal ceroid lipofuscinoses constitute one of many groups of rare childhood diseases for which disease-modifying treatments are nonexistent. Disease-specific barriers to therapeutic success include incomplete understanding of disease pathophysiology and limitations of treatments that cannot adequately cross the blood-brain barrier to access the central nervous system. Therapeutic development in the neuronal ceroid lipofuscinoses shares many challenges with other rare diseases, such as incomplete understanding of natural history to inform trial design, need for alternatives to the randomized controlled clinical trial, requirement for more sensitive outcome measures to quantify disease, limited access to resources required to mount a clinical trial (including funding), and difficulties of recruiting a small sample to participation. Solutions to these barriers will require multicenter collaboration, partnership with patient organizations, training a new generation of researchers interested in rare diseases, and leveraging existing resources.
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Affiliation(s)
- Erika F Augustine
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, NY, USA
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