Managing Gastrointestinal Symptoms Resulting from Treatment with Trofinetide for Rett Syndrome: Caregiver and Nurse Perspectives

Rett syndrome (RTT) is a rare genetic neurodevelopmental disorder mainly affecting female individuals. Trofinetide was recently approved as the first treatment for RTT, largely on the basis of results from the phase 3 LAVENDER trial, in which trofinetide showed improvements in core symptoms of RTT compared with placebo. However, gastrointestinal (GI) symptoms such as diarrhea and vomiting were commonly reported side effects, and taste was also a reported issue. The objective of this article is to describe the perspectives of five caregivers of girls in trofinetide clinical trials as well as those of three nurse trial coordinators, with a focus on management of GI symptoms of trofinetide treatment.Audio Abstract available for this article. Audio Abstract: Jane Lane provides an overview and discusses key findings of the article titled "Managing Gastrointestinal Symptoms Resulting from Treatment with Trofinetide for Rett Syndrome: Caregiver and Nurse Perspectives." (MP4 83274 KB).

Widening of the genetic and clinical spectrum of Lamb-Shaffer syndrome, a neurodevelopmental disorder due to SOX5 haploinsufficiency

PURPOSE

Lamb-Shaffer syndrome (LAMSHF) is a neurodevelopmental disorder described in just over two dozen patients with heterozygous genetic alterations involving SOX5, a gene encoding a transcription factor regulating cell fate and differentiation in neurogenesis and other discrete developmental processes. The genetic alterations described so far are mainly microdeletions. The present study was aimed at increasing our understanding of LAMSHF, its clinical and genetic spectrum, and the pathophysiological mechanisms involved.

METHODS

Clinical and genetic data were collected through GeneMatcher and clinical or genetic networks for 41 novel patients harboring various types ofSOX5 alterations. Functional consequences of selected substitutions were investigated.

RESULTS

Microdeletions and truncating variants occurred throughout SOX5. In contrast, most missense variants clustered in the pivotal SOX-specific high-mobility-group domain. The latter variants prevented SOX5 from binding DNA and promoting transactivation in vitro, whereas missense variants located outside the high-mobility-group domain did not. Clinical manifestations and severity varied among patients. No clear genotype-phenotype correlations were found, except that missense variants outside the high-mobility-group domain were generally better tolerated.

CONCLUSIONS

This study extends the clinical and genetic spectrum associated with LAMSHF and consolidates evidence that SOX5 haploinsufficiency leads to variable degrees of intellectual disability, language delay, and other clinical features.

Genetic, Phenotypic, and Interferon Biomarker Status in ADAR1-Related Neurological Disease

We investigated the genetic, phenotypic, and interferon status of 46 patients from 37 families with neurological disease due to mutations in ADAR1. The clinicoradiological phenotype encompassed a spectrum of Aicardi-Goutières syndrome, isolated bilateral striatal necrosis, spastic paraparesis with normal neuroimaging, a progressive spastic dystonic motor disorder, and adult-onset psychological difficulties with intracranial calcification. Homozygous missense mutations were recorded in five families. We observed a p.Pro193Ala variant in the heterozygous state in 22 of 23 families with compound heterozygous mutations. We also ascertained 11 cases from nine families with a p.Gly1007Arg dominant-negative mutation, which occurred de novo in four patients, and was inherited in three families in association with marked phenotypic variability. In 50 of 52 samples from 34 patients, we identified a marked upregulation of type I interferon-stimulated gene transcripts in peripheral blood, with a median interferon score of 16.99 (interquartile range [IQR]: 10.64-25.71) compared with controls (median: 0.93, IQR: 0.57-1.30). Thus, mutations in ADAR1 are associated with a variety of clinically distinct neurological phenotypes presenting from early infancy to adulthood, inherited either as an autosomal recessive or dominant trait. Testing for an interferon signature in blood represents a useful biomarker in this context.

Circadian regulation of cellular physiology

The circadian clock synchronizes behavioral and physiological processes on a daily basis in anticipation of the light-dark cycle. In mammals, molecular clocks are present in both the central pacemaker neurons and in nearly all peripheral tissues. Clock transcription factors in metabolic tissues coordinate metabolic fuel utilization and storage with alternating periods of feeding and fasting corresponding to the rest-activity cycle. In vitro and in vivo biochemical approaches have led to the discovery of mechanisms underlying the interplay between the molecular clock and the metabolic networks. For example, recent studies have demonstrated that the circadian clock controls rhythmic synthesis of the cofactor nicotinamide adenine dinucleotide (NAD(+)) and activity of NAD(+)-dependent sirtuin deacetylase enzymes to regulate mitochondrial function across the circadian cycle. In this chapter, we review current state-of-the-art methods to analyze circadian cycles in mitochondrial bioenergetics, glycolysis, and nucleotide metabolism in both cell-based and animal models.

Characterization of X chromosome inactivation using integrated analysis of whole-exome and mRNA sequencing

In females, X chromosome inactivation (XCI) is an epigenetic, gene dosage compensatory mechanism by inactivation of one copy of X in cells. Random XCI of one of the parental chromosomes results in an approximately equal proportion of cells expressing alleles from either the maternally or paternally inherited active X, and is defined by the XCI ratio. Skewed XCI ratio is suggestive of non-random inactivation, which can play an important role in X-linked genetic conditions. Current methods rely on indirect, semi-quantitative DNA methylation-based assay to estimate XCI ratio. Here we report a direct approach to estimate XCI ratio by integrated, family-trio based whole-exome and mRNA sequencing using phase-by-transmission of alleles coupled with allele-specific expression analysis. We applied this method to in silico data and to a clinical patient with mild cognitive impairment but no clear diagnosis or understanding molecular mechanism underlying the phenotype. Simulation showed that phased and unphased heterozygous allele expression can be used to estimate XCI ratio. Segregation analysis of the patient's exome uncovered a de novo, interstitial, 1.7 Mb deletion on Xp22.31 that originated on the paternally inherited X and previously been associated with heterogeneous, neurological phenotype. Phased, allelic expression data suggested an 83∶20 moderately skewed XCI that favored the expression of the maternally inherited, cytogenetically normal X and suggested that the deleterious affect of the de novo event on the paternal copy may be offset by skewed XCI that favors expression of the wild-type X. This study shows the utility of integrated sequencing approach in XCI ratio estimation.

Circadian clocks in fuel harvesting and energy homeostasis

Circadian systems have evolved in plants, eubacteria, neurospora, and the metazoa as a mechanism to optimize energy acquisition and storage in synchrony with the rotation of the Earth on its axis. In plants, circadian clocks drive the expression of genes involved in oxygenic photosynthesis during the light and nitrogen fixation during the dark, repeating this cycle each day. In mammals, the core clock in the suprachiasmatic nucleus (SCN) functions to entrain extra-SCN and peripheral clocks to the light cycle, including regions central to energy homeostasis and sleep, as well as peripheral tissues involved in glucose and lipid metabolism. Tissue-specific gene targeting has shown a primary role of clock genes in endocrine pancreas insulin secretion, indicating that local clocks play a cell-autonomous role in organismal homeostasis. A present focus is to dissect the consequences of clock disruption on modulation of nuclear hormone receptor signaling and on posttranscriptional regulation of intermediary metabolism. Experimental genetic studies have pointed toward extensive interplay between circadian and metabolic systems and offer a means to dissect the impact of local tissue molecular clocks on fuel utilization across the sleep-wake cycle.

Comparisons of risk factors for HIV-1 infection in Jefferson and Mobile County, Alabama

A study of the Alabama state AIDS database was conducted to determine whether differences exist in demographic and risk characteristics between patients with HIV-1 in Jefferson and Mobile County. The authors found that the age distribution of patients with HIV-1, the percent of those having AIDS, and the percent of those surviving were very similar. However, significant differences existed in patient-reported risk factors in the two counties. Homosexuality was reported as the major risk factor in both counties. However, there was proportionately more homosexuality reported in Jefferson County and, conversely, more heterosexuality reported in Mobile. There also were significant differences in race and gender distributions in the two counties. This was due in part to the proportionately higher prevalence of African American females of reproductive age with HIV-1 in Mobile County. This may pose a significantly greater risk for pediatric AIDS among African American females in Mobile County.

Recurrent non-0:1 Vibrio cholerae bacteremia in a patient with multiple myeloma

BACKGROUND

Episodes of bacteremia with non-0:1 Vibrio cholerae are rarely reported, even though the organism is endemic along the Gulf Coast of the United States. Recurrent episodes of bacteremia with non-0:1 V. cholerae are described even more rarely. A patient is reported who had multiple myeloma and experienced two episodes of bacteremia with non-0:1 V. cholerae.

METHODS

Hospital records and the medical literature were reviewed, and the organism was serotyped by the Alabama State Laboratory.

RESULTS

The patient had no prodromal illnesses or diarrhea with either episode of bacteremia. Treatment with empiric antibiotic therapy resulted in successful resolution of his bacteremia, which is fatal in almost 50% of reported cases in patients with malignant neoplasms.

CONCLUSIONS

This is the first reported case of non-0:1 V. cholerae bacteremia occurring in a patient with multiple myeloma. Both his initial episode and a second episode of bacteremia responded to broad-spectrum antibiotics, which are used as empiric therapy for patients with hematologic malignancies and fever. Emphasis is placed on the paucity of clinical manifestations and the need for empiric therapy for non-0:1 V. cholerae infection in patients with hematologic malignancies.

Human immunodeficiency virus infection elicits early antibody not detected by standard tests: implications for diagnostics and viral immunology

The FDA-approved tests for diagnosis of HIV exposure depend on detection of specific antibody in serum. HIV infection is missed in some individuals because they score seronegative by the standard clinical EIA and Western blot assays. This apparent immunological "silent" period following infection may last for months and has been reported to be as long as 3 years in rare cases. Is there truly a lack of an immune response or is there a more subtle, narrowly focused antibody response in these HIV-infected individuals which is not detected by the current tests? Using a nondenaturing serological assay (immunofluorescence of live infected T-cells), we found that each of four infected individuals "seronegative" by the standard tests did possess antibody against native HIV proteins expressed on infected cells. These antibodies reacting with native HIV antigenic epitopes were of the IgG isotype, they cross-reacted with many, but not all, of seven random HIV-1 isolates, and one of the sera immunoprecipitated HIV gp160 from NP-40-solubilized infected cells. These results show that seronegative, high-risk, infected individuals can actually be seropositive and that different types of assays using native antigenic epitopes may be required for screening. Implementation of these findings thus may decrease HIV transmission. These results also highlight the importance of protein conformation for many natural viral antigenic epitopes.

Viral pneumonias. A diagnostic and therapeutic challenge

Viral pneumonias are both a diagnostic and a therapeutic challenge for primary care physicians. The illness should be suspected when an upper respiratory tract infection progresses to include dyspnea and cyanosis. Rapid diagnostic tests are now available to detect most of the viruses that cause pneumonias. Fortunately, viral pneumonias usually resolve without specific antiviral therapy; however, ribavirin is indicated for respiratory syncytial virus pneumonia in children and ganciclovir sodium (Cytovene) for cytomegalovirus pneumonia in immunocompromised patients. Acyclovir (Zovirax) is indicated for pneumonias due to herpes simplex virus and varicella-zoster virus infections. A high index of suspicion for bacterial superinfections is essential to reduce the risk of death from this complication.

Heightened cutaneous reactions to mosquito bites in patients with acquired immunodeficiency syndrome receiving zidovudine

Three patients with acquired immunodeficiency syndrome noted changing cutaneous reactions to mosquito bites one to three months after starting zidovudine therapy. Enhanced T-cell function is one possibility for the heightened response to mosquito bites in these patients.

Role of marrow stromal cells in the establishment of a transformed lymphoblastic B-cell line from a normal human subject

A monoclonal human B-lymphoblastoid cell line (UTMB-460) arose spontaneously from the bone marrow of a normal healthy woman who was seropositive for an EB-virus infection. Chromosomally, the UTMB-460 cells are near tetraploid, with a specific translocation (8;9) (p11.2; p24), and have surface IgMk. The UTMB-460 cells are resistant to killing in vitro by spontaneous and rIFN alpha 2 and rIL-2 stimulated NK cells from the patient and other normal subjects, but are killed by lymphokine activated killer cells. The index patient has not developed leukemia/lymphoma during the follow-up interval of 22 months. The growth of UTMB-460 cells is supported by undefined growth factors in FCS and by BCGF in the absence of FCS. rIL-2 stimulates DNA synthesis by UTMB-460 cells. The UTMB-460 cells were adherent to the normal MSC in the primary culture and show specific heterotypic adherence to normal MSC when compared to skin fibroblasts. In addition, 6/6 normal marrow stromal cells and 4/6 normal skin fibroblasts induced growth of colonies from UTMB-460 cells. These data suggest that MSC interacted with the transformed cells (UTMB-460) in vitro and played a critical role in the establishment of the UTMB-460 cell line.

Comparative virulence and immunogenicity of the Towne strain and a nonattenuated strain of cytomegalovirus

The Towne strain cytomegalovirus and a low-passage strain, Toledo-1, were compared for virulence and immunogenicity in healthy adult male subjects to determine the suitability of the Towne strain for vaccination. Five seropositive subjects who received the Toledo-1 strain developed infections ranging in severity from laboratory abnormalities to mild mononucleosis syndromes (mean incubation, 4.7 weeks). None of the four seronegative subjects receiving the Towne strain developed systemic infection, but all developed delayed local reactions at the injection sites. All subjects developed cytotoxic lymphocyte responses specific to cytomegalovirus, usually HLA-restricted, but these were of greater magnitude and duration in the Toledo-1 recipients. The latter also developed natural killer cell and interferon responses, atypical lymphocytosis, inversion of helper/suppressor cell ratios, and depressed responses to T-cell mitogens, none of which occurred in Towne strain recipients. The results further substantiate the avirulence and immunogenicity of the Towne strain cytomegalovirus.

Decreased circulating large granular lymphocytes associated with depressed natural killer cell activity in renal transplant recipients

Renal transplant recipients (RTR) receiving prednisone and azathioprine (AZ) frequently have depressed natural killer (NK) cell activity. In humans, NK activity is mediated by the large granular lymphocyte (LGL). To determine the mechanism of depressed NK activity among RTR, we quantitated the NK activity of peripheral blood lymphocytes (PBL) and the percentage of circulating LGL in Giemsa-stained cytocentrifuge preparations of PBL from 20 RTR and 6 healthy volunteers. In addition, the PBL were incubated with 1000 U/ml IFN beta to assess augmentation of NK activity. Finally, single-cell cytotoxicity assays in agarose using highly purified LGL from our study subjects were performed to assess the ability of the LGL to bind and to kill the K562 target cells. Mean (+/- 1SD) NK activity at a 50:1 effector-to-target ratio using K562 targets was 51.2 +/- 21.8% among normals and 12.9 +/- 10.3% in RTR, and it was augmented to 60.5 +/- 13.1% and 17.5 +/- 10.3%, respectively, following interferon (IFN) exposure. Mean percentage of LGL among PBL in normals was 13.2 +/- 1.2%, and 4.0 +/- 1.7% in RTR. A significant correlation existed (R = 0.90) between NK activity and the numbers of LGL (P less than .001). In two patients, NK activity following cessation of azathioprine and prednisone increased significantly (P less than .005), and an increase of LGL from 6%-30% among PBL accompanied the increase in NK activity in one patient. Incubation with IFN boosted this patient's NK activity from 22% to 62%, suggesting the presence of circulating pre-NK cells among the LGL. There was no significant difference in the binding or killing of K562 targets by LGL in single-cell assays comparing RTR with normal controls (P greater than 0.1), indicating normal functioning LGL in our study subjects. These results indicate that decreased circulating LGL among RTR receiving AZ and prednisone is associated with depressed NK activity. The ability of IFN to augment the NK activity of RTR significantly suggests the presence of circulating pre-NK cells. Finally, the rebound of both the circulating number of LGL and the NK activity after cessation of immunosuppressive drugs suggests a direct effect of those drugs in the inhibition of NK in RTR.

Lymphokine-activated killer cell phenomenon. II. Precursor phenotype is serologically distinct from peripheral T lymphocytes, memory cytotoxic thymus-derived lymphocytes, and natural killer cells

Culture of human peripheral blood lymphocytes (PBL) in partially purified and lectin-free interleukin 2 results in the generation of cytotoxic effector cells which have the unique property of lysing natural killer (NK)-resistant fresh human tumor cells. We have termed these effector cells "lymphokine- activated killer" cells (LAK). LAK are generated from both normal and cancer patients' PBL and are able to lyse both autologous and allogeneic tumor cells from all histologic tumor types tested. Our previous studies suggested that the LAK phenomenon was distinct from either the cytotoxic thymus-derived lymphocyte (CTL) or NK systems based on a variety of criteria. This study reports that the cell type involved is also distinct, as determined by phenotypic characteristics. The LAK effector cell phenotype was analyzed in parallel with alloimmune CTL, and LAK were found to be similarly susceptible to the monoclonal anti-T cell antibodies OKT-3 or OKT-8 plus complement. In contrast the LAK precursor was not susceptible to the OKT-3 or Leu-1 antibodies plus complement, while the ability to generate alloimmune CTL was totally obliterated when tested using the same PBL responder population; in fact, generation of LAK was found to be augmented five- to sixfold, clearly suggesting that LAK precursor cells are not T lymphocytes as defined by these antibodies. LAK precursors were found to be abundant in NK cell-enriched Percoll gradient fractions, which had been depleted of the 29 degrees C E- rosetting "high affinity" T cells. However, LAK precursors were found to be distinct from the majority of NK cells since lysis of fresh PBL with the monoclonal antibodies OKM-1, Leu-7, or OKT-11 significantly depleted or totally eliminated NK activity, while subsequent activation of the remaining cells generated high levels of LAK and in some cases augmented levels of LAK. LAK precursors were found to be distributed in the thymus, bone marrow, spleen, lymph node, and thoracic duct in addition to the PBL. Therefore, while the cell(s) responsible for activation and expression of LAK activity have some common features with the classic T cell-mediated CTL and NK cell systems, the LAK precursor cells are clearly distinct as determined by phenotype analysis using monoclonal antibodies and complement, and at present must be classified as a "null" cell.