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Benatar M, Wuu J, Huey ED, McMillan CT, Petersen RC, Postuma R, McHutchison C, Dratch L, Arias JJ, Crawley A, Houlden H, McDermott MP, Cai X, Thakur N, Boxer A, Rosen H, Boeve BF, Dacks P, Cosentino S, Abrahams S, Shneider N, Lingor P, Shefner J, Andersen PM, Al-Chalabi A, Turner MR. The Miami Framework for ALS and related neurodegenerative disorders: an integrated view of phenotype and biology. Nat Rev Neurol 2024:10.1038/s41582-024-00961-z. [PMID: 38769202 DOI: 10.1038/s41582-024-00961-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/22/2024]
Abstract
Increasing appreciation of the phenotypic and biological overlap between amyotrophic lateral sclerosis (ALS) and frontotemporal dementia, alongside evolving biomarker evidence for a pre-symptomatic stage of disease and observations that this stage of disease might not always be clinically silent, is challenging traditional views of these disorders. These advances have highlighted the need to adapt ingrained notions of these clinical syndromes to include both the full phenotypic continuum - from clinically silent, to prodromal, to clinically manifest - and the expanded phenotypic spectrum that includes ALS, frontotemporal dementia and some movement disorders. The updated clinical paradigms should also align with our understanding of the biology of these disorders, reflected in measurable biomarkers. The Miami Framework, emerging from discussions at the Second International Pre-Symptomatic ALS Workshop in Miami (February 2023; a full list of attendees and their affiliations appears in the Supplementary Information) proposes a classification system built on: first, three parallel phenotypic axes - motor neuron, frontotemporal and extrapyramidal - rather than the unitary approach of combining all phenotypic elements into a single clinical entity; and second, biomarkers that reflect different aspects of the underlying pathology and biology of neurodegeneration. This framework decouples clinical syndromes from biomarker evidence of disease and builds on experiences from other neurodegenerative diseases to offer a unified approach to specifying the pleiotropic clinical manifestations of disease and describing the trajectory of emergent biomarkers.
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Affiliation(s)
- Michael Benatar
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA.
| | - Joanne Wuu
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Edward D Huey
- Department of Psychiatry and Human Behaviour, Alpert Medical School of Brown University, Providence, RI, USA
| | - Corey T McMillan
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Ronald Postuma
- Department of Neurology, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Caroline McHutchison
- Human Cognitive Neuroscience, Department of Psychology, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for MND Research, University of Edinburgh, Edinburgh, UK
| | - Laynie Dratch
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jalayne J Arias
- Department of Health Policy & Behavioral Sciences, School of Public Health, Georgia State University, Atlanta, GA, USA
| | | | - Henry Houlden
- UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | | | - Adam Boxer
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Howard Rosen
- Department of Neurology, University of California, San Francisco, CA, USA
| | | | - Penny Dacks
- Association for Frontotemporal Degeneration, King of Prussia, PA, USA
| | | | - Sharon Abrahams
- Human Cognitive Neuroscience, Department of Psychology, University of Edinburgh, Edinburgh, UK
- Euan MacDonald Centre for MND Research, University of Edinburgh, Edinburgh, UK
| | - Neil Shneider
- Department of Neurology, Columbia University, New York, NY, USA
| | - Paul Lingor
- Department of Neurology, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Jeremy Shefner
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Peter M Andersen
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
- Department of Neurology, King's College Hospital, London, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Howard J, Mazanderani F, Keenan KF, Turner MR, Locock L. Fluctuating salience in those living with genetic risk of motor neuron disease: A qualitative interview study. Health Expect 2024; 27:e14024. [PMID: 38528673 DOI: 10.1111/hex.14024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/23/2024] [Accepted: 03/12/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Motor neuron disease (MND) (also known as amyotrophic lateral sclerosis) is a life-limiting neurodegenerative condition. In up to 20% of people with MND, a pathogenic variant associated with autosomal dominant inheritance can be identified. Children of people carrying a pathogenic variant have a 50% chance of inheriting this and a higher, although harder to predict, chance of developing the disease compared to the general adult population. This paper explores the experience of living with the genetic risk of MND. METHODS We undertook a UK-based interview study with 35 individuals, including: 7 people living with genetically-mediated forms of MND; 24 asymptomatic relatives, the majority of whom had an increased risk of developing the disease; and 4 unrelated partners. RESULTS We explore how individuals make sense of genetic risk, unpacking the interplay between genetic knowledge, personal perception, experiences of the disease in the family, age and life stage and the implications that living with risk has for different aspects of their lives. We balance an emphasis on the emotional and psychological impact described by participants, with a recognition that the salience of risk fluctuates over time. Furthermore, we highlight the diverse strategies and approaches people employ to live well in the face of uncertainty and the complex ways they engage with the possibility of developing symptoms in the future. Finally, we outline the need for open-ended, tailored support and information provision. CONCLUSIONS Drawing on wider literature on genetic risk, we foreground how knowledge of MND risk can disrupt individuals' taken-for-granted assumptions on life and perceptions of the future, but also its contextuality, whereby its relevance becomes more prominent at critical junctures. This research has been used in the development of a public-facing resource on the healthtalk.org website. PATIENT OR PUBLIC CONTRIBUTION People with experience of living with genetic risk were involved throughout the design and conduct of the study and advised on aspects including the topic guide, sampling and recruitment and the developing analysis. Two patient and public involvement contributors joined a formal advisory panel.
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Affiliation(s)
- Jade Howard
- Division of Neuroscience, Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Fadhila Mazanderani
- School of Social and Political Science, Science, Technology and Innovation Studies, University of Edinburgh, Edinburgh, UK
| | | | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Louise Locock
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Turner MR. We need to talk about brain donation. Pract Neurol 2024:pn-2024-004102. [PMID: 38499333 DOI: 10.1136/pn-2024-004102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Thompson AG, Taschler B, Smith SM, Turner MR. Premorbid brain structure influences risk of amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2024; 95:360-365. [PMID: 38050140 PMCID: PMC10958375 DOI: 10.1136/jnnp-2023-332322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/25/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a disease of the motor network associated with brain structure and functional connectivity alterations that are implicated in disease progression. Whether such changes have a causal role in ALS, fitting with a postulated influence of premorbid cerebral architecture on the phenotypes associated with neurodegenerative disorders is not known. METHODS This study considered causal effects and shared genetic risk of 2240 structural and functional MRI brain scan imaging-derived phenotypes (IDPs) on ALS using two sample Mendelian randomisation, with putative associations further examined with extensive sensitivity analysis. Shared genetic predisposition between IDPs and ALS was explored using genetic correlation analysis. RESULTS Increased white matter volume in the cerebral hemispheres was causally associated with ALS. Weaker causal associations were observed for brain stem grey matter volume, parieto-occipital white matter surface and volume of the left thalamic ventral anterior nucleus. Genetic correlation was observed between ALS and intracellular volume fraction and isotropic free water volume fraction within the posterior limb of the internal capsule. CONCLUSIONS This study provides evidence that premorbid brain structure, in particular white matter volume, contributes to the risk of ALS.
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Affiliation(s)
| | - Bernd Taschler
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Stephen M Smith
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Dellar ER, Vendrell I, Talbot K, Kessler BM, Fischer R, Turner MR, Thompson AG. Data-independent acquisition proteomics of cerebrospinal fluid implicates endoplasmic reticulum and inflammatory mechanisms in amyotrophic lateral sclerosis. J Neurochem 2024; 168:115-127. [PMID: 38087504 PMCID: PMC10952667 DOI: 10.1111/jnc.16030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/29/2023] [Accepted: 12/02/2023] [Indexed: 01/26/2024]
Abstract
While unbiased proteomics of human cerebrospinal fluid (CSF) has been used successfully to identify biomarkers of amyotrophic lateral sclerosis (ALS), high-abundance proteins mask the presence of lower abundance proteins that may have diagnostic and prognostic value. However, developments in mass spectrometry (MS) proteomic data acquisition methods offer improved protein depth. In this study, MS with library-free data-independent acquisition (DIA) was used to compare the CSF proteome of people with ALS (n = 40), healthy (n = 15) and disease (n = 8) controls. Quantified protein groups were subsequently correlated with clinical variables. Univariate analysis identified 7 proteins, all significantly upregulated in ALS versus healthy controls, and 9 with altered abundance in ALS versus disease controls (FDR < 0.1). Elevated chitotriosidase-1 (CHIT1) was common to both comparisons and was proportional to ALS disability progression rate (Pearson r = 0.41, FDR-adjusted p = 0.035) but not overall survival. Ubiquitin carboxyl-terminal hydrolase isozyme L1 (UCHL1; upregulated in ALS versus healthy controls) was proportional to disability progression rate (Pearson r = 0.53, FDR-adjusted p = 0.003) and survival (Kaplan Meier log-rank p = 0.013) but not independently in multivariate proportional hazards models. Weighted correlation network analysis was used to identify functionally relevant modules of proteins. One module, enriched for inflammatory functions, was associated with age at symptom onset (Pearson r = 0.58, FDR-adjusted p = 0.005) and survival (Hazard Ratio = 1.78, FDR = 0.065), and a second module, enriched for endoplasmic reticulum proteins, was negatively correlated with disability progression rate (r = -0.42, FDR-adjusted p = 0.109). DIA acquisition methodology therefore strengthened the biomarker candidacy of CHIT1 and UCHL1 in ALS, while additionally highlighted inflammatory and endoplasmic reticulum proteins as novel sources of prognostic biomarkers.
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Affiliation(s)
| | - Iolanda Vendrell
- Centre for Medicines Discovery, Nuffield Department of Medicine, Target Discovery InstituteUniversity of OxfordOxfordUK
- Nuffield Department of Medicine, Chinese Academy of Medical Sciences Oxford InstituteUniversity of OxfordOxfordUK
| | - Kevin Talbot
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
- Kavli Institute for Nanoscience DiscoveryUniversity of OxfordOxfordUK
| | - Benedikt M. Kessler
- Centre for Medicines Discovery, Nuffield Department of Medicine, Target Discovery InstituteUniversity of OxfordOxfordUK
- Nuffield Department of Medicine, Chinese Academy of Medical Sciences Oxford InstituteUniversity of OxfordOxfordUK
| | - Roman Fischer
- Centre for Medicines Discovery, Nuffield Department of Medicine, Target Discovery InstituteUniversity of OxfordOxfordUK
- Nuffield Department of Medicine, Chinese Academy of Medical Sciences Oxford InstituteUniversity of OxfordOxfordUK
| | - Martin R. Turner
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
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6
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Sattler R, Traynor BJ, Robertson J, Van Den Bosch L, Barmada SJ, Svendsen CN, Disney MD, Gendron TF, Wong PC, Turner MR, Boxer A, Babu S, Benatar M, Kurnellas M, Rohrer JD, Donnelly CJ, Bustos LM, Van Keuren-Jensen K, Dacks PA, Sabbagh MN. Roadmap for C9ORF72 in Frontotemporal Dementia and Amyotrophic Lateral Sclerosis: Report on the C9ORF72 FTD/ALS Summit. Neurol Ther 2023; 12:1821-1843. [PMID: 37847372 PMCID: PMC10630271 DOI: 10.1007/s40120-023-00548-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 09/14/2023] [Indexed: 10/18/2023] Open
Abstract
A summit held March 2023 in Scottsdale, Arizona (USA) focused on the intronic hexanucleotide expansion in the C9ORF72 gene and its relevance in frontotemporal dementia (FTD) and amyotrophic lateral sclerosis (ALS; C9ORF72-FTD/ALS). The goal of this summit was to connect basic scientists, clinical researchers, drug developers, and individuals affected by C9ORF72-FTD/ALS to evaluate how collaborative efforts across the FTD-ALS disease spectrum might break down existing disease silos. Presentations and discussions covered recent discoveries in C9ORF72-FTD/ALS disease mechanisms, availability of disease biomarkers and recent advances in therapeutic development, and clinical trial design for prevention and treatment for individuals affected by C9ORF72-FTD/ALS and asymptomatic pathological expansion carriers. The C9ORF72-associated hexanucleotide repeat expansion is an important locus for both ALS and FTD. C9ORF72-FTD/ALS may be characterized by loss of function of the C9ORF72 protein and toxic gain of functions caused by both dipeptide repeat (DPR) proteins and hexanucleotide repeat RNA. C9ORF72-FTD/ALS therapeutic strategies discussed at the summit included the use of antisense oligonucleotides, adeno-associated virus (AAV)-mediated gene silencing and gene delivery, and engineered small molecules targeting RNA structures associated with the C9ORF72 expansion. Neurofilament light chain, DPR proteins, and transactive response (TAR) DNA-binding protein 43 (TDP-43)-associated molecular changes were presented as biomarker candidates. Similarly, brain imaging modalities (i.e., magnetic resonance imaging [MRI] and positron emission tomography [PET]) measuring structural, functional, and metabolic changes were discussed as important tools to monitor individuals affected with C9ORF72-FTD/ALS, at both pre-symptomatic and symptomatic disease stages. Finally, summit attendees evaluated current clinical trial designs available for FTD or ALS patients and concluded that therapeutics relevant to FTD/ALS patients, such as those specifically targeting C9ORF72, may need to be tested with composite endpoints covering clinical symptoms of both FTD and ALS. The latter will require novel clinical trial designs to be inclusive of all patient subgroups spanning the FTD/ALS spectrum.
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Affiliation(s)
- Rita Sattler
- Barrow Neurological Institute, 2910 N Third Ave, Phoenix, AZ, 85013, USA.
| | - Bryan J Traynor
- Neuromuscular Diseases Research Section, Laboratory of Neurogenetics, National Institute on Aging, National Institutes of Health, Bethesda, MD, USA
| | - Janice Robertson
- Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, Toronto, ON, Canada
| | - Ludo Van Den Bosch
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology and KU Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology and Leuven Brain Institute (LBI), University of Leuven, Leuven, Belgium
| | - Sami J Barmada
- Department of Neurology, Neuroscience Program, University of Michigan, Ann Arbor, MI, USA
| | - Clive N Svendsen
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Matthew D Disney
- Department of Chemistry, The Herbert Wertheim UF-Scripps Institute for Biomedical Research and Innovation, The Scripps Research Institute, Jupiter, FL, USA
| | - Tania F Gendron
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | - Philip C Wong
- Departments of Pathology and Neuroscience, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Adam Boxer
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of San Francisco, San Francisco, CA, USA
| | - Suma Babu
- Sean M. Healey and AMG Center for ALS and the Neurological Clinical Research Institute, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Michael Benatar
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, 33129, USA
| | | | - Jonathan D Rohrer
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Christopher J Donnelly
- LiveLikeLou Center for ALS Research, Brain Institute, University of Pittsburgh, Pittsburgh, USA
- Department of Neurobiology, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lynette M Bustos
- Barrow Neurological Institute, 2910 N Third Ave, Phoenix, AZ, 85013, USA
| | | | - Penny A Dacks
- The Association for Frontotemporal Degeneration and FTD Disorders Registry, King of Prussia, PA, USA
| | - Marwan N Sabbagh
- Barrow Neurological Institute, 2910 N Third Ave, Phoenix, AZ, 85013, USA.
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Vahsen BF, Nalluru S, Morgan GR, Farrimond L, Carroll E, Xu Y, Cramb KML, Amein B, Scaber J, Katsikoudi A, Candalija A, Carcolé M, Dafinca R, Isaacs AM, Wade-Martins R, Gray E, Turner MR, Cowley SA, Talbot K. C9orf72-ALS human iPSC microglia are pro-inflammatory and toxic to co-cultured motor neurons via MMP9. Nat Commun 2023; 14:5898. [PMID: 37736756 PMCID: PMC10517114 DOI: 10.1038/s41467-023-41603-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by progressive motor neuron loss, with additional pathophysiological involvement of non-neuronal cells such as microglia. The commonest ALS-associated genetic variant is a hexanucleotide repeat expansion (HRE) mutation in C9orf72. Here, we study its consequences for microglial function using human iPSC-derived microglia. By RNA-sequencing, we identify enrichment of pathways associated with immune cell activation and cyto-/chemokines in C9orf72 HRE mutant microglia versus healthy controls, most prominently after LPS priming. Specifically, LPS-primed C9orf72 HRE mutant microglia show consistently increased expression and release of matrix metalloproteinase-9 (MMP9). LPS-primed C9orf72 HRE mutant microglia are toxic to co-cultured healthy motor neurons, which is ameliorated by concomitant application of an MMP9 inhibitor. Finally, we identify release of dipeptidyl peptidase-4 (DPP4) as a marker for MMP9-dependent microglial dysregulation in co-culture. These results demonstrate cellular dysfunction of C9orf72 HRE mutant microglia, and a non-cell-autonomous role in driving C9orf72-ALS pathophysiology in motor neurons through MMP9 signaling.
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Affiliation(s)
- Björn F Vahsen
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QU, UK
| | - Sumedha Nalluru
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Georgia R Morgan
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Lucy Farrimond
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QU, UK
| | - Emily Carroll
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QU, UK
| | - Yinyan Xu
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QU, UK
- Chinese Academy of Medical Sciences (CAMS), CAMS Oxford Institute (COI), Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK
| | - Kaitlyn M L Cramb
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QU, UK
- Oxford Parkinson's Disease Centre, Department of Physiology, Anatomy and Genetics, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QX, UK
| | - Benazir Amein
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Jakub Scaber
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QU, UK
| | - Antigoni Katsikoudi
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QU, UK
- Molecular Neurodegeneration Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QU, UK
| | - Ana Candalija
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Mireia Carcolé
- UK Dementia Research Institute at UCL and Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, WCIN 3BG, UK
| | - Ruxandra Dafinca
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QU, UK
| | - Adrian M Isaacs
- UK Dementia Research Institute at UCL and Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, WCIN 3BG, UK
| | - Richard Wade-Martins
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QU, UK
- Oxford Parkinson's Disease Centre, Department of Physiology, Anatomy and Genetics, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QX, UK
| | - Elizabeth Gray
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Martin R Turner
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Sally A Cowley
- James and Lillian Martin Centre for Stem Cell Research, Sir William Dunn School of Pathology, University of Oxford, Oxford, OX1 3RE, UK.
| | - Kevin Talbot
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, Oxford, OX1 3QU, UK.
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De Oliveira HM, Soma A, Baker MR, Turner MR, Talbot K, Williams TL. A survey of current practice in genetic testing in amyotrophic lateral sclerosis in the UK and Republic of Ireland: implications for future planning. Amyotroph Lateral Scler Frontotemporal Degener 2023; 24:405-413. [PMID: 36458618 DOI: 10.1080/21678421.2022.2150556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022]
Abstract
Objective: To determine the current practice in genetic testing for patients with apparently sporadic motor neurone disease/amyotrophic lateral sclerosis (MND/ALS) and asymptomatic at-risk relatives of familial MND/ALS patients seen in specialized care centers in the UK. Methods: An online survey with 10 questions distributed to specialist healthcare professionals with a role in requesting genetic testing working at MND/ALS care centers. Results: Considerable variation in practice was found. Almost 30% of respondents reported some discomfort in discussing genetic testing with MND/ALS patients and a majority (77%) did not think that all patients with apparently sporadic disease should be routinely offered genetic testing at present. Particular concerns were identified in relation to testing asymptomatic at-risk individuals and the majority view was that clinical genetics services should have a role in supporting genetic testing in MND/ALS, especially in asymptomatic individuals at-risk of carrying pathogenic variants. Conclusions: Variation in practice in genetic testing among MND/ALS clinics may be driven by differences in experience and perceived competence, compounded by the increasing complexity of the genetic underpinnings of MND/ALS. Clear and accessible guidelines for referral pathways between MND/ALS clinics and clinical genetics may be the best way to standardize and improve current practice, ensuring that patients and relatives receive optimal and geographically equitable support.
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Affiliation(s)
- Hugo M De Oliveira
- Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Arunachalam Soma
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Mark R Baker
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Clinical Neurophysiology, Royal Victoria Infirmary, Newcastle upon Tyne, UK, and
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences. Level 6, John Radcliffe Hospital, Oxford, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences. Level 6, John Radcliffe Hospital, Oxford, UK
| | - Timothy L Williams
- Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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Abstract
PURPOSE OF REVIEW Significant progress in characterizing presymptomatic amyotrophic lateral sclerosis (ALS) is ushering in an era of potential disease prevention. Although these advances have largely been based on cohorts of deep-phenotyped mutation carriers at an elevated risk for ALS, there are increasing opportunities to apply principles and insights gleaned, to the broader population at risk for ALS [and frontotemporal dementia (FTD)]. RECENT FINDINGS The discovery that blood neurofilament light chain (NfL) level increases presymptomatically and may serve as a susceptibility biomarker, predicting timing of phenoconversion in some mutation carriers, has empowered the first-ever prevention trial in SOD1 -ALS. Moreover, there is emerging evidence that presymptomatic disease is not uniformly clinically silent, with mild motor impairment (MMI), mild cognitive impairment (MCI), and/or mild behavioral impairment (MBI) representing a prodromal stage of disease. Structural and functional brain abnormalities, as well as systemic markers of metabolic dysfunction, have emerged as potentially even earlier markers of presymptomatic disease. Ongoing longitudinal studies will determine the extent to which these reflect an endophenotype of genetic risk. SUMMARY The discovery of presymptomatic biomarkers and the delineation of prodromal states is yielding unprecedented opportunities for earlier diagnosis, treatment, and perhaps even prevention of genetic and apparently sporadic forms of disease.
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Affiliation(s)
- Michael Benatar
- Department of Neurology, University of Miami, Miami, FL, 33136, USA
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Joanne Wuu
- Department of Neurology, University of Miami, Miami, FL, 33136, USA
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10
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Scaber J, Thompson AG, Farrimond L, Feneberg E, Proudfoot M, Ossher L, Turner MR, Talbot K. Advantages of routine next-generation sequencing over standard genetic testing in the amyotrophic lateral sclerosis clinic. Eur J Neurol 2023; 30:2240-2249. [PMID: 37159497 PMCID: PMC10947345 DOI: 10.1111/ene.15855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 04/17/2023] [Accepted: 05/04/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Next-generation sequencing has enhanced our understanding of amyotrophic lateral sclerosis (ALS) and its genetic epidemiology. Outside the research setting, testing is often restricted to those who report a family history. The aim of this study was to explore the added benefit of offering routine genetic testing to all patients in a regional ALS centre. METHODS C9ORF72 expansion testing and exome sequencing was offered to consecutive patients (150 with ALS and 12 with primary lateral sclerosis [PLS]) attending the Oxford Motor Neuron Disease Clinic within a defined time period. RESULTS A total of 17 (11.3%) highly penetrant pathogenic variants in C9ORF72, SOD1, TARDBP, FUS and TBK1 were detected, of which 10 were also found through standard clinical genetic testing pathways. The systematic approach resulted in five additional diagnoses of a C9ORF72 expansion (number needed to test [NNT] = 28), and two further missense variants in TARDBP and SOD1 (NNT = 69). Additionally, 3 patients were found to carry pathogenic risk variants in NEK1, and 13 patients harboured common missense variants in CFAP410 and KIF5A, also associated with an increased risk of ALS. We report two novel non-coding loss-of-function splice variants in TBK1 and OPTN. No relevant variants were found in the PLS patients. Patients were offered double-blinded participation, but >80% requested disclosure of the results. CONCLUSIONS This study provides evidence that expanding genetic testing to all patients with a clinical diagnosis of ALS enhances the potential for recruitment to clinical trials, but will have direct resource implications for genetic counselling.
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Affiliation(s)
- Jakub Scaber
- Nuffield Department of Clinical NeurosciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
- Kavli Institute for Nanoscience DiscoveryUniversity of OxfordOxfordUK
| | - Alexander G. Thompson
- Nuffield Department of Clinical NeurosciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
| | - Lucy Farrimond
- Nuffield Department of Clinical NeurosciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
- Kavli Institute for Nanoscience DiscoveryUniversity of OxfordOxfordUK
| | - Emily Feneberg
- Nuffield Department of Clinical NeurosciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
| | - Malcolm Proudfoot
- Nuffield Department of Clinical NeurosciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
| | - Lynn Ossher
- Nuffield Department of Clinical NeurosciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
| | - Martin R. Turner
- Nuffield Department of Clinical NeurosciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
| | - Kevin Talbot
- Nuffield Department of Clinical NeurosciencesUniversity of Oxford, John Radcliffe HospitalOxfordUK
- Kavli Institute for Nanoscience DiscoveryUniversity of OxfordOxfordUK
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11
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Thompson AG, Marsden R, Talbot K, Turner MR. Primary care blood tests show lipid profile changes in pre-symptomatic amyotrophic lateral sclerosis. Brain Commun 2023; 5:fcad211. [PMID: 37577380 PMCID: PMC10412752 DOI: 10.1093/braincomms/fcad211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 07/04/2023] [Accepted: 07/27/2023] [Indexed: 08/15/2023] Open
Abstract
Multiple sources of evidence suggest that changes in metabolism may precede the onset of motor symptoms in amyotrophic lateral sclerosis. This study aimed to seek evidence for alterations in the levels of blood indices collected routinely in the primary care setting prior to the onset of motor symptoms in amyotrophic lateral sclerosis. Premorbid data, measured as part of routine health screening, for total cholesterol, high-density and low-density lipoprotein cholesterol, triglyceride, glycated haemoglobin A1c and creatinine were collected retrospectively from (i) a cohort of amyotrophic lateral sclerosis patients attending a specialist clinic (n = 143) and (ii) from primary care-linked data within UK Biobank. Data were fitted using linear mixed effects models with linear b-splines to identify inflection points, controlling for age and sex. In specialist amyotrophic lateral sclerosis clinic cases, models indicated decreasing levels of total and low-density lipoprotein cholesterol prior to an inflection point in the years before symptom onset (total cholesterol 3.25 years, low-density lipoprotein cholesterol 1.25 years), after which they stabilized or rose. A similar pattern was observed in amyotrophic lateral sclerosis cases within UK Biobank, occurring several years prior to diagnosis (total cholesterol 7 years, low-density lipoprotein cholesterol 7.25 years), differing significantly from matched controls. High-density lipoprotein cholesterol followed a similar pattern but was less robust to sensitivity analyses. Levels of triglyceride remained stable throughout. Glycated haemoglobin temporal profiles were not consistent between the clinic and biobank cohorts. Creatinine level trajectories prior to amyotrophic lateral sclerosis did not differ significantly from controls but decreased significantly in the symptomatic period after an inflection point of 0.25 years after symptom onset (clinic cohort) or 0.5 years before diagnosis (UK Biobank). These data provide further evidence for a pre-symptomatic period of dynamic metabolic change in amyotrophic lateral sclerosis, consistently associated with alterations in blood cholesterols. Such changes may ultimately contribute to biomarkers applicable to population screening and for pathways guiding the targeting of preventative therapy.
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Affiliation(s)
- Alexander G Thompson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Rachael Marsden
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
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12
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Davies JC, Dharmadasa T, Thompson AG, Edmond EC, Yoganathan K, Gao J, Talbot K, Turner MR. Limited value of serum neurofilament light chain in diagnosing amyotrophic lateral sclerosis. Brain Commun 2023; 5:fcad163. [PMID: 37292457 PMCID: PMC10244039 DOI: 10.1093/braincomms/fcad163] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/21/2023] [Accepted: 05/17/2023] [Indexed: 06/10/2023] Open
Abstract
A biomarker specific for the diagnosis of amyotrophic lateral sclerosis must be sensitive across a spectrum of clinical heterogeneity. Neurofilament light chain levels in amyotrophic lateral sclerosis correlate with the rate of disability progression. Previous attempts to establish a diagnostic role for neurofilament light chain have been limited to comparison with healthy individuals or controls with alternative diagnoses unlikely to be confused with amyotrophic lateral sclerosis in real-world clinical practice. In a tertiary amyotrophic lateral sclerosis referral clinic, at first visit, serum was taken for neurofilament light chain measurement after prospectively recording the clinical diagnosis as 'amyotrophic lateral sclerosis', 'primary lateral sclerosis', 'alternative' or 'currently uncertain'. Of 133 referrals, 93 patients were diagnosed with amyotrophic lateral sclerosis (median neurofilament light chain 218.1 pg/ml, interquartile range 130.7-311.9), three primary lateral sclerosis (65.6, 51.5-106.9) and 19 alternative diagnoses (45.2, 13.5-71.9) at first visit. Of 18 initially uncertain diagnoses, eight were subsequently diagnosed with amyotrophic lateral sclerosis (98.5, 45.3-300.1). Neurofilament light chain ≥110.9 pg/ml had a positive predictive value of 0.92 for amyotrophic lateral sclerosis; <110.9 pg/ml had a negative predictive value of 0.48. In a specialized clinic, neurofilament light chain is largely confirmatory to clinical judgement in diagnosing amyotrophic lateral sclerosis and has limited ability to exclude alternative diagnoses. The current, important, value of neurofilament light chain is its potential to stratify patients with amyotrophic lateral sclerosis by disease activity and as a biomarker in therapeutic trials.
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Affiliation(s)
| | | | | | - Evan C Edmond
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Katie Yoganathan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Jiali Gao
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
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13
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Chen Z, Reynolds RH, Pardiñas AF, Gagliano Taliun SA, van Rheenen W, Lin K, Shatunov A, Gustavsson EK, Fogh I, Jones AR, Robberecht W, Corcia P, Chiò A, Shaw PJ, Morrison KE, Veldink JH, van den Berg LH, Shaw CE, Powell JF, Silani V, Hardy JA, Houlden H, Owen MJ, Turner MR, Ryten M, Al-Chalabi A. The contribution of Neanderthal introgression and natural selection to neurodegenerative diseases. Neurobiol Dis 2023; 180:106082. [PMID: 36925053 DOI: 10.1016/j.nbd.2023.106082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Humans are thought to be more susceptible to neurodegeneration than equivalently-aged primates. It is not known whether this vulnerability is specific to anatomically-modern humans or shared with other hominids. The contribution of introgressed Neanderthal DNA to neurodegenerative disorders remains uncertain. It is also unclear how common variants associated with neurodegenerative disease risk are maintained by natural selection in the population despite their deleterious effects. In this study, we aimed to quantify the genome-wide contribution of Neanderthal introgression and positive selection to the heritability of complex neurodegenerative disorders to address these questions. We used stratified-linkage disequilibrium score regression to investigate the relationship between five SNP-based signatures of natural selection, reflecting different timepoints of evolution, and genome-wide associated variants of the three most prevalent neurodegenerative disorders: Alzheimer's disease, amyotrophic lateral sclerosis and Parkinson's disease. We found no evidence for enrichment of positively-selected SNPs in the heritability of Alzheimer's disease, amyotrophic lateral sclerosis and Parkinson's disease, suggesting that common deleterious disease variants are unlikely to be maintained by positive selection. There was no enrichment of Neanderthal introgression in the SNP-heritability of these disorders, suggesting that Neanderthal admixture is unlikely to have contributed to disease risk. These findings provide insight into the origins of neurodegenerative disorders within the evolution of Homo sapiens and addresses a long-standing debate, showing that Neanderthal admixture is unlikely to have contributed to common genetic risk of neurodegeneration in anatomically-modern humans.
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Affiliation(s)
- Zhongbo Chen
- Department of Neurodegenerative Disease, Queen Square Institute of Neurology, University College London (UCL), London, UK; Department of Genetics and Genomic Medicine, Great Ormond Street Institute of Child Health, UCL, London, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, UCL, London, UK.
| | - Regina H Reynolds
- Department of Genetics and Genomic Medicine, Great Ormond Street Institute of Child Health, UCL, London, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, UCL, London, UK
| | - Antonio F Pardiñas
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Sarah A Gagliano Taliun
- Department of Medicine & Department of Neurosciences, Université de Montréal, Montréal, Québec, Canada; Montréal Heart Institute, Montréal, Québec, Canada
| | - Wouter van Rheenen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Kuang Lin
- Nuffield Department of Population Health, Oxford University, Oxford, UK
| | - Aleksey Shatunov
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Emil K Gustavsson
- Department of Genetics and Genomic Medicine, Great Ormond Street Institute of Child Health, UCL, London, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, UCL, London, UK
| | - Isabella Fogh
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ashley R Jones
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Wim Robberecht
- Department of Neurology, University Hospital Leuven, Leuven, Belgium; Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease, Leuven, Belgium; Vesalius Research Center, Laboratory of Neurobiology, Leuven, Belgium
| | - Philippe Corcia
- ALS Center, Department of Neurology, CHRU Bretonneau, Tours, France
| | - Adriano Chiò
- Rita Levi Montalcini Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy; Azienda Ospedaliera Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Pamela J Shaw
- Academic Neurology Unit, Department of Neuroscience, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
| | - Karen E Morrison
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Jan H Veldink
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Leonard H van den Berg
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Christopher E Shaw
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - John F Powell
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Vincenzo Silani
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, Milano, Italy; Department of Pathophysiology and Transplantation, Dino Ferrari Center, Università degli Studi di Milano, 20122 Milano, Italy
| | - John A Hardy
- Department of Neurodegenerative Disease, Queen Square Institute of Neurology, University College London (UCL), London, UK; Reta Lila Weston Institute, Queen Square Institute of Neurology, UCL, London, UK; UK Dementia Research Institute, Queen Square Institute of Neurology, UCL, London, UK; NIHR University College London Hospitals Biomedical Research Centre, London, UK; Institute for Advanced Study, The Hong Kong University of Science and Technology, Hong Kong, SAR, China
| | - Henry Houlden
- Department of Neuromuscular Disease, Queen Square Institute of Neurology, UCL, London, UK
| | - Michael J Owen
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Mina Ryten
- Department of Genetics and Genomic Medicine, Great Ormond Street Institute of Child Health, UCL, London, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, UCL, London, UK
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
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14
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Wilson E, Turner N, Faull C, Palmer J, Turner MR, Davidson S. Understanding living with tracheostomy ventilation for motor neuron disease and the implications for quality of life: a qualitative study protocol. BMJ Open 2023; 13:e071624. [PMID: 36914199 PMCID: PMC10016280 DOI: 10.1136/bmjopen-2023-071624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/06/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION Home mechanical ventilation can be used to manage symptoms of breathlessness and sustain life for people living with motor neuron disease (plwMND). In the UK, less than 1% of plwMND use tracheostomy ventilation (TV). This contrasts with some other countries, where rates are much higher. Due to a lack of evidence about its feasibility, cost-effectiveness or outcomes, TV is not covered in the UK National Institute for Health and Care Excellence guidance. Most plwMND receiving TV in the UK do so as an unplanned crisis intervention, which can lead to a prolonged hospital stay while a complex care package is arranged. There is insufficient literature addressing the burdens and benefits of TV, how it should be initiated and delivered, and how future care choices for plwMND can be supported. The aim of this research is to provide new understandings of the experiences of plwMND using TV, and those of family members and healthcare professionals (HCPs) involved in their care. METHODS AND ANALYSIS A UK-wide qualitative study with two workstreams: (1) Patient focused case studies (n=6) including plwMND, family members and HCPs to focus on experiences and tasks of daily living from multiple perspectives. (2) Interviews with plwMND (n=10), family members, including bereaved family members (n=10) and HCPs (n=20) on broader experiences and issues relating to use of TV, such as ethical considerations and decision making. ETHICS AND DISSEMINATION Ethical approval has been granted by the Leicester South Research Ethics Committee (22/EM/0256). All participants will be asked to provide electronic, written and/or audio recorded informed consent. Study findings will be disseminated in peer-reviewed journals and conference presentations and used to develop new resources for teaching and public information.
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Affiliation(s)
- Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Nicola Turner
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Jonathan Palmer
- Department of Thoracic Medicine, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Scott Davidson
- Acute Services, NHS Greater Glasgow and Clyde, Glasgow, UK
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15
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Balendra R, Jones AR, Al Khleifat A, Chiwera T, Wicks P, Young CA, Shaw PJ, Turner MR, Leigh PN, Al-Chalabi A. Comparison Of King's Clinical Staging In Multinational Amyotrophic Lateral Sclerosis Cohorts. Amyotroph Lateral Scler Frontotemporal Degener 2023; 24:71-81. [PMID: 35852375 DOI: 10.1080/21678421.2022.2090847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Amyotrophic lateral sclerosis (ALS) shows considerable clinical heterogeneity, which affects clinical trials. A clinical staging system has been proposed for ALS with potential applications in patient care, research, trial design and health economic analyses. The King's system consists of five stages. We have previously shown that progressive clinical stages were reached at predictable proportions through the disease course, but this needs to be validated in other independent samples. Objectives: We aimed to compare King's clinical staging in ALS in four patient groups, located in different regions and countries and using different health care systems from the original study population in South London. Methods: Clinical data were extracted from two European phase 3 randomized controlled trials (MitoTarget and LiCALS) and from two databases predominately from the United States: the PRO-ACT Consortium Database and a database of patients from the PatientsLikeMe website. Clinical stage was estimated using an algorithm, and standardized time to each clinical stage was calculated in deceased patients. Results: 8,796 patients were included, of whom 1,959 had died by the end of follow-up. Stages occurred in the same order as in the original study for all cohorts. Median standardized times to stages (interquartile range) were Stage 2: 0.61 (0.47-0.75), Stage 3: 0.68 (0.56-0.81), Stage 4A: 0.82 (0.71-0.91), Stage 4B: 0.82 (0.69-0.92) and Stage 4 0.80 (0.67-0.91). Discussion: Timings for all stages were similar to those reported in the original study, except Stage 2 which occurred later in the clinical trial databases due to recruitment occurring after diagnosis.
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Affiliation(s)
- Rubika Balendra
- UK Dementia Research Institute, University College London, London, UK
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
| | - Ashley R Jones
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, UK
| | - Ahmad Al Khleifat
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, UK
| | - Theresa Chiwera
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, UK
| | - Paul Wicks
- Wicks Digital Health, Wicks Digital Health, Lichfield, UK
| | - Carolyn A Young
- Department of Neurology, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience (SITraN), Department of Neuroscience, University of Sheffield, Sheffield, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, OX3 9DU, UK
| | - P Nigel Leigh
- Department of Neuroscience, Brighton and Sussex Medical School, Trafford Centre for Biomedical Research, University of Sussex, Falmer, East Sussex, BN1 9RY, UK
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, UK
- Department of Neurology, King's College Hospital, London, UK
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16
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Cooper‐Knock J, Julian TH, Feneberg E, Highley JR, Sidra M, Turner MR, Talbot K, Ansorge O, Allen SP, Moll T, Shelkovnikova T, Castelli L, Hautbergue GM, Hewitt C, Kirby J, Wharton SB, Mead RJ, Shaw PJ. Atypical TDP-43 protein expression in an ALS pedigree carrying a p.Y374X truncation mutation in TARDBP. Brain Pathol 2023; 33:e13104. [PMID: 35871544 PMCID: PMC9836368 DOI: 10.1111/bpa.13104] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 05/30/2022] [Indexed: 01/25/2023] Open
Abstract
We describe an autosomal dominant, multi-generational, amyotrophic lateral sclerosis (ALS) pedigree in which disease co-segregates with a heterozygous p.Y374X nonsense mutation within TDP-43. Mislocalization of TDP-43 and formation of insoluble TDP-43-positive neuronal cytoplasmic inclusions is the hallmark pathology in >95% of ALS patients. Neuropathological examination of the single case for which CNS tissue was available indicated typical TDP-43 pathology within lower motor neurons, but classical TDP-43-positive inclusions were absent from motor cortex. The mutated allele is transcribed and translated in patient fibroblasts and motor cortex tissue, but overall TDP-43 protein expression is reduced compared to wild-type controls. Despite absence of TDP-43-positive inclusions we confirmed deficient TDP-43 splicing function within motor cortex tissue. Furthermore, urea fractionation and mass spectrometry of motor cortex tissue carrying the mutation revealed atypical TDP-43 protein species but not typical C-terminal fragments. We conclude that the p.Y374X mutation underpins a monogenic, fully penetrant form of ALS. Reduced expression of TDP-43 combined with atypical TDP-43 protein species and absent C-terminal fragments extends the molecular phenotypes associated with TDP-43 mutations and with ALS more broadly. Future work will need to include the findings from this pedigree in dissecting the mechanisms of TDP-43-mediated toxicity.
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Affiliation(s)
- Johnathan Cooper‐Knock
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Thomas H. Julian
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Emily Feneberg
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
- Neurology Department, Klinikum Rechts der IsarTechnical University of MunichMunichGermany
| | - J. Robin Highley
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Maurice Sidra
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Martin R. Turner
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
| | - Kevin Talbot
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
| | - Olaf Ansorge
- Academic Unit of NeuropathologyUniversity of OxfordOxfordUK
| | - Scott P. Allen
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Tobias Moll
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Tatyana Shelkovnikova
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Lydia Castelli
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Guillaume M. Hautbergue
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Christopher Hewitt
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
- Amarin UK LimitedAmarin CorporationLondonUK
| | - Janine Kirby
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Stephen B. Wharton
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Richard J. Mead
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Pamela J. Shaw
- Sheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
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17
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Yildiz O, Schroth J, Tree T, Turner MR, Shaw PJ, Henson SM, Malaspina A. Senescent-like Blood Lymphocytes and Disease Progression in Amyotrophic Lateral Sclerosis. Neurol Neuroimmunol Neuroinflamm 2023; 10:e200042. [PMID: 36323511 PMCID: PMC9673751 DOI: 10.1212/nxi.0000000000200042] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/22/2022] [Indexed: 03/11/2023]
Abstract
BACKGROUND AND OBJECTIVES Aging is known to exacerbate neuroinflammation, and in the neurodegenerative disorder amyotrophic lateral sclerosis (ALS), an older age is associated with a worse prognosis. We have previously shown the activation of cell senescence pathways in the proteome of peripheral blood mononuclear cells and the increase of proinflammatory cytokines in blood from individuals living with ALS. In this single-center, retrospective study, we investigated the expression of senescent-like blood mononuclear cells in ALS. METHODS We first applied multidimensional cytometry by time-of-flight (CyTOF) to study the senescent immunophenotype of blood mononuclear cells from 21 patients with ALS and 10 healthy controls (HCs). We then used targeted flow cytometry (FC) to investigate frequencies of senescent blood lymphocytes in 40 patients with ALS and 20 HCs. Longitudinal analysis included 2 additional time points in 17 patients with ALS. Frequencies of senescent-like lymphocytes were analyzed in relation to survival. RESULTS Unsupervised clustering of CyTOF data showed higher frequencies of senescent CD4+CD27-CD57+ T cells in patients with ALS compared with those in HCs (p = 0.0017, false discovery (FDR)-adjusted p = 0.029). Moderate to strong negative correlations were identified between CD4 T central memory-cell frequencies and survival (R = -061, p = 0.01; FDR-adjusted p < 0.1) and between CD95 CD8 cells and ALS functional rating scale revised at baseline (R = -0.72, p = 0.001; FDR-adjusted p < 0.1).Targeted FC analysis showed higher memory T regulatory cells (p = 0.0052) and memory CD8+ T cell (M-Tc; p = 0.0006) in bulbar ALS (A-B) compared with those in limb ALS (A-L), while late memory B cells (LM-B) were also elevated in A-B and fast-progressing ALS (p = 0.0059). Higher M-Tc levels separated A-B from A-L (AUC: 0.887; p < 0.0001). A linear regression model with prespecified clinical independent variables and neurofilament light chain plasma concentration showed that higher frequencies of LM-B predicted a shorter survival (hazard ratio: 1.094, CI: 1.026-1.167; p = 0.006). DISCUSSION Our data suggest that a systemic elevation of senescent and late memory T and B lymphocytes is a feature of faster progressing ALS and of ALS individuals with bulbar involvement. Lymphocyte senescence and their memory state may be central to the immune dysregulation known to drive disease progression in ALS and a target for biomarkers and therapeutics discovery.
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Affiliation(s)
- Ozlem Yildiz
- From the Neuroscience and Trauma Centre (O.Y., A.M.), Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London; Queen Square Motor Neuron Disease Centre (A.M.), Neuromuscular Department, Institute of Neurology, University College London; Translational Medicine and Therapeutics (J.S., S.M.H.), William Harvey Research Institute, Barts and the London, Queen Mary University of London; Department of Immunobiology (T.T.), School of Immunology & Microbial Sciences, King's College London; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford; and Sheffield Institute for Translational Neuroscience (P.J.S.), University of Sheffield, UK
| | - Johannes Schroth
- From the Neuroscience and Trauma Centre (O.Y., A.M.), Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London; Queen Square Motor Neuron Disease Centre (A.M.), Neuromuscular Department, Institute of Neurology, University College London; Translational Medicine and Therapeutics (J.S., S.M.H.), William Harvey Research Institute, Barts and the London, Queen Mary University of London; Department of Immunobiology (T.T.), School of Immunology & Microbial Sciences, King's College London; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford; and Sheffield Institute for Translational Neuroscience (P.J.S.), University of Sheffield, UK
| | - Timothy Tree
- From the Neuroscience and Trauma Centre (O.Y., A.M.), Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London; Queen Square Motor Neuron Disease Centre (A.M.), Neuromuscular Department, Institute of Neurology, University College London; Translational Medicine and Therapeutics (J.S., S.M.H.), William Harvey Research Institute, Barts and the London, Queen Mary University of London; Department of Immunobiology (T.T.), School of Immunology & Microbial Sciences, King's College London; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford; and Sheffield Institute for Translational Neuroscience (P.J.S.), University of Sheffield, UK
| | - Martin R Turner
- From the Neuroscience and Trauma Centre (O.Y., A.M.), Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London; Queen Square Motor Neuron Disease Centre (A.M.), Neuromuscular Department, Institute of Neurology, University College London; Translational Medicine and Therapeutics (J.S., S.M.H.), William Harvey Research Institute, Barts and the London, Queen Mary University of London; Department of Immunobiology (T.T.), School of Immunology & Microbial Sciences, King's College London; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford; and Sheffield Institute for Translational Neuroscience (P.J.S.), University of Sheffield, UK
| | - Pamela J Shaw
- From the Neuroscience and Trauma Centre (O.Y., A.M.), Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London; Queen Square Motor Neuron Disease Centre (A.M.), Neuromuscular Department, Institute of Neurology, University College London; Translational Medicine and Therapeutics (J.S., S.M.H.), William Harvey Research Institute, Barts and the London, Queen Mary University of London; Department of Immunobiology (T.T.), School of Immunology & Microbial Sciences, King's College London; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford; and Sheffield Institute for Translational Neuroscience (P.J.S.), University of Sheffield, UK
| | - Sian M Henson
- From the Neuroscience and Trauma Centre (O.Y., A.M.), Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London; Queen Square Motor Neuron Disease Centre (A.M.), Neuromuscular Department, Institute of Neurology, University College London; Translational Medicine and Therapeutics (J.S., S.M.H.), William Harvey Research Institute, Barts and the London, Queen Mary University of London; Department of Immunobiology (T.T.), School of Immunology & Microbial Sciences, King's College London; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford; and Sheffield Institute for Translational Neuroscience (P.J.S.), University of Sheffield, UK
| | - Andrea Malaspina
- From the Neuroscience and Trauma Centre (O.Y., A.M.), Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London; Queen Square Motor Neuron Disease Centre (A.M.), Neuromuscular Department, Institute of Neurology, University College London; Translational Medicine and Therapeutics (J.S., S.M.H.), William Harvey Research Institute, Barts and the London, Queen Mary University of London; Department of Immunobiology (T.T.), School of Immunology & Microbial Sciences, King's College London; Nuffield Department of Clinical Neurosciences (M.R.T.), University of Oxford; and Sheffield Institute for Translational Neuroscience (P.J.S.), University of Sheffield, UK.
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18
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Huszar IN, Pallebage-Gamarallage M, Bangerter-Christensen S, Brooks H, Fitzgibbon S, Foxley S, Hiemstra M, Howard AFD, Jbabdi S, Kor DZL, Leonte A, Mollink J, Smart A, Tendler BC, Turner MR, Ansorge O, Miller KL, Jenkinson M. Tensor image registration library: Deformable registration of stand-alone histology images to whole-brain post-mortem MRI data. Neuroimage 2023; 265:119792. [PMID: 36509214 PMCID: PMC10933796 DOI: 10.1016/j.neuroimage.2022.119792] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/26/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Accurate registration between microscopy and MRI data is necessary for validating imaging biomarkers against neuropathology, and to disentangle complex signal dependencies in microstructural MRI. Existing registration methods often rely on serial histological sampling or significant manual input, providing limited scope to work with a large number of stand-alone histology sections. Here we present a customisable pipeline to assist the registration of stand-alone histology sections to whole-brain MRI data. METHODS Our pipeline registers stained histology sections to whole-brain post-mortem MRI in 4 stages, with the help of two photographic intermediaries: a block face image (to undistort histology sections) and coronal brain slab photographs (to insert them into MRI space). Each registration stage is implemented as a configurable stand-alone Python script using our novel platform, Tensor Image Registration Library (TIRL), which provides flexibility for wider adaptation. We report our experience of registering 87 PLP-stained histology sections from 14 subjects and perform various experiments to assess the accuracy and robustness of each stage of the pipeline. RESULTS All 87 histology sections were successfully registered to MRI. Histology-to-block registration (Stage 1) achieved 0.2-0.4 mm accuracy, better than commonly used existing methods. Block-to-slice matching (Stage 2) showed great robustness in automatically identifying and inserting small tissue blocks into whole brain slices with 0.2 mm accuracy. Simulations demonstrated sub-voxel level accuracy (0.13 mm) of the slice-to-volume registration (Stage 3) algorithm, which was observed in over 200 actual brain slice registrations, compensating 3D slice deformations up to 6.5 mm. Stage 4 combined the previous stages and generated refined pixelwise aligned multi-modal histology-MRI stacks. CONCLUSIONS Our open-source pipeline provides robust automation tools for registering stand-alone histology sections to MRI data with sub-voxel level precision, and the underlying framework makes it readily adaptable to a diverse range of microscopy-MRI studies.
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Affiliation(s)
- Istvan N Huszar
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
| | | | - Sarah Bangerter-Christensen
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Brigham Young University, Provo, UT, USA
| | - Hannah Brooks
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sean Fitzgibbon
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sean Foxley
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Department of Radiology, University of Chicago, Chicago, IL, USA
| | - Marlies Hiemstra
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Department of Anatomy, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Amy F D Howard
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Saad Jbabdi
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Daniel Z L Kor
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Anna Leonte
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Department of Neuroscience, University of Groningen, Groningen, the Netherlands
| | - Jeroen Mollink
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Department of Anatomy, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Adele Smart
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Benjamin C Tendler
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Martin R Turner
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Olaf Ansorge
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Karla L Miller
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Mark Jenkinson
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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19
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Joilin G, Gray E, Thompson AG, Talbot K, Leigh PN, Newbury SF, Turner MR, Hafezparast M. Profiling non-coding RNA expression in cerebrospinal fluid of amyotrophic lateral sclerosis patients. Ann Med 2022; 54:3069-3078. [PMID: 36314539 PMCID: PMC9629092 DOI: 10.1080/07853890.2022.2138530] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Objective biomarkers for the fatal neurodegenerative disease amyotrophic lateral sclerosis or motor neuron disease (ALS/MND) are critical for diagnosis, drug development, clinical trials, and insight into disease pathology. Key candidates for biomarkers present in biofluids include non-coding RNA (ncRNA) transcripts including microRNA, piwi-interacting RNA and transfer RNA. To determine if the central nervous system was the source of the dysregulated ncRNA biomarkers we previously observed in serum, we sought to identify dysregulated ncRNA candidates in cerebrospinal fluid (CSF) which may provide new insight into the disease pathology. METHODS AND MATERIALS Small RNA sequencing (RNA-seq) was undertaken on CSF samples from healthy controls (n = 18), disease mimics (n = 8), and ALS patients (n = 40) in our Oxford Study for Biomarkers of ALS cohort, with RT-qPCR used to confirm their dysregulation. RESULTS We found a range of ncRNA that were dysregulated in the RNA-seq screen, but these failed to be validated or detected in some cases using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Additionally, our previously identified serum ncRNA biomarker showed no change in CSF or correlation to serum. CONCLUSIONS This study suggests the CSF may not be the source of dysregulated ncRNA in the serum and highlights the difficulty in identifying ncRNA in CSF as biomarkers for ALS.KEY MESSAGESIn this current study, we investigated the expression of non-coding RNA transcripts in the cerebrospinal fluid of ALS patients compared to healthy controls.RNA-seq identified dysregulated non-coding RNA transcripts, but these were not validated with RT-qPCR.We conclude that cerebrospinal fluid is not a suitable source of diagnostic biomarkers.
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Affiliation(s)
- Greig Joilin
- School of Life Sciences, University of Sussex, Brighton, UK
| | - Elizabeth Gray
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - P Nigel Leigh
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Sarah F Newbury
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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20
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Alix JJP, Verber NS, Schooling CN, Kadirkamanathan V, Turner MR, Malaspina A, Day JCC, Shaw PJ. Label-free fibre optic Raman spectroscopy with bounded simplex-structured matrix factorization for the serial study of serum in amyotrophic lateral sclerosis. Analyst 2022; 147:5113-5120. [PMID: 36222101 PMCID: PMC9639415 DOI: 10.1039/d2an00936f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is an incurable neurodegenerative disease in urgent need of disease biomarkers for the assessment of promising therapeutic candidates in clinical trials. Raman spectroscopy is an attractive technique for identifying disease related molecular changes due to its simplicity. Here, we describe a fibre optic fluid cell for undertaking spontaneous Raman spectroscopy studies of human biofluids that is suitable for use away from a standard laboratory setting. Using this system, we examined serum obtained from patients with ALS at their first presentation to our centre (n = 66) and 4 months later (n = 27). We analysed Raman spectra using bounded simplex-structured matrix factorization (BSSMF), a generalisation of non-negative matrix factorisation which uses the distribution of the original data to limit the factorisation modes (spectral patterns). Biomarkers associated with ALS disease such as measures of symptom severity, respiratory function and inflammatory/immune pathways (C3/C-reactive protein) correlated with baseline Raman modes. Between visit spectral changes were highly significant (p = 0.0002) and were related to protein structure. Comparison of Raman data with established ALS biomarkers as a trial outcome measure demonstrated a reduction in required sample size with BSSMF Raman. Our portable, simple to use fibre optic system allied to BSSMF shows promise in the quantification of disease-related changes in ALS over short timescales.
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Affiliation(s)
- James J P Alix
- Sheffield Institute for Translational Neuroscience, University of Sheffield, UK.
- Neuroscience Institute, University of Sheffield, UK
| | - Nick S Verber
- Sheffield Institute for Translational Neuroscience, University of Sheffield, UK.
- Neuroscience Institute, University of Sheffield, UK
| | - Chlöe N Schooling
- Sheffield Institute for Translational Neuroscience, University of Sheffield, UK.
- Department of Automatic Control and Systems Engineering, University of Sheffield, UK
| | | | - Martin R Turner
- Nuffield Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - John C C Day
- Interface Analysis Centre, School of Physics, University of Bristol, UK
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, UK.
- Neuroscience Institute, University of Sheffield, UK
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21
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Benatar M, Wuu J, Turner MR. Neurofilament light chain in drug development for amyotrophic lateral sclerosis: a critical appraisal. Brain 2022:6780887. [PMID: 36310538 DOI: 10.1093/brain/awac394] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/03/2022] [Accepted: 10/06/2022] [Indexed: 11/14/2022] Open
Abstract
Interest in amyotrophic lateral sclerosis (ALS) biomarkers has grown exponentially over the course of the last 25 years, with great hope that they might serve as tools to facilitate the development of meaningful therapies for this otherwise inexorably progressive and invariably fatal disease. Effective use of biomarkers, however, requires an understanding of what it means for them to be "fit-for-purpose" as well as an appreciation of the nuances of the clinical context(s) in which they will be applied. Neurofilament light chain (NfL) has emerged as a leading candidate with enormous potential to aid ALS therapy development; it is, however, also profoundly misunderstood. Within the conceptual framework of the BEST (Biomarkers, EndpointS, and other Tools) Resource, developed by the National Institutes of Health and the Food & Drug Administration in the United States, we consider the evidence supporting the use of NfL for a variety of purposes in different clinical contexts. We conclude that: (1) it may serve as a susceptibility/risk biomarker in populations at elevated risk for ALS; (2) it has value as a prognostic biomarker when measured early in the course of established disease, empowering stratification or dynamic randomization to amplify the signal-to-noise ratio of promising therapeutics; and (3) there is sufficient evidence to support the use of a reduction in NfL in response to an experimental therapeutic as a pharmacodynamic biomarker that may aid in phase 2 trial go/no-go decisions. Moreover, the basis for expecting that a reduction in NfL is a reasonably likely surrogate endpoint (i.e. reasonably likely to predict clinical benefit - which may be more than simply survival) is nuanced, and depends on when in the course of disease the experimental therapeutic is administered.
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Affiliation(s)
- Michael Benatar
- Department of Neurology, University of Miami, Miami, FL, 33136, USA
| | - Joanne Wuu
- Department of Neurology, University of Miami, Miami, FL, 33136, USA
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
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22
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Gao J, Dharmadasa T, Malaspina A, Shaw PJ, Talbot K, Turner MR, Thompson AG. Creatine kinase and prognosis in amyotrophic lateral sclerosis: a literature review and multi-centre cohort analysis. J Neurol 2022; 269:5395-5404. [PMID: 35614165 PMCID: PMC9467954 DOI: 10.1007/s00415-022-11195-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/05/2022] [Accepted: 05/15/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a prognostically heterogeneous neurodegenerative disease. Blood creatine kinase (CK) level has been inconsistently reported as a prognostic biomarker and raised levels in some ALS patients have been presumed to reflect muscle wasting, which is also variable. METHODS MEDLINE was systematically searched for papers related to CK in ALS and the relevant studies were reviewed. Using data from 222 ALS patients in a multi-centre, prospective, longitudinal cohort, survival analyses using Kaplan-Meier and Cox proportional hazards models were undertaken in relation to CK and other prognostic factors. RESULTS Twenty-five studies investigating CK in ALS were identified, of which 10 specifically studied the link between CK and survival. Five studies observed no association, four found that higher CK levels were associated with longer survival and one, the opposite. In our cohort (n = 222), 39% of patients had a CK level above the laboratory reference range. Levels were higher in males compared to females (p < 0.001), in patients with limb versus bulbar onset of symptoms (p < 0.001) and in patients with higher lower motor neuron burden (p < 0.001). There was no significant trend in longitudinal CK values. Although a higher standardised log (CK) at first visit was associated with longer survival in univariate analysis (hazard ratio 0.75, p = 0.003), there was no significant association after adjusting for other prognostic covariates. CONCLUSION While raised CK levels in ALS do reflect lower motor neuron denervation to a large extent, they are not independently associated with survival when measured in the symptomatic phase of the disease.
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Affiliation(s)
- Jiali Gao
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, West Wing level 3 / level 6, Oxford, OX3 9DU, UK
| | - Thanuja Dharmadasa
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, West Wing level 3 / level 6, Oxford, OX3 9DU, UK
| | | | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, West Wing level 3 / level 6, Oxford, OX3 9DU, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, West Wing level 3 / level 6, Oxford, OX3 9DU, UK.
| | - Alexander G Thompson
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, West Wing level 3 / level 6, Oxford, OX3 9DU, UK.
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23
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Jiménez-Villegas J, Kirby J, Mata A, Cadenas S, Turner MR, Malaspina A, Shaw PJ, Cuadrado A, Rojo AI. Dipeptide Repeat Pathology in C9orf72-ALS Is Associated with Redox, Mitochondrial and NRF2 Pathway Imbalance. Antioxidants (Basel) 2022; 11:1897. [PMID: 36290620 PMCID: PMC9598689 DOI: 10.3390/antiox11101897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
The hexanucleotide expansion of the C9orf72 gene is found in 40% of familial amyotrophic lateral sclerosis (ALS) patients. This genetic alteration has been connected with impaired management of reactive oxygen species. In this study, we conducted targeted transcriptional profiling in leukocytes from C9orf72 patients and control subjects by examining the mRNA levels of 84 redox-related genes. The expression of ten redox genes was altered in samples from C9orf72 ALS patients compared to healthy controls. Considering that Nuclear factor erythroid 2-Related Factor 2 (NRF2) modulates the expression of a wide range of redox genes, we further investigated its status on an in vitro model of dipeptide repeat (DPR) toxicity. This model mimics the gain of function, toxic mechanisms attributed to C9orf72 pathology. We found that exposure to DPRs increased superoxide levels and reduced mitochondrial potential as well as cell survival. Importantly, cells overexpressing DPRs exhibited reduced protein levels of NRF2 and its target genes upon inhibition of the proteasome or its canonical repressor, the E3 ligase adapter KEAP1. However, NRF2 activation was sufficient to recover cell viability and redox homeostasis. This study identifies NRF2 as a putative target in precision medicine for the therapy of ALS patients harboring C9orf72 expansion repeats.
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Affiliation(s)
- José Jiménez-Villegas
- Department of Biochemistry, Medical College, Autonomous University of Madrid (UAM), 28029 Madrid, Spain
- Instituto de Investigaciones Biomédicas “Alberto Sols” (CSIC/UAM), 28029 Madrid, Spain
- Instituto de Investigación Sanitaria La Paz (IdiPaz), 28029 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), 28029 Madrid, Spain
| | - Janine Kirby
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield S10 2HQ, UK
| | - Ana Mata
- Centro de Biología Molecular “Severo Ochoa” (CSIC/UAM), 28049 Madrid, Spain
- Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006 Madrid, Spain
| | - Susana Cadenas
- Centro de Biología Molecular “Severo Ochoa” (CSIC/UAM), 28049 Madrid, Spain
- Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006 Madrid, Spain
| | - Martin R. Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford OX3 9DU, UK
| | - Andrea Malaspina
- Neuroscience and Trauma Centre, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London E1 2AT, UK
- Queen Square Motor Neuron Disease Centre, Neuromuscular Department, Institute of Neurology, University College London, London WC1N 3BG, UK
| | - Pamela J. Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield S10 2HQ, UK
| | - Antonio Cuadrado
- Department of Biochemistry, Medical College, Autonomous University of Madrid (UAM), 28029 Madrid, Spain
- Instituto de Investigaciones Biomédicas “Alberto Sols” (CSIC/UAM), 28029 Madrid, Spain
- Instituto de Investigación Sanitaria La Paz (IdiPaz), 28029 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), 28029 Madrid, Spain
| | - Ana I. Rojo
- Department of Biochemistry, Medical College, Autonomous University of Madrid (UAM), 28029 Madrid, Spain
- Instituto de Investigaciones Biomédicas “Alberto Sols” (CSIC/UAM), 28029 Madrid, Spain
- Instituto de Investigación Sanitaria La Paz (IdiPaz), 28029 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), 28029 Madrid, Spain
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24
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Vahsen BF, Gray E, Candalija A, Cramb KML, Scaber J, Dafinca R, Katsikoudi A, Xu Y, Farrimond L, Wade-Martins R, James WS, Turner MR, Cowley SA, Talbot K. Human iPSC co-culture model to investigate the interaction between microglia and motor neurons. Sci Rep 2022; 12:12606. [PMID: 35871163 PMCID: PMC9308778 DOI: 10.1038/s41598-022-16896-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/18/2022] [Indexed: 11/23/2022] Open
Abstract
Motor neuron diseases such as amyotrophic lateral sclerosis are primarily characterized by motor neuron degeneration with additional involvement of non-neuronal cells, in particular, microglia. In previous work, we have established protocols for the differentiation of iPSC-derived spinal motor neurons and microglia. Here, we combine both cell lineages and establish a novel co-culture of iPSC-derived spinal motor neurons and microglia, which is compatible with motor neuron identity and function. Co-cultured microglia express key identity markers and transcriptomically resemble primary human microglia, have highly dynamic ramifications, are phagocytically competent, release relevant cytokines and respond to stimulation. Further, they express key amyotrophic lateral sclerosis-associated genes and release disease-relevant biomarkers. This novel and authentic human model system facilitates the study of physiological motor neuron-microglia crosstalk and will allow the investigation of non-cell-autonomous phenotypes in motor neuron diseases such as amyotrophic lateral sclerosis.
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Affiliation(s)
- Björn F Vahsen
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QU, UK
| | - Elizabeth Gray
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Ana Candalija
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Kaitlyn M L Cramb
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QU, UK
- Oxford Parkinson's Disease Centre, Department of Physiology, Anatomy and Genetics, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QX, UK
| | - Jakub Scaber
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QU, UK
| | - Ruxandra Dafinca
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QU, UK
| | - Antigoni Katsikoudi
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QU, UK
- Molecular Neurodegeneration Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QU, UK
| | - Yinyan Xu
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QU, UK
- Chinese Academy of Medical Sciences (CAMS), CAMS Oxford Institute (COI), Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK
| | - Lucy Farrimond
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QU, UK
| | - Richard Wade-Martins
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QU, UK
- Oxford Parkinson's Disease Centre, Department of Physiology, Anatomy and Genetics, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QX, UK
| | - William S James
- James and Lillian Martin Centre for Stem Cell Research, Sir William Dunn School of Pathology, University of Oxford, South Parks Road, Oxford, OX1 3RE, UK
| | - Martin R Turner
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Sally A Cowley
- James and Lillian Martin Centre for Stem Cell Research, Sir William Dunn School of Pathology, University of Oxford, South Parks Road, Oxford, OX1 3RE, UK.
| | - Kevin Talbot
- Oxford Motor Neuron Disease Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK.
- Kavli Institute for Nanoscience Discovery, University of Oxford, Dorothy Crowfoot Hodgkin Building, South Parks Road, Oxford, OX1 3QU, UK.
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Edmond EC, Dharmadasa T, Clarke W, Talbot K, Stagg CJ, Turner MR. Multimodal MRI demonstrates task-related cortical hyper-activation and neuro- chemical alteration in amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundThere is a paucity of reliable markers of disease activity and progression in ALS. Better biomarkers would also reduce clinical trial duration and cost by providing more sensitive measures of target engagement. Cortical hyperexcitability with transcranial magnetic stimulation, while promising, has not yet been clinically translatable. Multimodal correlation of cortical hyperexcitability could yield more robust composite biomarkers.MethodsThis project applies multimodal non-invasive neuroimaging (MRI, MEG) and neurophysiol- ogy (TMS) to explore cortical hyperexcitability in ALS. 11 affected ALS patients, 9 age matched healthy controls and 13 asymptomatic relatives at-risk of inheriting the disease-causing C9orf72 hexanucleotide repeat expansion were studied. MRI findings are reported here (diffusion-tensor imaging [DTI], functional MRI and MR spectroscopy).ResultsRight cortical activation with contralateral finger movement was significantly increased in patients (p = 0.04), while right cortical de-activation with ipsilateral movement was lost (p = 0.01). N-acetyl-aspar- tate (p=0.04) and glutamate (p = 0.01) are significantly reduced in patients. At-risk relatives occupy an intermediate profile.DiscussionBilateral motor cortex hyperexcitability was found in ALS. Asymmetry in task-related activa- tion is consistent with previously reported loss of cortical inhibition in early ALS. Integration of multimodal imaging and neurophysiological data could explain variable phenotype and disease mechanisms in ALS.eedmond@gmail.com
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Pandya S, Maia PD, Freeze B, Menke RAL, Talbot K, Turner MR, Raj A. Modeling seeding and neuroanatomic spread of pathology in amyotrophic lateral sclerosis. Neuroimage 2022; 251:118968. [PMID: 35143975 PMCID: PMC10729776 DOI: 10.1016/j.neuroimage.2022.118968] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 01/26/2022] [Accepted: 02/02/2022] [Indexed: 12/12/2022] Open
Abstract
The neurodegenerative disorder amyotrophic lateral sclerosis (ALS) is characterized by the progressive loss of upper and lower motor neurons, with pathological involvement of cerebral motor and extra-motor areas in a clinicopathological spectrum with frontotemporal dementia (FTD). A key unresolved issue is how the non-random distribution of pathology in ALS reflects differential network vulnerability, including molecular factors such as regional gene expression, or preferential spread of pathology via anatomical connections. A system of histopathological staging of ALS based on the regional burden of TDP-43 pathology observed in postmortem brains has been supported to some extent by analysis of distribution of in vivo structural MRI changes. In this paper, computational modeling using a Network Diffusion Model (NDM) was used to investigate whether a process of focal pathological 'seeding' followed by structural network-based spread recapitulated postmortem histopathological staging and, secondly, whether this had any correlation to the pattern of expression of a panel of genes implicated in ALS across the healthy brain. Regionally parcellated T1-weighted MRI data from ALS patients (baseline n=79) was studied in relation to a healthy control structural connectome and a database of associated regional cerebral gene expression. The NDM provided strong support for a structural network-based basis for regional pathological spread in ALS, but no simple relationship to the spatial distribution of ALS-related genes in the healthy brain. Interestingly, OPTN gene was identified as a significant but a weaker non-NDM contributor within the network-gene interaction model (LASSO). Intriguingly, the critical seed regions for spread within the model were not within the primary motor cortex but basal ganglia, thalamus and insula, where NDM recapitulated aspects of the postmortem histopathological staging system. Within the ALS-FTD clinicopathological spectrum, non-primary motor structures may be among the earliest sites of cerebral pathology.
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Affiliation(s)
- Sneha Pandya
- Department of Radiology, Weill Cornell Medicine, 1300 York Avenue, New York, NY, United States.
| | - Pedro D Maia
- Department of Mathematics, University of Texas at Arlington, TX, United States
| | - Benjamin Freeze
- Scripps Health/MD Anderson Cancer Center, Department of Radiology, CA, United States
| | - Ricarda A L Menke
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, West Wing Level 6, Oxford OX2 7PZ, United Kingdom
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Martin R Turner
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, West Wing Level 6, Oxford OX2 7PZ, United Kingdom; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
| | - Ashish Raj
- Department of Radiology, Weill Cornell Medicine, 1300 York Avenue, New York, NY, United States; Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA 94121, United States.
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27
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Dreger M, Steinbach R, Otto M, Turner MR, Grosskreutz J. Cerebrospinal fluid biomarkers of disease activity and progression in amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2022; 93:422-435. [PMID: 35105727 PMCID: PMC8921583 DOI: 10.1136/jnnp-2021-327503] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 11/29/2021] [Indexed: 12/04/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a relentlessly progressive neurodegenerative disease, and only modest disease-modifying strategies have been established to date. Numerous clinical trials have been conducted in the past years, but have been severely hampered by the wide-ranging heterogeneity of both the biological origins and clinical characteristics of the disease. Thus, reliable biomarkers of disease activity are urgently needed to stratify patients into homogenous groups with aligned disease trajectories to allow a more effective design of clinical trial. In this review, the most promising candidate biomarkers in the cerebrospinal fluid (CSF) of patients with ALS will be summarised. Correlations between biomarker levels and clinical outcome parameters are discussed, while highlighting potential pitfalls and intercorrelations of these clinical parameters. Several CSF molecules have shown potential as biomarkers of progression and prognosis, but large, international, multicentric and longitudinal studies are crucial for validation. A more standardised choice of clinical endpoints in these studies, as well as the application of individualised models of clinical progression, would allow the quantification of disease trajectories, thereby allowing a more accurate analysis of the clinical implications of candidate biomarkers. Additionally, a comparative analysis of several biomarkers and ideally the application of a multivariate analysis including comprehensive genotypic, phenotypic and clinical characteristics collectively contributing to biomarker levels in the CSF, could promote their verification. Thus, reliable prognostic markers and markers of disease activity may improve clinical trial design and patient management in the direction of precision medicine.
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Affiliation(s)
- Marie Dreger
- Department of Neurology, Jena University Hospital, Jena, Thüringen, Germany
| | - Robert Steinbach
- Department of Neurology, Jena University Hospital, Jena, Thüringen, Germany
| | - Markus Otto
- Department of Neurology, University of Halle (Saale), Halle (Saale), Germany
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, Oxfordshire, UK
| | - Julian Grosskreutz
- Precision Neurology, Department of Neurology, University of Luebeck Human Medicine, Luebeck, Schleswig-Holstein, Germany
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28
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Savva C, Turner MR. Pineal gland as the source of the soul and third eye. Pract Neurol 2022; 22:168-169. [PMID: 34965984 DOI: 10.1136/practneurol-2021-003246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Costa Savva
- Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford Medical Sciences Division, Oxford, UK
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Abstract
A minority (10%-15%) of cases of amyotrophic lateral sclerosis (ALS), the most common form of motor neurone disease (MND), are currently attributable to pathological variants in a single identifiable gene. With the emergence of new therapies targeting specific genetic subtypes of ALS, there is an increasing role for routine genetic testing for all those with a definite diagnosis. However, potential harm to both affected individuals and particularly to asymptomatic relatives can arise from the indiscriminate use of genetic screening, not least because of uncertainties around incomplete penetrance and variants of unknown significance. The most common hereditary cause of ALS, an intronic hexanucleotide repeat expansion in C9ORF72, may be associated with frontotemporal dementia independently within the same pedigree. The boundary of what constitutes a possible family history of MND has therefore extended to include dementia and associated psychiatric presentations. Notwithstanding the important role of clinical genetics specialists, all neurologists need a basic understanding of the current place of genetic testing in MND, which holds lessons for other neurological disorders.
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Affiliation(s)
- Thanuja Dharmadasa
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Jakub Scaber
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Evan Edmond
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Rachael Marsden
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alexander Thompson
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
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30
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Benatar M, Wuu J, McHutchison C, Postuma RB, Boeve BF, Petersen R, Ross CA, Rosen H, Arias JJ, Fradette S, McDermott MP, Shefner J, Stanislaw C, Abrahams S, Cosentino S, Andersen PM, Finkel RS, Granit V, Grignon AL, Rohrer JD, McMillan CT, Grossman M, Al-Chalabi A, Turner MR. Preventing amyotrophic lateral sclerosis: insights from pre-symptomatic neurodegenerative diseases. Brain 2022; 145:27-44. [PMID: 34677606 PMCID: PMC8967095 DOI: 10.1093/brain/awab404] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/16/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022] Open
Abstract
Significant progress has been made in understanding the pre-symptomatic phase of amyotrophic lateral sclerosis. While much is still unknown, advances in other neurodegenerative diseases offer valuable insights. Indeed, it is increasingly clear that the well-recognized clinical syndromes of Alzheimer's disease, Parkinson's disease, Huntington's disease, spinal muscular atrophy and frontotemporal dementia are also each preceded by a pre-symptomatic or prodromal period of varying duration, during which the underlying disease process unfolds, with associated compensatory changes and loss of inherent system redundancy. Key insights from these diseases highlight opportunities for discovery in amyotrophic lateral sclerosis. The development of biomarkers reflecting amyloid and tau has led to a shift in defining Alzheimer's disease based on inferred underlying histopathology. Parkinson's disease is unique among neurodegenerative diseases in the number and diversity of non-genetic biomarkers of pre-symptomatic disease, most notably REM sleep behaviour disorder. Huntington's disease benefits from an ability to predict the likely timing of clinically manifest disease based on age and CAG-repeat length alongside reliable neuroimaging markers of atrophy. Spinal muscular atrophy clinical trials have highlighted the transformational value of early therapeutic intervention, and studies in frontotemporal dementia illustrate the differential role of biomarkers based on genotype. Similar advances in amyotrophic lateral sclerosis would transform our understanding of key events in pathogenesis, thereby dramatically accelerating progress towards disease prevention. Deciphering the biology of pre-symptomatic amyotrophic lateral sclerosis relies on a clear conceptual framework for defining the earliest stages of disease. Clinically manifest amyotrophic lateral sclerosis may emerge abruptly, especially among those who harbour genetic mutations associated with rapidly progressive amyotrophic lateral sclerosis. However, the disease may also evolve more gradually, revealing a prodromal period of mild motor impairment preceding phenoconversion to clinically manifest disease. Similarly, cognitive and behavioural impairment, when present, may emerge gradually, evolving through a prodromal period of mild cognitive impairment or mild behavioural impairment before progression to amyotrophic lateral sclerosis. Biomarkers are critically important to studying pre-symptomatic amyotrophic lateral sclerosis and essential to efforts to intervene therapeutically before clinically manifest disease emerges. The use of non-genetic biomarkers, however, presents challenges related to counselling, informed consent, communication of results and limited protections afforded by existing legislation. Experiences from pre-symptomatic genetic testing and counselling, and the legal protections against discrimination based on genetic data, may serve as a guide. Building on what we have learned-more broadly from other pre-symptomatic neurodegenerative diseases and specifically from amyotrophic lateral sclerosis gene mutation carriers-we present a road map to early intervention, and perhaps even disease prevention, for all forms of amyotrophic lateral sclerosis.
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Affiliation(s)
- Michael Benatar
- Department of Neurology, University of Miami, Miami, FL, USA
| | - Joanne Wuu
- Department of Neurology, University of Miami, Miami, FL, USA
| | - Caroline McHutchison
- Human Cognitive Neuroscience, Department of Psychology, University of Edinburgh, Edinburgh, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, Edinburgh, UK
| | - Ronald B Postuma
- Department of Neurology, Montreal Neurological Institute, McGill University, Montreal, Canada
| | | | | | - Christopher A Ross
- Division of Neurobiology, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Howard Rosen
- Department of Neurology, University of California San Francisco, CA, USA
| | - Jalayne J Arias
- Department of Neurology, University of California San Francisco, CA, USA
| | | | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.,Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jeremy Shefner
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | - Sharon Abrahams
- Human Cognitive Neuroscience, Department of Psychology, University of Edinburgh, Edinburgh, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, Edinburgh, UK
| | | | - Peter M Andersen
- Department of Clinical Science, Neurosciences, Umeå University, Sweden
| | - Richard S Finkel
- Department of Pediatric Medicine, Center for Experimental Neurotherapeutics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Volkan Granit
- Department of Neurology, University of Miami, Miami, FL, USA
| | | | - Jonathan D Rohrer
- Department of Neurodegenerative Disease, Dementia Research Centre, UCL Institute of Neurology, Queen Square, London, UK
| | - Corey T McMillan
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Murray Grossman
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Tendler BC, Hanayik T, Ansorge O, Bangerter-Christensen S, Berns GS, Bertelsen MF, Bryant KL, Foxley S, van den Heuvel MP, Howard AFD, Huszar IN, Khrapitchev AA, Leonte A, Manger PR, Menke RAL, Mollink J, Mortimer D, Pallebage-Gamarallage M, Roumazeilles L, Sallet J, Scholtens LH, Scott C, Smart A, Turner MR, Wang C, Jbabdi S, Mars RB, Miller KL. The Digital Brain Bank, an open access platform for post-mortem imaging datasets. eLife 2022; 11:e73153. [PMID: 35297760 PMCID: PMC9042233 DOI: 10.7554/elife.73153] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 03/17/2022] [Indexed: 11/13/2022] Open
Abstract
Post-mortem magnetic resonance imaging (MRI) provides the opportunity to acquire high-resolution datasets to investigate neuroanatomy and validate the origins of image contrast through microscopy comparisons. We introduce the Digital Brain Bank (open.win.ox.ac.uk/DigitalBrainBank), a data release platform providing open access to curated, multimodal post-mortem neuroimaging datasets. Datasets span three themes-Digital Neuroanatomist: datasets for detailed neuroanatomical investigations; Digital Brain Zoo: datasets for comparative neuroanatomy; and Digital Pathologist: datasets for neuropathology investigations. The first Digital Brain Bank data release includes 21 distinctive whole-brain diffusion MRI datasets for structural connectivity investigations, alongside microscopy and complementary MRI modalities. This includes one of the highest-resolution whole-brain human diffusion MRI datasets ever acquired, whole-brain diffusion MRI in fourteen nonhuman primate species, and one of the largest post-mortem whole-brain cohort imaging studies in neurodegeneration. The Digital Brain Bank is the culmination of our lab's investment into post-mortem MRI methodology and MRI-microscopy analysis techniques. This manuscript provides a detailed overview of our work with post-mortem imaging to date, including the development of diffusion MRI methods to image large post-mortem samples, including whole, human brains. Taken together, the Digital Brain Bank provides cross-scale, cross-species datasets facilitating the incorporation of post-mortem data into neuroimaging studies.
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Affiliation(s)
- Benjamin C Tendler
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Taylor Hanayik
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Olaf Ansorge
- Division of Clinical Neurology, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Sarah Bangerter-Christensen
- Division of Clinical Neurology, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | | | - Mads F Bertelsen
- Centre for Zoo and Wild Animal Health, Copenhagen ZooFrederiksbergDenmark
| | - Katherine L Bryant
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Sean Foxley
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
- Department of Radiology, University of ChicagoChicagoUnited States
| | - Martijn P van den Heuvel
- Department of Complex Trait Genetics, Centre for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, Vrije Universiteit AmsterdamAmsterdamNetherlands
- Department of Child Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamNetherlands
| | - Amy FD Howard
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Istvan N Huszar
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Alexandre A Khrapitchev
- Medical Research Council Oxford Institute for Radiation Oncology, University of OxfordOxfordUnited Kingdom
| | - Anna Leonte
- Division of Clinical Neurology, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Paul R Manger
- School of Anatomical Sciences, Faculty of Health Sciences, University of the WitwatersrandJohannesburgSouth Africa
| | - Ricarda AL Menke
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Jeroen Mollink
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Duncan Mortimer
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Menuka Pallebage-Gamarallage
- Division of Clinical Neurology, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Lea Roumazeilles
- Wellcome Centre for Integrative Neuroimaging, Department of Experimental Psychology, University of OxfordOxfordUnited Kingdom
| | - Jerome Sallet
- Wellcome Centre for Integrative Neuroimaging, Department of Experimental Psychology, University of OxfordOxfordUnited Kingdom
- Stem Cell and Brain Research Institute, Université Lyon 1, INSERMBronFrance
| | - Lianne H Scholtens
- Department of Complex Trait Genetics, Centre for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, Vrije Universiteit AmsterdamAmsterdamNetherlands
| | - Connor Scott
- Division of Clinical Neurology, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Adele Smart
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
- Division of Clinical Neurology, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Martin R Turner
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
- Division of Clinical Neurology, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Chaoyue Wang
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Saad Jbabdi
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
| | - Rogier B Mars
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
- Donders Institute for Brain, Cognition and Behaviour, Radboud University NijmegenNijmegenNetherlands
| | - Karla L Miller
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of OxfordOxfordUnited Kingdom
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Kliest T, Van Eijk RPA, Al-Chalabi A, Albanese A, Andersen PM, Amador MDM, BrÅthen G, Brunaud-Danel V, Brylev L, Camu W, De Carvalho M, Cereda C, Cetin H, Chaverri D, Chiò A, Corcia P, Couratier P, De Marchi F, Desnuelle C, Van Es MA, Esteban J, Filosto M, GarcÍa Redondo A, Grosskreutz J, Hanemann CO, HolmØy T, HØyer H, Ingre C, Koritnik B, Kuzma-Kozakiewicz M, Lambert T, Leigh PN, Lunetta C, Mandrioli J, Mcdermott CJ, Meyer T, Mora JS, Petri S, Povedano MÓ, Reviers E, Riva N, Roes KCB, Rubio MÁ, Salachas F, Sarafov S, SorarÙ G, Stevic Z, Svenstrup K, MØller AT, Turner MR, Van Damme P, Van Leeuwen LAG, Varona L, VÁzquez Costa JF, Weber M, Hardiman O, Van Den Berg LH. Clinical trials in pediatric ALS: a TRICALS feasibility study. Amyotroph Lateral Scler Frontotemporal Degener 2022; 23:481-488. [PMID: 35172656 PMCID: PMC9662181 DOI: 10.1080/21678421.2021.2024856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: Pediatric investigation plans (PIPs) describe how adult drugs can be studied in children. In 2015, PIPs for Amyotrophic Lateral Sclerosis (ALS) became mandatory for European marketing-authorization of adult treatments, unless a waiver is granted by the European Medicines Agency (EMA). Objective: To assess the feasibility of clinical studies on the effect of therapy in children (<18 years) with ALS in Europe. Methods: The EMA database was searched for submitted PIPs in ALS. A questionnaire was sent to 58 European ALS centers to collect the prevalence of pediatric ALS during the past ten years, the recruitment potential for future pediatric trials, and opinions of ALS experts concerning a waiver for ALS. Results: Four PIPs were identified; two were waived and two are planned for the future. In total, 49 (84.5%) centers responded to the questionnaire. The diagnosis of 44,858 patients with ALS was reported by 46 sites; 39 of the patients had an onset < 18 years (prevalence of 0.008 cases per 100,000 or 0.087% of all diagnosed patients). The estimated recruitment potential (47 sites) was 26 pediatric patients within five years. A majority of ALS experts (75.5%) recommend a waiver should apply for ALS due to the low prevalence of pediatric ALS. Conclusions: ALS with an onset before 18 years is extremely rare and may be a distinct entity from adult ALS. Conducting studies on the effect of disease-modifying therapy in pediatric ALS may involve lengthy recruitment periods, high costs, ethical/legal implications, challenges in trial design and limited information.
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Affiliation(s)
- Tessa Kliest
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ruben P A Van Eijk
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands.,Biostatistics & Research Support, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, King's College London, Maurice Wohl Clinical Neuroscience Institute, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | | | - Peter M Andersen
- Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden
| | - Maria Del Mar Amador
- Département de Neurologie, Centre de référence SLA Ile de France.,Hôpital de la Pitié Salpêtrière, AP-HP, Paris, France
| | - Geir BrÅthen
- Department of Neurology, University Hospital of Trondheim, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Lev Brylev
- Bujanov Moscow City Clinical Hospital, Moscow, Russian Federation.,Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russian Federation
| | - William Camu
- ALS Centre CHU Gui de Chauliac, University of Montpellier, Montpellier, France
| | - Mamede De Carvalho
- Institute of Physiology-Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.,Department of Neurosciences and Mental Health, H Santa Maria-CHLN, Lisbon, Portugal
| | - Cristina Cereda
- Regional Newborn Screening Laboratory, Vittore Buzzi Children's Hospital-University of Milan, Italy
| | - Hakan Cetin
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Delia Chaverri
- Neurology Service, Hospital Universitario La Paz, Madrid, Spain
| | - Adriano Chiò
- 'Rita Levi Montalcini' Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy.,Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | - Philippe Corcia
- Centre Constitutif SLA, CHRU de Tours - Fédération des centres SLA Tours-Limoges, LitORALS, Tours, France
| | - Philippe Couratier
- Centre Constitutif de reference SLA-Fédération Tours-Limoges, CHU de Limoges, Limoges, France
| | | | | | - Michael A Van Es
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - JesÚs Esteban
- ALS Research Lab - ALS Unit, Instituto de Investigación Sanitaria Hospital 12 de Octubre "i + 12", CIBERER, Madrid, Spain
| | - Massimiliano Filosto
- Department of Clinical and Experimental Sciences, University of Brescia; NeMO-Brescia Clinical Center for Neuromuscular Diseases, Brescia, Italy
| | - Alberto GarcÍa Redondo
- ALS Research Lab - ALS Unit, Instituto de Investigación Sanitaria Hospital 12 de Octubre "i + 12", CIBERER, Madrid, Spain
| | - Julian Grosskreutz
- Precision Neurology, Dept. of Neurology, Lübeck University Hospital, Lübeck, Germany
| | - Clemens O Hanemann
- University of Plymouth, Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Trygve HolmØy
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Helle HØyer
- Department of Medical Genetics, Telemark Hospital, Skien, Norway
| | - Caroline Ingre
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Blaz Koritnik
- Institute of Clinical Neurophysiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Thomas Lambert
- Department of Neurology, Royal Stoke University Hospital, Stoke, United Kingdom
| | - Peter N Leigh
- Department of Neuroscience, Brighton and Sussex Medical School, Trafford Centre for Biomedical Research, University of Sussex, Brighton, UK
| | - Christian Lunetta
- NEMO Clinical Center, Serena Onlus Foundation, Milan, Italy.,NEMO LAB, Milan, Italy
| | - Jessica Mandrioli
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy.,Department of Neuroscience, St. Agostino Estense Hospital, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Christopher J Mcdermott
- Department of Neuroscience, University of Sheffield, Sheffield Institute for Translational Neuroscience, Sheffield, United Kingdom
| | - Thomas Meyer
- ALS Outpatient Department, Charité - Universitatsmedizin Berlin, Berlin, Germany
| | - Jesus S Mora
- ALS Unit/Neurology, Hospital San Rafael, Madrid, Spain
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - MÓnica Povedano
- Functional Unit of Amyotrophic Lateral Sclerosis (UFELA), Service of Neurology, Bellvitge University Hospital, Hospitalet de Llobregat, Spain
| | - Evy Reviers
- European Organization for Professionals and Patients with ALS (EUpALS) & ALS Liga Belgium, Leuven, Belgium
| | - Nilo Riva
- Department of Neurology, Experimental Neuropathology Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - Kit C B Roes
- Department of Health Evidence, Section Biostatistics, Radboud University Medical Centre Nijmegen, Nijmegen, the Netherlands
| | - Miguel Á Rubio
- Neuromuscular Unit, Department of Neurology, Hospital del Mar, Barcelona, Spain.,Instituto Hospital del Mar de Investivaciones Médicas (IMIM), Barcelona, Spain
| | - FranÇois Salachas
- Département de Neurologie, Centre de référence SLA Ile de France.,Hôpital de la Pitié Salpêtrière, AP-HP, Paris, France
| | - Stayko Sarafov
- Clinic of General Neurology, Medical University Sofia, University Hospital Alexandrovska, Sofia, Bulgaria
| | - Gianni SorarÙ
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Zorica Stevic
- Clinic of Neurology, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Kirsten Svenstrup
- Department of Neurology, Bispebjerg-Frederiksberg Hospital and Rigshospitalet, University Hospital of Copenhagen, Denmark
| | | | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Philip Van Damme
- Department of Neurosciences, Laboratory for Neurobiology, KU Leuven and Centre for Brain & Disease Research, VIB, Leuven Brain Institute, Leuven, Belgium.,Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Lucie A G Van Leeuwen
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Luis Varona
- Department of Neurology, Basurto University Hospital, Vizcaya, Spain
| | - Juan F VÁzquez Costa
- ALS Unit and Neuromuscular Disease Unit, Department of Neurology, Hospital La Fe, Valencia, Spain
| | - Markus Weber
- Neuromoscular Disease Unit/ALS Clinic, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Orla Hardiman
- Academic Unit of Neurology Trinity College Dublin Ireland, Dublin, Ireland
| | - Leonard H Van Den Berg
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
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Affiliation(s)
- Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford Medical Sciences Division, Oxford OX3 9DU, UK
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Thompson AG, Talbot K, Turner MR. Higher blood high density lipoprotein and apolipoprotein A1 levels are associated with reduced risk of developing amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2022; 93:75-81. [PMID: 34518331 PMCID: PMC8685635 DOI: 10.1136/jnnp-2021-327133] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/08/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Premorbid body mass index, physical activity, diabetes and cardiovascular disease have been associated with an altered risk of developing amyotrophic lateral sclerosis (ALS). There is evidence of shared genetic risk between ALS and lipid metabolism. A very large prospective longitudinal population cohort permits the study of a range of metabolic parameters and the risk of subsequent diagnosis of ALS. METHODS The risk of subsequent ALS diagnosis in those enrolled prospectively to the UK Biobank (n=502 409) was examined in relation to baseline levels of blood high and low density lipoprotein (HDL, LDL), total cholesterol, total cholesterol:HDL ratio, apolipoproteins A1 and B (apoA1, apoB), triglycerides, glycated haemoglobin A1c (HbA1c) and creatinine, plus self-reported exercise and body mass index. RESULTS Controlling for age and sex, higher HDL (HR 0.84, 95% CI 0.73 to 0.96, p=0.010) and apoA1 (HR 0.83, 95% CI 0.72 to 0.94, p=0.005) were associated with a reduced risk of ALS. Higher total cholesterol:HDL was associated with an increased risk of ALS (HR 1.17, 95% CI 1.05 to 1.31, p=0.006). In models incorporating multiple metabolic markers, higher LDL or apoB was associated with an increased risk of ALS, in addition to a lower risk with higher HDL or apoA. Coronary artery disease, cerebrovascular disease and increasing age were also associated with an increased risk of ALS. CONCLUSIONS The association of HDL, apoA1 and LDL levels with risk of ALS contributes to an increasing body of evidence that the premorbid metabolic landscape may play a role in pathogenesis. Understanding the molecular basis for these changes will inform presymptomatic biomarker development and therapeutic targeting.
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Affiliation(s)
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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35
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Thompson AG, Gray E, Verber N, Bobeva Y, Lombardi V, Shepheard SR, Yildiz O, Feneberg E, Farrimond L, Dharmadasa T, Gray P, Edmond EC, Scaber J, Gagliardi D, Kirby J, Jenkins TM, Fratta P, McDermott CJ, Manohar SG, Talbot K, Malaspina A, Shaw PJ, Turner MR. OUP accepted manuscript. Brain Commun 2022; 4:fcac029. [PMID: 35224491 PMCID: PMC8870425 DOI: 10.1093/braincomms/fcac029] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 11/25/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
The routine clinical integration of individualized objective markers of disease activity in those diagnosed with the neurodegenerative disorder amyotrophic lateral sclerosis is a key requirement for therapeutic development. A large, multicentre, clinic-based, longitudinal cohort was used to systematically appraise the leading candidate biofluid biomarkers in the stratification and potential therapeutic assessment of those with amyotrophic lateral sclerosis. Incident patients diagnosed with amyotrophic lateral sclerosis (n = 258), other neurological diseases (n = 80) and healthy control participants (n = 101), were recruited and followed at intervals of 3–6 months for up to 30 months. Cerebrospinal fluid neurofilament light chain and chitotriosidase 1 and blood neurofilament light chain, creatine kinase, ferritin, complement C3 and C4 and C-reactive protein were measured. Blood neurofilament light chain, creatine kinase, serum ferritin, C3 and cerebrospinal fluid neurofilament light chain and chitotriosidase 1 were all significantly elevated in amyotrophic lateral sclerosis patients. First-visit plasma neurofilament light chain level was additionally strongly associated with survival (hazard ratio for one standard deviation increase in log10 plasma neurofilament light chain 2.99, 95% confidence interval 1.65–5.41, P = 0.016) and rate of disability progression, independent of other prognostic factors. A small increase in level was noted within the first 12 months after reported symptom onset (slope 0.031 log10 units per month, 95% confidence interval 0.012–0.049, P = 0.006). Modelling the inclusion of plasma neurofilament light chain as a therapeutic trial outcome measure demonstrated that a significant reduction in sample size and earlier detection of disease-slowing is possible, compared with using the revised Amyotrophic Lateral Sclerosis Functional Rating Scale. This study provides strong evidence that blood neurofilament light chain levels outperform conventional measures of disease activity at the group level. The application of blood neurofilament light chain has the potential to radically reduce the duration and cost of therapeutic trials. It might also offer a first step towards the goal of more personalized objective disease activity monitoring for those living with amyotrophic lateral sclerosis.
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Affiliation(s)
| | - Elizabeth Gray
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Nick Verber
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Yoana Bobeva
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Stephanie R. Shepheard
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Ozlem Yildiz
- Blizard Institute, Queen Mary University of London, London, UK
| | - Emily Feneberg
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Lucy Farrimond
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Thanuja Dharmadasa
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Pamela Gray
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Evan C. Edmond
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Jakub Scaber
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Delia Gagliardi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Janine Kirby
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Thomas M. Jenkins
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Pietro Fratta
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Sanjay G. Manohar
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Andrea Malaspina
- Blizard Institute, Queen Mary University of London, London, UK
- Correspondence may also be addressed to: Prof Andrea Malaspina Blizard Institute 4 Newark St, Whitechapel London, E1 2AT, UK E-mail:
| | - Pamela J. Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
- Correspondence may also be addressed to: Prof Dame Pamela Shaw Sheffield Institute for Translational Neuroscience (SITraN) University of Sheffield, 385a Glossop Rd Broomhall, Sheffield, S10 2HQ, UK E-mail:
| | - Martin R. Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Correspondence to: Prof Martin Turner Nuffield Department of Clinical Neurosciences Level 6, West Wing, John Radcliffe Hospital Oxford, OX3 9DU, UK E-mail:
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Thompson AG, Oeckl P, Feneberg E, Bowser R, Otto M, Fischer R, Kessler B, Turner MR. Advancing mechanistic understanding and biomarker development in amyotrophic lateral sclerosis. Expert Rev Proteomics 2021; 18:977-994. [PMID: 34758687 DOI: 10.1080/14789450.2021.2004890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Proteomic analysis has contributed significantly to the study of the neurodegenerative disease amyotrophic lateral sclerosis (ALS). It has helped to define the pathological change common to nearly all cases, namely intracellular aggregates of phosphorylated TDP-43, shifting the focus of pathogenesis in ALS toward RNA biology. Proteomics has also uniquely underpinned the delineation of disease mechanisms in model systems and has been central to recent advances in human ALS biomarker development. AREAS COVERED The contribution of proteomics to understanding the cellular pathological changes, disease mechanisms, and biomarker development in ALS are covered. EXPERT OPINION Proteomics has delivered unique insights into the pathogenesis of ALS and advanced the goal of objective measurements of disease activity to improve therapeutic trials. Further developments in sensitivity and quantification are expected, with application to the presymptomatic phase of human disease offering the hope of prevention strategies.
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Affiliation(s)
| | - Patrick Oeckl
- Department of Neurology, University of Ulm, Ulm, Germany.,German Center for Neurodegenerative Diseases (Dzne e.V.), Ulm, Germany
| | - Emily Feneberg
- Department of Neurology, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Robert Bowser
- Departments of Neurology and Translational Neuroscience, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Markus Otto
- Department of Neurology, University of Ulm, Ulm, Germany.,Department of Neurology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Roman Fischer
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Benedikt Kessler
- Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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37
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Nolan M, Barbagallo P, Turner MR, Keogh MJ, Chinnery PF, Talbot K, Ansorge O. Isolated homozygous R217X OPTN mutation causes knock-out of functional C-terminal optineurin domains and associated oligodendrogliopathy-dominant ALS-TDP. J Neurol Neurosurg Psychiatry 2021; 92:1022-1024. [PMID: 33727253 PMCID: PMC8372379 DOI: 10.1136/jnnp-2020-325803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Matthew Nolan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Paola Barbagallo
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Michael John Keogh
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Patrick F Chinnery
- Department of Clinical Neurosciences, MRC Mitochondrial Biology Unit, Cambridge, Cambridgeshire, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Olaf Ansorge
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, Oxfordshire, UK
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38
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Barohn RJ, Fink JK, Heiman-Patterson T, Huey ED, Murphy J, Statland JM, Turner MR, Elman L. The clinical spectrum of primary lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2021; 21:3-10. [PMID: 33602013 DOI: 10.1080/21678421.2020.1837178] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Primary lateral sclerosis is a distinct entity that has recently been classified as a "restricted phenotype" of ALS. It is characterized by a pattern of isolated upper motor neuron involvement that often begins in the legs and spreads diffusely. Distinction from other conditions requires careful consideration of clinical presentation and time course of disease. Mills' Syndrome is a rare unilateral variant of primary lateral sclerosis. Cognitive and behavioral involvement may occur.
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Affiliation(s)
- Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - John K Fink
- Department of Neurology, Ann Arbor Veterans Affairs Medical Center, University of Michigan, Ann Arbor, MI, USA
| | - Terry Heiman-Patterson
- Department of Neurology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Edward D Huey
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jennifer Murphy
- Department of Neurology, University of California at San Francisco, San Francisco, CA, USA
| | - Jeffrey M Statland
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Martin R Turner
- Nuffield Department of Neurosciences, University of Oxford, Oxford, UK
| | - Lauren Elman
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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39
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Ross Russell AL, Hardwick M, Jeyanantham A, White LM, Deb S, Burnside G, Joy HM, Smith CJ, Pollak TA, Nicholson TR, Davies NWS, Manji H, Easton A, Ray S, Zandi MS, Coles JP, Menon DK, Varatharaj A, McCausland B, Ellul MA, Thomas N, Breen G, Keddie S, Lunn MP, Burn JPS, Quattrocchi G, Dixon L, Rice CM, Pengas G, Al-Shahi Salman R, Carson A, Joyce EM, Turner MR, Benjamin LA, Solomon T, Kneen R, Pett S, Thomas RH, Michael BD, Galea I. Spectrum, risk factors and outcomes of neurological and psychiatric complications of COVID-19: a UK-wide cross-sectional surveillance study. Brain Commun 2021; 3:fcab168. [PMID: 34409289 PMCID: PMC8364668 DOI: 10.1093/braincomms/fcab168] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 01/06/2023] Open
Abstract
SARS-CoV-2 is associated with new-onset neurological and psychiatric conditions. Detailed clinical data, including factors associated with recovery, are lacking, hampering prediction modelling and targeted therapeutic interventions. In a UK-wide cross-sectional surveillance study of adult hospitalized patients during the first COVID-19 wave, with multi-professional input from general and sub-specialty neurologists, psychiatrists, stroke physicians, and intensivists, we captured detailed data on demographics, risk factors, pre-COVID-19 Rockwood frailty score, comorbidities, neurological presentation and outcome. A priori clinical case definitions were used, with cross-specialty independent adjudication for discrepant cases. Multivariable logistic regression was performed using demographic and clinical variables, to determine the factors associated with outcome. A total of 267 cases were included. Cerebrovascular events were most frequently reported (131, 49%), followed by other central disorders (95, 36%) including delirium (28, 11%), central inflammatory (25, 9%), psychiatric (25, 9%), and other encephalopathies (17, 7%), including a severe encephalopathy (n = 13) not meeting delirium criteria; and peripheral nerve disorders (41, 15%). Those with the severe encephalopathy, in comparison to delirium, were younger, had higher rates of admission to intensive care and a longer duration of ventilation. Compared to normative data during the equivalent time period prior to the pandemic, cases of stroke in association with COVID-19 were younger and had a greater number of conventional, modifiable cerebrovascular risk factors. Twenty-seven per cent of strokes occurred in patients <60 years. Relative to those >60 years old, the younger stroke patients presented with delayed onset from respiratory symptoms, higher rates of multi-vessel occlusion (31%) and systemic thrombotic events. Clinical outcomes varied between disease groups, with cerebrovascular disease conferring the worst prognosis, but this effect was less marked than the pre-morbid factors of older age and a higher pre-COVID-19 frailty score, and a high admission white cell count, which were independently associated with a poor outcome. In summary, this study describes the spectrum of neurological and psychiatric conditions associated with COVID-19. In addition, we identify a severe COVID-19 encephalopathy atypical for delirium, and a phenotype of COVID-19 associated stroke in younger adults with a tendency for multiple infarcts and systemic thromboses. These clinical data will be useful to inform mechanistic studies and stratification of patients in clinical trials.
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Affiliation(s)
- Amy L Ross Russell
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Marc Hardwick
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Athavan Jeyanantham
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Laura M White
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK
| | - Saumitro Deb
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, L3 5TR, UK
| | - Girvan Burnside
- Department of Health Data Science, University of Liverpool, Liverpool, L69 3BX, UK
| | - Harriet M Joy
- Neuroradiology Department, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Craig J Smith
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Salford, M6 8HD, UK
- Division of Cardiovascular Sciences, Lydia Becker Institute for Immunology and Inflammation, University of Manchester, Manchester, M13 9PL, UK
| | - Thomas A Pollak
- Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, SE5 8AF, UK
| | - Timothy R Nicholson
- Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, SE5 8AF, UK
| | | | - Hadi Manji
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology, London, WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, University College London, London, WC1N 3BG, UK
| | - Ava Easton
- Encephalitis Society, Malton, Malton, YO17 7DT, UK
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
| | - Stephen Ray
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, L69 7BE, UK
| | - Michael S Zandi
- UCL Queen Square Institute of Neurology, University College London, London, WC1N 3BG, UK
| | - Jonathan P Coles
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - Aravinthan Varatharaj
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Beth McCausland
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- Memory Assessment and Research Centre, Moorgreen Hospital, Southern Health Foundation Trust, Southampton, SO40 2RZ, UK
| | - Mark A Ellul
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, L69 7BE, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK
| | - Naomi Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle, NE1 7RU, UK
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle, NE2 4HH, UK
| | - Gerome Breen
- Department of Social Genetic and Developmental Psychiatry, King’s College London, London, SE5 8AF, UK
| | - Stephen Keddie
- Department of Neuromuscular Diseases, University College London, London, WC1N 3BG, UK
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, WC1N 3BG, UK
| | - Michael P Lunn
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology, London, WC1N 3BG, UK
- UCL Queen Square Institute of Neurology, University College London, London, WC1N 3BG, UK
| | - John P S Burn
- Rehabilitation Department, Poole Hospital, University Hospitals Dorset NHS Foundation Trust, Poole, BH15 2JB, UK
| | - Graziella Quattrocchi
- Department of Neurology, North Middlesex University Hospital NHS Trust, London, N18 1QX, UK
| | - Luke Dixon
- Department of Neuroradiology, Imperial College NHS Healthcare Trust, London, W2 1NY, UK
| | - Claire M Rice
- Department of Neurology, Southmead Hospital, North Bristol NHS Trust, Bristol, S10 5NB, UK
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 1TH, UK
| | - George Pengas
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | | | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Eileen M Joyce
- UCL Queen Square Institute of Neurology, University College London, London, WC1N 3BG, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Laura A Benjamin
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, L69 7BE, UK
- Laboratory of Molecular and Cell Biology, UCL, Gower St, King’s Cross, London, London, WC1E 6BT, UK
| | - Tom Solomon
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, L69 7BE, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK
| | - Rachel Kneen
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- Department of Neurology, Alder Hey Children’s NHS Foundation Trust, Liverpool, Liverpool, L14 5AB, UK
| | - Sarah Pett
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, WC1V 6LJ, UK
- Institute for Global Health, University College London, London, WC1N 1EH, UK
| | - Rhys H Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle, NE1 7RU, UK
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle, NE2 4HH, UK
- Department of Neurology, Royal Victoria Infirmary, Newcastle, NE1 4LP, UK
| | - Benedict D Michael
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, L7 3EA, UK
- The National Institute for Health Research Health Protection Research Unit for Emerging and Zoonotic Infections, University of Liverpool, Liverpool, L69 7BE, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK
| | - Ian Galea
- Department of Neurology, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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Affiliation(s)
| | - Jon Sussman
- Neurology, Manchester Centre for Clinical Neuroscience, Greater Manchester, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
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41
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Shepheard SR, Parker MD, Cooper-Knock J, Verber NS, Tuddenham L, Heath P, Beauchamp N, Place E, Sollars ESA, Turner MR, Malaspina A, Fratta P, Hewamadduma C, Jenkins TM, McDermott CJ, Wang D, Kirby J, Shaw PJ. Value of systematic genetic screening of patients with amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2021; 92:510-518. [PMID: 33589474 PMCID: PMC8053339 DOI: 10.1136/jnnp-2020-325014] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/15/2020] [Accepted: 11/25/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The clinical utility of routine genetic sequencing in amyotrophic lateral sclerosis (ALS) is uncertain. Our aim was to determine whether routine targeted sequencing of 44 ALS-relevant genes would have a significant impact on disease subclassification and clinical care. METHODS We performed targeted sequencing of a 44-gene panel in a prospective case series of 100 patients with ALS recruited consecutively from the Sheffield Motor Neuron Disorders Clinic, UK. All participants were diagnosed with ALS by a specialist Consultant Neurologist. 7/100 patients had familial ALS, but the majority were apparently sporadic cases. RESULTS 21% of patients with ALS carried a confirmed pathogenic or likely pathogenic mutation, of whom 93% had no family history of ALS. 15% met the inclusion criteria for a current ALS genetic-therapy trial. 5/21 patients with a pathogenic mutation had an additional variant of uncertain significance (VUS). An additional 21% of patients with ALS carried a VUS in an ALS-associated gene. Overall, 13% of patients carried more than one genetic variant (pathogenic or VUS). Patients with ALS carrying two variants developed disease at a significantly earlier age compared with patients with a single variant (median age of onset=56 vs 60 years, p=0.0074). CONCLUSIONS Routine screening for ALS-associated pathogenic mutations in a specialised ALS referral clinic will impact clinical care in 21% of cases. An additional 21% of patients have variants in the ALS gene panel currently of unconfirmed significance after removing non-specific or predicted benign variants. Overall, variants within known ALS-linked genes are of potential clinical importance in 42% of patients.
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Affiliation(s)
- Stephanie R Shepheard
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
| | - Matthew D Parker
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
| | - Johnathan Cooper-Knock
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
| | - Nick S Verber
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
| | - Lee Tuddenham
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
| | - Paul Heath
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
| | - Nick Beauchamp
- Human Genetics, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Elsie Place
- Human Genetics, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | | | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Andrea Malaspina
- Neuroscience and Trauma, Queen Mary University of London, London, UK
| | - Pietro Fratta
- Department of Neuromuscular Diseases, University College London Institute of Neurology, London, UK
- MRC Centre for Neuromuscular Diseases, University College London Institute of Neurology, London, UK
| | - Channa Hewamadduma
- Academic Directorate of Neuroscience, Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Thomas M Jenkins
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
| | - Christopher J McDermott
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
| | - Dennis Wang
- Sheffield Bioinformatics Core, The University of Sheffield, Sheffield, UK
| | - Janine Kirby
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
- Academic Directorate of Neuroscience, Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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42
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Thompson AG, Gray E, Charles PD, Hu MTM, Talbot K, Fischer R, Kessler BM, Turner MR. Network Analysis of the CSF Proteome Characterizes Convergent Pathways of Cellular Dysfunction in ALS. Front Neurosci 2021; 15:642324. [PMID: 33815045 PMCID: PMC8010303 DOI: 10.3389/fnins.2021.642324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/18/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis is a clinical syndrome with complex biological determinants, but which in most cases is characterized by TDP-43 pathology. The identification in CSF of a protein signature of TDP-43 network dysfunction would have the potential to inform the identification of new biomarkers and therapeutic targets. METHODS We compared CSF proteomic data from patients with ALS (n = 41), Parkinson's disease (n = 19) and healthy control participants (n = 20). Weighted correlation network analysis was used to identify modules within the CSF protein network and combined with gene ontology enrichment analysis to functionally annotate module proteins. Analysis of module eigenproteins and differential correlation analysis of the CSF protein network was used to compare ALS and Parkinson's disease protein co-correlation with healthy controls. In order to monitor temporal changes in the CSF proteome, we performed longitudinal analysis of the CSF proteome in a subset of ALS patients. RESULTS Weighted correlation network analysis identified 10 modules, including those enriched for terms involved in gene expression including nucleic acid binding, RNA metabolism and translation; humoral immune system function, including complement pathways; membrane proteins, axonal outgrowth and adherence; and glutamatergic synapses. Immune system module eigenproteins were increased in ALS, whilst axonal module eigenproteins were decreased in ALS. The 19 altered protein correlations in ALS were enriched for gene expression (OR 3.05, p = 0.017) and membrane protein modules (OR 17.48, p = 0.011), including intramodular hub proteins previously identified as TDP-43 interactors. Proteins decreasing over longitudinal analysis ALS were enriched in glutamatergic synapse and axonal outgrowth modules. Protein correlation network disruptions in Parkinson's disease showed no module enrichment. CONCLUSIONS Alterations in the co-correlation network in CSF samples identified a set of pathways known to be associated with TDP-43 dysfunction in the pathogenesis of ALS, with important implications for therapeutic targeting and biomarker development.
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Affiliation(s)
- Alexander G. Thompson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Elizabeth Gray
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Philip D. Charles
- Target Discovery Institute, Centre for Medicines Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Michele T. M. Hu
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Roman Fischer
- Target Discovery Institute, Centre for Medicines Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Benedikt M. Kessler
- Target Discovery Institute, Centre for Medicines Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Martin R. Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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43
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de Carvalho M, Kiernan MC, Pullman SL, Rezania K, Turner MR, Simmons Z. Neurophysiological features of primary lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2021; 21:11-17. [DOI: 10.1080/21678421.2020.1837174] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Mamede de Carvalho
- Instituto de Fisiologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal
| | - Matthew C. Kiernan
- Brain and Mind Centre, University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Seth L Pullman
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Kourosh Rezania
- Department of Neurology, The University of Chicago, Chicago, IL, USA
| | - MR Turner
- Department of Clinical Neurology, University of Oxford, John Radcliffe Hospital, Oxford, UK, and
| | - Zachary Simmons
- Department of Neurology, Pennsylvania State University, Hershey, PA, US
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44
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Rutkove SB, Shefner JM, Bowser R, Turner MR, Benatar M. To Zoom or Not to Zoom: The Should I Travel Index Revisited during the Coronavirus Disease Pandemic. Ann Neurol 2021; 89:1057-1058. [PMID: 33522018 DOI: 10.1002/ana.26038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 01/30/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Seward B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | | | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Michael Benatar
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, FL, USA
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45
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Steinacker P, Feneberg E, Halbgebauer S, Witzel S, Verde F, Oeckl P, Van Damme P, Gaur N, Gray E, Grosskreutz J, Jardel CG, Kachanov M, Kuhle J, Lamari F, Maceski A, Del Mar Amador M, Mayer B, Morelli C, Petri S, Poesen K, Raaphorst J, Salachas F, Silani V, Turner MR, Verbeek MM, Volk AE, Weishaupt JH, Weydt P, Ludolph AC, Otto M. Chitotriosidase as biomarker for early stage amyotrophic lateral sclerosis: a multicenter study. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:276-286. [PMID: 33576252 DOI: 10.1080/21678421.2020.1861023] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective: Levels of chitotriosidase (CHIT1) are increased in the cerebrospinal fluid (CSF) of amyotrophic lateral sclerosis (ALS) patients reflecting microglial activation. Here, we determine the diagnostic and prognostic potential of CHIT1 for early symptomatic ALS. Methods: Overall, 275 patients from 8 European neurological centers were examined. We included ALS with <6 and >6 months from symptom onset, other motoneuron diseases (oMND), ALS mimics (DCon) and non-neurodegenerative controls (Con). CSF CHIT1 levels were analyzed for diagnostic power and association with progression and survival in comparison to the benchmark neurofilament. The 24-bp duplication polymorphism of CHIT1 was analyzed in a subset of patients (N = 65). Results: Homozygous CHIT1 duplication mutation carriers (9%) invariably had undetectable CSF CHIT1 levels, while heterozygous carriers had similar levels as patients with wildtype CHIT1 (p = 0.414). In both early and late symptomatic ALS CHIT1 levels was increased, did not correlate with patients' progression rates, and was higher in patients diagnosed with higher diagnostic certainty. Neurofilament levels correlated with CHIT1 levels and prevailed over CHIT1 regarding diagnostic performance. Both CHIT1 and neurofilaments were identified as independent predictors of survival in late but not early symptomatic ALS. Evidence is provided that CHIT1 predicts progression in El Escorial diagnostic category in the group of ALS cases with a short duration. Conclusions: CSF CHIT1 level may have additional value in the prognostication of ALS patients with a short history of symptoms classified in diagnostic categories of lower clinical certainty. To fully interpret apparently low CHIT1 levels knowledge of CHIT1 genotype is needed.
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Affiliation(s)
| | - Emily Feneberg
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Simon Witzel
- Department of Neurology, Ulm University, Ulm, Germany
| | - Federico Verde
- Department of Neurology - Stroke Unit and Laboratory of Neuroscience, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Pathophysiology and Transplantation - "Dino Ferrari" Center, Università degli Studi di Milano, Milan, Italy
| | - Patrick Oeckl
- Department of Neurology, Ulm University, Ulm, Germany
| | - Philip Van Damme
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, VIB - Center for Brain & Disease Research, Experimental Neurology - Laboratory of Neurobiology, KU Leuven - University of Leuven, Leuven, Belgium
| | - Nayana Gaur
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Elizabeth Gray
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Claude G Jardel
- Department of Metabolic Biochemistry, Hôpitaux Universitaires Pitié Salpeêtrière-Charles Foix, Paris, France
| | - Mykyta Kachanov
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Kuhle
- Neurology, Departments of Biomedicine, Medicine and Clinical Research, University and University Hospital Basel, Basel, Switzerland
| | - Foudil Lamari
- Department of Metabolic Biochemistry, Hôpitaux Universitaires Pitié Salpeêtrière-Charles Foix, Paris, France
| | - Aleksandra Maceski
- Neurology, Departments of Biomedicine, Medicine and Clinical Research, University and University Hospital Basel, Basel, Switzerland
| | - Maria Del Mar Amador
- Neurological Diseases Department, Paris ALS Reference Center, Hôpitaux Universitaires Pitié Salpeêtrière-Charles Foix, Paris, France
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Claudia Morelli
- Department of Neurology - Stroke Unit and Laboratory of Neuroscience, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Koen Poesen
- Laboratory of Molecular Neurobiomarker Research, Leuven Brain Institute, KU Leuven and Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - Joost Raaphorst
- Department of Neurology, Amsterdam Neuroscience Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - François Salachas
- Neurological Diseases Department, Paris ALS Reference Center, Hôpitaux Universitaires Pitié Salpeêtrière-Charles Foix, Paris, France
| | - Vincenzo Silani
- Department of Neurology - Stroke Unit and Laboratory of Neuroscience, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Pathophysiology and Transplantation - "Dino Ferrari" Center, Università degli Studi di Milano, Milan, Italy
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Marcel M Verbeek
- Departments of Neurology and Laboratory Medicine, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander E Volk
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Patrick Weydt
- Department for Neurodegenerative Disorders and Gerontopsychiatry, Bonn University, Bonn, Germany
| | | | - Markus Otto
- Department of Neurology, Ulm University, Ulm, Germany
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46
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Kiernan MC, Vucic S, Talbot K, McDermott CJ, Hardiman O, Shefner JM, Al-Chalabi A, Huynh W, Cudkowicz M, Talman P, Van den Berg LH, Dharmadasa T, Wicks P, Reilly C, Turner MR. Improving clinical trial outcomes in amyotrophic lateral sclerosis. Nat Rev Neurol 2021; 17:104-118. [PMID: 33340024 PMCID: PMC7747476 DOI: 10.1038/s41582-020-00434-z] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/11/2022]
Abstract
Individuals who are diagnosed with amyotrophic lateral sclerosis (ALS) today face the same historically intransigent problem that has existed since the initial description of the disease in the 1860s - a lack of effective therapies. In part, the development of new treatments has been hampered by an imperfect understanding of the biological processes that trigger ALS and promote disease progression. Advances in our understanding of these biological processes, including the causative genetic mutations, and of the influence of environmental factors have deepened our appreciation of disease pathophysiology. The consequent identification of pathogenic targets means that the introduction of effective therapies is becoming a realistic prospect. Progress in precision medicine, including genetically targeted therapies, will undoubtedly change the natural history of ALS. The evolution of clinical trial designs combined with improved methods for patient stratification will facilitate the translation of novel therapies into the clinic. In addition, the refinement of emerging biomarkers of therapeutic benefits is critical to the streamlining of care for individuals. In this Review, we synthesize these developments in ALS and discuss the further developments and refinements needed to accelerate the introduction of effective therapeutic approaches.
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Affiliation(s)
- Matthew C Kiernan
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
| | - Steve Vucic
- Sydney Medical School Westmead, University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Christopher J McDermott
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield, UK
| | - Orla Hardiman
- Academic Neurology Unit, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
- National Neuroscience Centre, Beaumont Hospital, Dublin, Ireland
| | - Jeremy M Shefner
- Department of Neurology, Barrow Neurological Institute, University of Arizona College of Medicine Phoenix, Creighton University, Phoenix, AZ, USA
| | - Ammar Al-Chalabi
- King's College London, Maurice Wohl Clinical Neuroscience Institute, Department of Basic and Clinical Neuroscience, London, UK
| | - William Huynh
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Merit Cudkowicz
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Paul Talman
- Neurosciences Department, Barwon Health District, Melbourne, Victoria, Australia
| | - Leonard H Van den Berg
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Thanuja Dharmadasa
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Paul Wicks
- Wicks Digital Health, Lichfield, United Kingdom
| | - Claire Reilly
- The Motor Neurone Disease Association of New Zealand, Auckland, New Zealand
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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47
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Feneberg E, Charles PD, Finelli MJ, Scott C, Kessler BM, Fischer R, Ansorge O, Gray E, Talbot K, Turner MR. Detection and quantification of novel C-terminal TDP-43 fragments in ALS-TDP. Brain Pathol 2021; 31:e12923. [PMID: 33300249 PMCID: PMC8412074 DOI: 10.1111/bpa.12923] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/13/2020] [Accepted: 12/07/2020] [Indexed: 12/25/2022] Open
Abstract
The pathological hallmark of amyotrophic lateral sclerosis (ALS) is the presence of cytoplasmic inclusions, containing C-terminal fragments of the protein TDP-43. Here, we tested the hypothesis that highly sensitive mass spectrometry with parallel reaction monitoring (MS-PRM) can generate a high-resolution map of pathological TDP-43 peptide ratios to form the basis for quantitation of abnormal C-terminal TDP-43 fragment enrichment. Human cortex and spinal cord, microscopically staged for the presence of p-TDP-43, p-tau, alpha-synuclein, and beta-amyloid pathology, were biochemically fractionated and analyzed by immunoblot and MS for the detection of full-length and truncated (disease-specific) TDP-43 peptides. This informed the synthesis of heavy isotope-labeled peptides for absolute quantification of TDP-43 by MS-PRM across 16 ALS, 8 Parkinson's, 8 Alzheimer's disease, and 8 aged control cases. We confirmed by immunoblot the previously described enrichment of pathological C-terminal fragments in ALS-TDP urea fractions. Subsequent MS analysis resolved specific TDP-43 N- and C-terminal peptides, including a novel N-terminal truncation site-specific peptide. Absolute quantification of peptides by MS-PRM showed an increased C:N-terminal TDP-43 peptide ratio in ALS-TDP brain compared to normal and disease controls. A C:N-terminal ratio >1.5 discriminated ALS from controls with a sensitivity of 100% (CI 79.6-100) and specificity of 100% (CI 68-100), and from Parkinson's and Alzheimer's disease with a sensitivity of 93% (CI 70-100) and specificity of 100% (CI 68-100). N-terminal truncation site-specific peptides were increased in ALS in line with C-terminal fragment enrichment, but were also found in a proportion of Alzheimer cases with normal C:N-terminal ratio but coexistent limbic TDP-43 neuropathological changes. In conclusion this is a novel, sensitive, and specific method to quantify the enrichment of pathological TDP-43 fragments in human brain, which could form the basis for an antibody-free assay. Our methodology has the potential to help clarify if specific pathological TDP-43 peptide signatures are associated with primary or secondary TDP-43 proteinopathies.
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Affiliation(s)
- Emily Feneberg
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Philip D Charles
- Nuffield Department of Medicine, Centre for Medicines Discovery, Target Discovery Institute, University of Oxford, Headington, UK
| | - Mattéa J Finelli
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Connor Scott
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Benedikt M Kessler
- Nuffield Department of Medicine, Centre for Medicines Discovery, Target Discovery Institute, University of Oxford, Headington, UK
| | - Roman Fischer
- Nuffield Department of Medicine, Centre for Medicines Discovery, Target Discovery Institute, University of Oxford, Headington, UK
| | - Olaf Ansorge
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Elizabeth Gray
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
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48
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Wang C, Foxley S, Ansorge O, Bangerter-Christensen S, Chiew M, Leonte A, Menke RA, Mollink J, Pallebage-Gamarallage M, Turner MR, Miller KL, Tendler BC. Methods for quantitative susceptibility and R2* mapping in whole post-mortem brains at 7T applied to amyotrophic lateral sclerosis. Neuroimage 2020; 222:117216. [PMID: 32745677 PMCID: PMC7775972 DOI: 10.1016/j.neuroimage.2020.117216] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/03/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
Susceptibility weighted magnetic resonance imaging (MRI) is sensitive to the local concentration of iron and myelin. Here, we describe a robust image processing pipeline for quantitative susceptibility mapping (QSM) and R2* mapping of fixed post-mortem, whole-brain data. Using this pipeline, we compare the resulting quantitative maps in brains from patients with amyotrophic lateral sclerosis (ALS) and controls, with validation against iron and myelin histology. Twelve post-mortem brains were scanned with a multi-echo gradient echo sequence at 7T, from which susceptibility and R2* maps were generated. Semi-quantitative histological analysis for ferritin (the principal iron storage protein) and myelin proteolipid protein was performed in the primary motor, anterior cingulate and visual cortices. Magnetic susceptibility and R2* values in primary motor cortex were higher in ALS compared to control brains. Magnetic susceptibility and R2* showed positive correlations with both myelin and ferritin estimates from histology. Four out of nine ALS brains exhibited clearly visible hyperintense susceptibility and R2* values in the primary motor cortex. Our results demonstrate the potential for MRI-histology studies in whole, fixed post-mortem brains to investigate the biophysical source of susceptibility weighted MRI signals in neurodegenerative diseases like ALS.
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Affiliation(s)
- Chaoyue Wang
- Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging, FMRIB, University of Oxford, United Kingdom.
| | - Sean Foxley
- Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging, FMRIB, University of Oxford, United Kingdom; Department of Radiology, University of Chicago, United States
| | - Olaf Ansorge
- Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Sarah Bangerter-Christensen
- Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom; Brigham Young University, Provo, United States
| | - Mark Chiew
- Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging, FMRIB, University of Oxford, United Kingdom
| | - Anna Leonte
- Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging, FMRIB, University of Oxford, United Kingdom; University of Groningen,the Netherlands
| | - Ricarda Al Menke
- Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging, FMRIB, University of Oxford, United Kingdom
| | - Jeroen Mollink
- Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging, FMRIB, University of Oxford, United Kingdom; Department of Anatomy, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, the Netherlands
| | | | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging, FMRIB, University of Oxford, United Kingdom; Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - Karla L Miller
- Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging, FMRIB, University of Oxford, United Kingdom
| | - Benjamin C Tendler
- Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging, FMRIB, University of Oxford, United Kingdom
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49
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Pioro EP, Turner MR, Bede P. Neuroimaging in primary lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2020; 21:18-27. [PMID: 33602015 DOI: 10.1080/21678421.2020.1837176] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/15/2022]
Abstract
Increased interest in the underlying pathogenesis of primary lateral sclerosis (PLS) and its relationship to amyotrophic lateral sclerosis (ALS) has corresponded to a growing number of CNS imaging studies, especially in the past decade. Both its rarity and uncertainty of definite diagnosis prior to 4 years from symptom onset have resulted in PLS being less studied than ALS. In this review, we highlight most relevant papers applying magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), and positron emission tomography (PET) to analyzing CNS changes in PLS, often in relation to ALS. In patients with PLS, mostly brain, but also spinal cord has been evaluated since significant neurodegeneration is essentially restricted to upper motor neuron (UMN) structures and related pathways. Abnormalities of cortex and subcortical white matter tracts have been identified by structural and functional MRI and MRS studies, while metabolic and cell-specific changes in PLS brain have been revealed using various PET radiotracers. Future neuroimaging studies will continue to explore the interface between the PLS-ALS continuum, identify more changes unique to PLS, apply novel MRI and MRS sequences showing greater structural and neurochemical detail, as well as expand the repertoire of PET radiotracers that reveal various cellular pathologies. Neuroimaging has the potential to play an important role in the evaluation of novel therapies for patients with PLS.
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Affiliation(s)
- Erik P Pioro
- Section of ALS & Related Disorders, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter Bede
- Computational Neuroimaging Group, Trinity College Dublin, Dublin, Ireland
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50
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Mitsumoto H, Turner MR, Ajroud-Driss S, Andres P, Andrews J, Gomez EA, Atehortua JMS, Babu S, Barohn R, Bede P, Benatar M, Chew S, Conwit R, Corcia P, Cudkowicz M, Davis F, Carvalho MD, Drory V, Elman L, Factor-Litvak P, Fernandes JAM, Ferrey D, Finegan E, Fink J, Floeter MK, Fournier C, Genge A, Govindarajan R, Granit V, Haase G, Hardiman O, Harms M, Hayat G, Heiman-Patterson T, Hill B, Hübers A, Huey E, Jawdat O, Kano O, Kau K, Kiernan M, Kisanuki Y, Kurent J, Kwan J, Lange D, Ludolph A, Mackenzie I, Manfredi G, Marren D, Morita M, Murphy J, Nations S, Oskarsson B, Paganoni S, Pellerin D, Ravits J, Rezania K, Rouleau G, Scelsa S, Siddique T, Siddique N, Silani V, Simmons Z, Statland J, Traynor B, Blitterswijk MV, Berg LVD, Walk D, Warden D, Wymer J. Preface: promoting research in PLS: current knowledge and future challenges. Amyotroph Lateral Scler Frontotemporal Degener 2020; 21:1-2. [PMID: 33602018 DOI: 10.1080/21678421.2020.1840795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Hiroshi Mitsumoto
- Eleanor and Lou Gehrig ALS Center, Columbia University Medical Center, New York, NY, USA, and
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, Oxford University, London, UK
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