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Bar-Or A, Thanei GA, Harp C, Bernasconi C, Bonati U, Cross AH, Fischer S, Gaetano L, Hauser SL, Hendricks R, Kappos L, Kuhle J, Leppert D, Model F, Sauter A, Koendgen H, Jia X, Herman AE. Blood neurofilament light levels predict non-relapsing progression following anti-CD20 therapy in relapsing and primary progressive multiple sclerosis: findings from the ocrelizumab randomised, double-blind phase 3 clinical trials. EBioMedicine 2023; 93:104662. [PMID: 37354600 DOI: 10.1016/j.ebiom.2023.104662] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/25/2023] [Accepted: 06/03/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Neurofilament light chain (NfL), a neuronal cytoskeletal protein that is released upon neuroaxonal injury, is associated with multiple sclerosis (MS) relapsing activity and has demonstrated some prognostic ability for future relapse-related disease progression, yet its value in assessing non-relapsing disease progression remains unclear. METHODS We examined baseline and longitudinal blood NfL levels in 1421 persons with relapsing MS (RMS) and 596 persons with primary progressive MS (PPMS) from the pivotal ocrelizumab MS trials. NfL treatment-response and risk for disease worsening (including disability progression into the open-label extension period and slowly expanding lesions [SELs] on brain MRI) at baseline and following treatment with ocrelizumab were evaluated using time-to-event analysis and linear regression models. FINDINGS In persons from the RMS control arms without acute disease activity and in the entire PPMS control arm, higher baseline NfL was prognostic for greater whole brain and thalamic atrophy, greater volume expansion of SELs, and clinical progression. Ocrelizumab reduced NfL levels vs. controls in persons with RMS and those with PPMS, and abrogated the prognostic value of baseline NfL on disability progression. Following effective suppression of relapse activity by ocrelizumab, NfL levels at weeks 24 and 48 were significantly associated with long-term risk for disability progression, including up to 9 years of observation in RMS and PPMS. INTERPRETATION Highly elevated NfL from acute MS disease activity may mask a more subtle NfL abnormality that reflects underlying non-relapsing progressive biology. Ocrelizumab significantly reduced NfL levels, consistent with its effects on acute disease activity and disability progression. Persistently elevated NfL levels, observed in a subgroup of persons under ocrelizumab treatment, demonstrate potential clinical utility as a predictive biomarker of increased risk for clinical progression. Suppression of relapsing biology with high-efficacy immunotherapy provides a window into the relationship between NfL levels and future non-relapsing progression. FUNDING F. Hoffmann-La Roche Ltd.
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Affiliation(s)
- Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | | | | | | | | | - Anne H Cross
- Washington University School of Medicine, St Louis, MO, USA
| | | | | | | | | | - Ludwig Kappos
- Multiple Sclerosis Centre, Neurology, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel and University of Basel, Switzerland
| | - Jens Kuhle
- Multiple Sclerosis Centre, Neurology, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel and University of Basel, Switzerland
| | - David Leppert
- Multiple Sclerosis Centre, Neurology, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital Basel and University of Basel, Switzerland
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Kolind S, Gaetano L, Assemlal HE, Bernasconi C, Bonati U, Elliott C, Hagenbuch N, Magon S, Arnold DL, Traboulsee A. Ocrelizumab-treated patients with relapsing multiple sclerosis show volume loss rates similar to healthy aging. Mult Scler 2023; 29:741-747. [PMID: 37148240 PMCID: PMC10176619 DOI: 10.1177/13524585231162586] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
BACKGROUND Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system characterized by two major and interconnected hallmarks: inflammation and progressive neurodegeneration. OBJECTIVE The aim of this work was to compare neurodegenerative processes, in the form of global and regional brain volume loss rates, in healthy controls (HCs) and in patients with relapsing MS (RMS) treated with ocrelizumab, which suppresses acute inflammation. METHODS Whole brain, white matter, cortical gray matter, thalamic, and cerebellar volume loss rates were assessed in 44 HCs that were part of a substudy in the OPERA II randomized controlled trial (NCT01412333) and 59 patients with RMS enrolled in the same substudy as well as age- and sex-matched patients in OPERA I (NCT01247324) and II. Volume loss rates were computed using random coefficients models over a period of 2 years. RESULTS Ocrelizumab-treated patients showed global and regional brain volume loss rates that were approaching that of HCs. CONCLUSION These findings are consistent with an important role of inflammation on overall tissue loss and the role of ocrelizumab in reducing this phenomenon.
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Affiliation(s)
- Shannon Kolind
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | | | | | | | - Douglas L Arnold
- NeuroRx Research, Montreal, QC, Canada/Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
| | - Anthony Traboulsee
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Arnold DL, Sprenger T, Bar-Or A, Wolinsky JS, Kappos L, Kolind S, Bonati U, Magon S, van Beek J, Koendgen H, Bortolami O, Bernasconi C, Gaetano L, Traboulsee A. Ocrelizumab reduces thalamic volume loss in patients with RMS and PPMS. Mult Scler 2022; 28:1927-1936. [PMID: 35672926 PMCID: PMC9493406 DOI: 10.1177/13524585221097561] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: In multiple sclerosis (MS), thalamic integrity is affected directly by demyelination and neuronal loss, and indirectly by gray/white matter lesions outside the thalamus, altering thalamic neuronal projections. Objective: To assess the efficacy of ocrelizumab compared with interferon beta-1a (IFNβ1a)/placebo on thalamic volume loss and the effect of switching to ocrelizumab on volume change in the Phase III trials in relapsing MS (RMS, OPERA I/II; NCT01247324/NCT01412333) and in primary progressive MS (PPMS, ORATORIO; NCT01194570). Methods: Thalamic volume change was computed using paired Jacobian integration and analyzed using an adjusted mixed-effects repeated measurement model. Results: Over the double-blind period, ocrelizumab treatment significantly reduced thalamic volume loss with the largest effect size (Cohen’s d: RMS: 0.561 at week 96; PPMS: 0.427 at week 120) compared with whole brain, cortical gray matter, and white matter volume loss. At the end of up to 7 years of follow-up, patients initially randomized to ocrelizumab still showed less thalamic volume loss than those switching from IFNβ1a ( p < 0.001) or placebo ( p < 0.001). Conclusion: Ocrelizumab effectively reduced thalamic volume loss compared with IFNβ1a/placebo. Early treatment effects on thalamic tissue preservation persisted over time. Thalamic volume loss could be a potential sensitive marker of persisting tissue damage.
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Affiliation(s)
- Douglas L Arnold
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada/NeuroRx Research, Montreal, QC, Canada
| | - Till Sprenger
- Department of Neurology, DKD Helios Klinik Wiesbaden, Wiesbaden, Germany/Research Center for Clinical Neuroimmunology and Neuroscience and MS Center, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Amit Bar-Or
- Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jerry S Wolinsky
- McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience and MS Center, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | | | | | - Johan van Beek
- F. Hoffmann-La Roche Ltd, Basel, Switzerland/Biogen, Baar, Switzerland
| | - Harold Koendgen
- F. Hoffmann-La Roche Ltd, Basel, Switzerland/UCB Farchim SA, Bulle, Switzerland
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Hughes R, Whitley L, Fitovski K, Schneble HM, Muros E, Sauter A, Craveiro L, Dillon P, Bonati U, Jessop N, Pedotti R, Koendgen H. COVID-19 in ocrelizumab-treated people with multiple sclerosis. Mult Scler Relat Disord 2020; 49:102725. [PMID: 33482590 PMCID: PMC7772086 DOI: 10.1016/j.msard.2020.102725] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [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: 10/16/2020] [Revised: 12/22/2020] [Accepted: 12/26/2020] [Indexed: 12/11/2022]
Abstract
Background There are limited data on the impact of coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on people with multiple sclerosis (MS). Objective To better understand SARS-CoV-2 infection in ocrelizumab-treated people with MS. Methods Internal Roche/Genentech data sources: Cases of COVID-19 from ongoing Roche/Genentech clinical trials and from post-marketing use of ocrelizumab until July 31, 2020 were identified and assessed using descriptive statistics. External real-world data (RWD) source: An MS COVID-19 cohort and an ocrelizumab-treated MS COVID-19 cohort were identified and assessed from the OPTUMⓇ de-identified COVID-19 electronic health record (EHR) database. Results Roche/Genentech clinical trial data: There were 51 (1.3%) suspected or confirmed cases of COVID-19 identified from 4,000 patients ongoing in 10 Roche/Genentech clinical trials. Of these, 26 (51%) were confirmed COVID-19 and 25 (49%) were suspected COVID-19. Sixteen (31.4%) patients were hospitalized. COVID-19 severity was mild to moderate in most patients (35, 68.6%). Ten (19.6%) patients had severe disease and there were three (5.9%) fatal cases. Most patients (43, 84.3%) recovered or were recovering. There was no association apparent between duration of exposure to ocrelizumab and COVID-19. Among COVID-19 patients with previous serum immunoglobulin status (27/51, 52.9%), all (27/27, 100%) had IgG levels within the normal range. Roche/Genentech post-marketing safety database data: There were 307 post-marketing cases of COVID-19 in the Roche/Genentech global safety database. Of these, 263 (85.7%) were confirmed and 44 (14.3%) were suspected COVID-19. 100 (32.6%) patients were hospitalized. COVID-19 was asymptomatic, mild or moderate in 143 (46.6%) patients, severe in 52 (16.9%) patients, and critical in 15 (4.9%) patients. There were 17 (5.5%) fatal cases. Information on severity was not reported in 80 (26.1%) cases. Most patients (211, 68.7%) recovered or were recovering at the time of the report. External RWD data source: As of July 13, 2020, the OPTUMⓇ database included EHRs for almost 1.2 million patients with suspected COVID-19, 130,500 of whom met the criteria for confirmed/clinically diagnosed COVID-19. A total of 357 patients with MS with confirmed COVID-19 were identified. Forty-eight (13.4%) were treated with ocrelizumab, of whom 12 (25.0%) were hospitalized and one died (2.1%). Similar rates of hospitalization, invasive ventilation, and death were observed in the ocrelizumab-treated and non-ocrelizumab-treated MS cohorts. Across the Roche/Genentech and RWD sources assessed, age, male sex, and the presence of comorbidities such as hypertension were associated with a more severe disease course of COVID-19. There was a higher number of comorbidities present in hospitalized versus non-hospitalized patients. Conclusions This assessment provides evidence that COVID-19 in ocrelizumab-treated people with MS is predominantly mild to moderate in severity with most patients not requiring hospitalization; in line with data reported from the general population and MS datasets. Risk factors known to be associated with severe COVID-19 outcomes in the general population also appear to influence COVID-19 severity in ocrelizumab-treated people with MS. Case fatality rates for ocrelizumab-treated people with MS were within published ranges for the general population and other MS cohorts.
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Affiliation(s)
| | | | | | | | - Erwan Muros
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | | | | | - Paul Dillon
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
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Hafner P, Bonati U, Klein A, Rubino D, Gocheva V, Schmidt S, Schroeder J, Bernert G, Laugel V, Steinlin M, Capone A, Gloor M, Bieri O, Hemkens LG, Speich B, Zumbrunn T, Gueven N, Fischer D. Effect of Combination l-Citrulline and Metformin Treatment on Motor Function in Patients With Duchenne Muscular Dystrophy: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e1914171. [PMID: 31664444 PMCID: PMC6824222 DOI: 10.1001/jamanetworkopen.2019.14171] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Nitric oxide precursors, such as the amino acid l-arginine and the biguanide antidiabetic drug metformin, have been associated with metabolism and muscle function in patients with Duchenne muscular dystrophy (DMD). The treatment of DMD remains an unmet medical need. OBJECTIVE To evaluate the benefits and harms of a combination of l-citrulline and metformin treatment among patients with DMD. DESIGN, SETTING, AND PARTICIPANTS A single-center randomized double-blind placebo-controlled parallel-group clinical trial was conducted between December 12, 2013, and March 30, 2016, at the University Children's Hospital Basel in Switzerland. A total of 47 ambulant male patients aged 6.5 to 10 years with genetically confirmed DMD were recruited locally and from the patient registries of Switzerland, Germany, Austria, and France. Data were analyzed from April 6, 2016, to September 5, 2019. INTERVENTIONS Patients in the treatment group received 2500 mg of l-citrulline and 250 mg of metformin (combination therapy) 3 times a day for 26 weeks compared with patients in the control group, who received placebo. MAIN OUTCOMES AND MEASURES The primary end point was the change in transfer and standing posture, as assessed by the first dimension of the Motor Function Measure, version 32, from baseline to week 26. Secondary end points included assessments of timed function, quantitative muscle force, biomarkers for muscle necrosis, and adverse events. The 2 prespecified subgroups comprised patients who were able to walk 350 m or more in 6 minutes (stable subgroup) and patients who were not able to walk 350 m in 6 minutes (unstable subgroup) at baseline. RESULTS Among 49 ambulant male children with DMD who were screened for eligibility, 47 patients with a mean (SD) age of 8.2 (1.1) years were randomized to a treatment group receiving combination therapy (n = 23) or a control group receiving placebo (n = 24), and 45 patients completed the study. No significant differences between groups were found in the results of timed function and muscle force tests for overall, proximal and axial, and distal motor function. Among patients receiving combination therapy, the Motor Function Measure first dimension subscore decrease was 5.5% greater than that of patients receiving placebo (95% CI, -1.0% to 12.1%; P = .09). The administration of combination therapy had significantly favorable effects on the first dimension subscore decrease among the 29 patients in the stable subgroup (6.7%; 95% CI, 0.9%-12.6%; P = .03) but not among the 15 patients in the unstable subgroup (3.9%; 95% CI, -13.2% to 20.9%; P = .63). Overall, the treatment was well tolerated with only mild adverse effects. CONCLUSIONS AND RELEVANCE Treatment with combination therapy was not associated with an overall reduction in motor function decline among ambulant patients with DMD; however, a reduction in motor function decline was observed among the stable subgroup of patients treated with combination therapy. The statistically nonsignificant difference of distal motor function in favor of combination therapy and the reduced degeneration of muscle tissue appear to support the treatment concept, but the study may have lacked sufficient statistical power. Further research exploring this treatment option with a greater number of patients is warranted. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01995032.
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Affiliation(s)
- Patricia Hafner
- Division of Pediatric Neurology, University Children's Hospital Basel, Basel, Switzerland
- Division of Neurology, Medical University Clinic, Kantonsspital Baselland, Bruderholz, Switzerland
| | - Ulrike Bonati
- Division of Pediatric Neurology, University Children's Hospital Basel, Basel, Switzerland
| | - Andrea Klein
- Division of Pediatric Neurology, University Children's Hospital Basel, Basel, Switzerland
- Division of Pediatric Neurology, University of Berne Hospital, Berne, Switzerland
- Division of Pediatric Neurology, Lausanne University Hospital, Lausanne, Switzerland
| | - Daniela Rubino
- Division of Pediatric Neurology, University Children's Hospital Basel, Basel, Switzerland
| | - Vanya Gocheva
- Division of Pediatric Neurology, University Children's Hospital Basel, Basel, Switzerland
| | - Simone Schmidt
- Division of Pediatric Neurology, University Children's Hospital Basel, Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jonas Schroeder
- Division of Pediatric Neurology, University Children's Hospital Basel, Basel, Switzerland
| | - Günther Bernert
- Department of Pediatrics, Kaiser Franz Josef Hospital, Vienna, Austria
| | - Vincent Laugel
- Department of Pediatric Neurology, Strasbourg University Hospital, Strasbourg, France
| | - Maja Steinlin
- Division of Pediatric Neurology, University of Berne Hospital, Berne, Switzerland
| | - Andrea Capone
- Division of Pediatric Neurology, Children's Hospital, Aarau, Switzerland
| | - Monika Gloor
- Division of Radiological Physics, Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Oliver Bieri
- Division of Radiological Physics, Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Lars G. Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Benjamin Speich
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Thomas Zumbrunn
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nuri Gueven
- Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Dirk Fischer
- Division of Pediatric Neurology, University Children's Hospital Basel, Basel, Switzerland
- Division of Neurology, Medical University Clinic, Kantonsspital Baselland, Bruderholz, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
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Nagy S, Schädelin S, Hafner P, Bonati U, Scherrer D, Ebi S, Schmidt S, Orsini AL, Bieri O, Fischer D. Longitudinal reliability of outcome measures in patients with Duchenne muscular dystrophy. Muscle Nerve 2019; 61:63-68. [PMID: 31469921 DOI: 10.1002/mus.26690] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 03/28/2019] [Revised: 08/22/2019] [Accepted: 08/27/2019] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The definition of reliable outcome measures is of increasing interest in patients with Duchenne muscular dystrophy (DMD). METHODS In this retrospective study, we analyzed the longitudinal reliability of clinical and radiological endpoints in 29 ambulant patients with DMD. Clinical outcome measures included motor function measure (MFM) and timed function tests, while quantitative MRI data were mean fat fraction (MFF) and T2 relaxation time of thigh muscles. Statistical analysis was based on 3-, 6-, and 12-month follow-up data. RESULTS Quantitative MRI using the MFF was the most sensitive and powerful marker of disease progression with a sample size of four at 1-year follow-up, followed by the D1 domain of MFM (standing and transfer function) with a sample size of 12. DISCUSSION Our data support the longitudinal design of clinical trials over at least 12 months and the combinational use of clinical and radiological surrogate outcome measures.
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Affiliation(s)
- Sara Nagy
- Division of Neuropaediatrics, University of Basel Children's Hospital, University of Basel, Basel, Switzerland.,Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Patricia Hafner
- Division of Neuropaediatrics, University of Basel Children's Hospital, University of Basel, Basel, Switzerland
| | - Ulrike Bonati
- Division of Neuropaediatrics, University of Basel Children's Hospital, University of Basel, Basel, Switzerland.,Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Delia Scherrer
- Division of Neuropaediatrics, University of Basel Children's Hospital, University of Basel, Basel, Switzerland
| | - Selina Ebi
- Division of Neuropaediatrics, University of Basel Children's Hospital, University of Basel, Basel, Switzerland
| | - Simone Schmidt
- Division of Neuropaediatrics, University of Basel Children's Hospital, University of Basel, Basel, Switzerland
| | - Anna-Lena Orsini
- Division of Neuropaediatrics, University of Basel Children's Hospital, University of Basel, Basel, Switzerland.,Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Oliver Bieri
- Department of Radiology, Division of Radiological Physics, University of Basel Hospital, University of Basel, Basel, Switzerland
| | - Dirk Fischer
- Division of Neuropaediatrics, University of Basel Children's Hospital, University of Basel, Basel, Switzerland
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Nagy S, Schmidt S, Hafner P, Klein A, Rubino-Nacht D, Gocheva V, Bieri O, Vuillerot C, Bonati U, Fischer D. Measurements of Motor Function and Other Clinical Outcome Parameters in Ambulant Children with Duchenne Muscular Dystrophy. J Vis Exp 2019. [PMID: 30688316 DOI: 10.3791/58784] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
While the number of new treatment options tested in patients with Duchenne muscular dystrophy (DMD) is increasing, there is still no defining of the most reliable assessments regarding therapeutic efficacy. We present clinical and radiological outcome measures used in ambulatory patients participating in our trial "Treatment with L-citrulline and metformin in Duchenne muscular dystrophy". The motor function measure is a validated test in patients with neuromuscular disorders that consists of 32 items and assesses all three dimensions of motor performance including standing and transfer (D1 subscore), axial and proximal motor function (D2 subscore), and distal motor function (D3 subscore). The test shows high intra- and inter-rater variability but only when strictly following guidelines of the materials, examination steps, and calculation of scores. The 6-minute walk test, timed 10-meter walk/run test, and supine-up time are commonly used timed functional tests that also sufficiently monitor changes in muscle function; however, they strongly depend on patient collaboration. Quantitative MRI is an objective and sensitive biomarker to detect subclinical changes, though the examination costs may be a reason for its limited use. In this study, a high correlation between all clinical assessments and quantitative MRI scans was found. The combinational use of these methods provides a better understanding about disease progression; however, longitudinal studies are needed to validate their reliability.
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Affiliation(s)
- Sara Nagy
- Division of Pediatric Neurology, University Children's Hospital Basel (UKBB), University of Basel; Department of Neurology, University Hospital Basel, University of Basel;
| | - Simone Schmidt
- Division of Pediatric Neurology, University Children's Hospital Basel (UKBB), University of Basel; Department of Neurology, University Hospital Basel, University of Basel
| | - Patricia Hafner
- Division of Pediatric Neurology, University Children's Hospital Basel (UKBB), University of Basel; Division of Neurology, University Clinic of Medicine, Cantonal Hospital Baselland, Bruderholz
| | - Andrea Klein
- Division of Pediatric Neurology, University Children's Hospital Basel (UKBB), University of Basel; Division of Pediatric Neurology, CHUV; Division of Neuropaediatrics, Inselspital, University Children's Hospital Bern
| | - Daniela Rubino-Nacht
- Division of Pediatric Neurology, University Children's Hospital Basel (UKBB), University of Basel
| | - Vanya Gocheva
- Division of Pediatric Neurology, University Children's Hospital Basel (UKBB), University of Basel
| | - Oliver Bieri
- Department of Radiology, Division of Radiological Physics, University Hospital Basel, University of Basel
| | - Carole Vuillerot
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfant, L'Escale, Service de Médecine Physique et de Réadaptation Pédiatrique
| | - Ulrike Bonati
- Division of Pediatric Neurology, University Children's Hospital Basel (UKBB), University of Basel; Department of Neurology, University Hospital Basel, University of Basel
| | - Dirk Fischer
- Division of Pediatric Neurology, University Children's Hospital Basel (UKBB), University of Basel; Department of Neurology, University Hospital Basel, University of Basel; Division of Neurology, University Clinic of Medicine, Cantonal Hospital Baselland, Bruderholz
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Tsagkas C, Altermatt A, Bonati U, Pezold S, Reinhard J, Amann M, Cattin P, Wuerfel J, Fischer D, Parmar K, Fischmann A. Reliable and fast volumetry of the lumbar spinal cord using cord image analyser (Cordial). Eur Radiol 2018; 28:4488-4495. [PMID: 29713776 DOI: 10.1007/s00330-018-5431-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 02/28/2018] [Accepted: 03/16/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To validate the precision and accuracy of the semi-automated cord image analyser (Cordial) for lumbar spinal cord (SC) volumetry in 3D T1w MRI data of healthy controls (HC). MATERIALS AND METHODS 40 3D T1w images of 10 HC (w/m: 6/4; age range: 18-41 years) were acquired at one 3T-scanner in two MRI sessions (time interval 14.9±6.1 days). Each subject was scanned twice per session, allowing determination of test-retest reliability both in back-to-back (intra-session) and scan-rescan images (inter-session). Cordial was applied for lumbar cord segmentation twice per image by two raters, allowing for assessment of intra- and inter-rater reliability, and compared to a manual gold standard. RESULTS While manually segmented volumes were larger (mean: 2028±245 mm3 vs. Cordial: 1636±300 mm3, p<0.001), accuracy assessments between manually and semi-automatically segmented images showed a mean Dice-coefficient of 0.88±0.05. Calculation of within-subject coefficients of variation (COV) demonstrated high intra-session (1.22-1.86%), inter-session (1.26-1.84%), as well as intra-rater (1.73-1.83%) reproducibility. No significant difference was shown between intra- and inter-session reproducibility or between intra-rater reliabilities. Although inter-rater reproducibility (COV: 2.87%) was slightly lower compared to all other reproducibility measures, between rater consistency was very strong (intraclass correlation coefficient: 0.974). CONCLUSION While under-estimating the lumbar SCV, Cordial still provides excellent inter- and intra-session reproducibility showing high potential for application in longitudinal trials. KEY POINTS • Lumbar spinal cord segmentation using the semi-automated cord image analyser (Cordial) is feasible. • Lumbar spinal cord is 40-mm cord segment 60 mm above conus medullaris. • Cordial provides excellent inter- and intra-session reproducibility in lumbar spinal cord region. • Cordial shows high potential for application in longitudinal trials.
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Affiliation(s)
- Charidimos Tsagkas
- Department of Neurology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland
- Medical Image Analysis Center (MIAC AG), Basel, Mittlere Strasse 83, CH - 4031, Basel, Switzerland
| | - Anna Altermatt
- Medical Image Analysis Center (MIAC AG), Basel, Mittlere Strasse 83, CH - 4031, Basel, Switzerland
- Center for medical Image Analysis & Navigation (CIAN), Department of Bioengineering, University Basel, Gewerbestrasse 14, CH-4123, Allschwil, Switzerland
| | - Ulrike Bonati
- Division of Neuropediatrics, University of Basel Children's Hospital, Spitalstrasse 33, CH-4056, Basel, Switzerland
| | - Simon Pezold
- Center for medical Image Analysis & Navigation (CIAN), Department of Bioengineering, University Basel, Gewerbestrasse 14, CH-4123, Allschwil, Switzerland
| | - Julia Reinhard
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland
| | - Michael Amann
- Department of Neurology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland
- Medical Image Analysis Center (MIAC AG), Basel, Mittlere Strasse 83, CH - 4031, Basel, Switzerland
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland
| | - Philippe Cattin
- Center for medical Image Analysis & Navigation (CIAN), Department of Bioengineering, University Basel, Gewerbestrasse 14, CH-4123, Allschwil, Switzerland
| | - Jens Wuerfel
- Medical Image Analysis Center (MIAC AG), Basel, Mittlere Strasse 83, CH - 4031, Basel, Switzerland
- Center for medical Image Analysis & Navigation (CIAN), Department of Bioengineering, University Basel, Gewerbestrasse 14, CH-4123, Allschwil, Switzerland
| | - Dirk Fischer
- Division of Neuropediatrics, University of Basel Children's Hospital, Spitalstrasse 33, CH-4056, Basel, Switzerland
| | - Katrin Parmar
- Department of Neurology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland.
| | - Arne Fischmann
- Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland
- Division of Neuroradiology, Hirslanden Klinik St. Anna, St. Anna-Strasse 32, CH-6006, Luzern, Switzerland
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9
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Chen X, Wolf D, Siebourg-Polster J, Czech C, Bonati U, Fischer D, Khwaja O, Strahm M. An Objective and Child-friendly Assessment of Arm Function by Using a 3-D Sensor. J Vis Exp 2018. [PMID: 29553555 PMCID: PMC5912404 DOI: 10.3791/57014] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Progressive and irreversible muscle atrophy characterizes Spinal Muscular Atrophy (SMA) and other similar muscle disorder diseases. Objective assessment of muscle functions is an essential and important, although challenging, prerequisite for successful clinical trials. Current clinical rating scales restrain the movement abnormalities to certain predefined coarse-grained individual items. The Kinect 3-D sensor has emerged as a low-cost and portable motion sensing technology used to capture and track people's movement in many medical and research fields. A novel approach using this 3-D sensor was developed and a game-like test was designed to objectively measure the upper limb function of patients with SMA. The prototype test targeted joint movement capability. While sitting in a virtual scene, the patient was instructed to extend, flex, and lift the whole arm in order to reach and place some objects. Both kinematic and spatiotemporal characteristics of upper limb movement were extracted and analyzed, e.g., elbow extension and flexion angles, hand velocity, and acceleration. The first study included a small cohort of 18 ambulant SMA patients and 19 age- and gender-matched healthy controls. A comprehensive analysis of arm movement was achieved; however, no significant difference between the groups were found due to the mismatch of patient's capability and the test difficulty. Based on this experience, a second version of the test consisting of a modified version of the first game with increased difficulties and a second game targeting muscle endurance were designed and implemented. The new test has not been conducted in any patient groups yet. Our work has demonstrated the potential capability of the 3-D sensor in assessing such muscle function and suggested an objective approach to complement the clinical rating scales.
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Affiliation(s)
- Xing Chen
- Data Science, Roche Pharmaceutical Research and Early Development Informatics, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd.;
| | - Detlef Wolf
- Data Science, Roche Pharmaceutical Research and Early Development Informatics, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd
| | - Juliane Siebourg-Polster
- Translational Technologies and Bioinformatics, Pharmaceutical Sciences, Roche Pharmaceutical Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd
| | - Christian Czech
- Biomarker Experimental Medicine, Neuroscience, Roche Pharmaceutical Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd
| | - Ulrike Bonati
- Division of Neuropediatrics, University of Basel Children's Hospital; Department of Neurology, University of Basel Hospital
| | - Dirk Fischer
- Division of Neuropediatrics, University of Basel Children's Hospital; Department of Neurology, University of Basel Hospital
| | - Omar Khwaja
- Translational Medicine, Neuroscience and Rare Diseases, Roche Pharmaceutical Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd
| | - Martin Strahm
- Data Science, Roche Pharmaceutical Research and Early Development Informatics, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd
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10
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Bonati U, Holiga Š, Hellbach N, Risterucci C, Bergauer T, Tang W, Hafner P, Thoeni A, Bieri O, Gerlach I, Marquet A, Khwaja O, Sambataro F, Bertolino A, Dukart J, Fischmann A, Fischer D, Czech C. Longitudinal characterization of biomarkers for spinal muscular atrophy. Ann Clin Transl Neurol 2017; 4:292-304. [PMID: 28491897 PMCID: PMC5420809 DOI: 10.1002/acn3.406] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 03/05/2017] [Indexed: 12/27/2022] Open
Abstract
Objective Recent advances in understanding Spinal Muscular Atrophy (SMA) etiopathogenesis prompted development of potent intervention strategies and raised need for sensitive outcome measures capable of assessing disease progression and response to treatment. Several biomarkers have been proposed; nevertheless, no general consensus has been reached on the most feasible ones. We observed a wide range of measures over 1 year to assess their ability to monitor the disease status and progression. Methods 18 SMA patients and 19 healthy volunteers (HV) were followed in this 52‐weeks observational study. Quantitative‐MRI (qMRI) of both thighs and clinical evaluation of motor function was performed at baseline, 6, 9 and 12 months follow‐up. Blood samples were taken in patients for molecular characterization at screening, 9 and 12 month follow‐up. Progression, responsiveness and reliability of collected indices were quantified. Correlation analysis was performed to test for potential associations. Results QMRI indices, clinical scales and molecular measures showed high to excellent reliability. Significant differences were found between qMRI of SMA patients and HV. Significant associations were revealed between multiple qMRI measures and functional clinical scales. None of the qMRI, clinical, or molecular measures was able to detect significant disease progression over 1 year. Interpretation We probed a variety of quantitative measures for SMA in a slowly‐progressing disease population over 1 year. The presented measures demonstrated potential to provide a closer link to underlying disease biology as compared to conventional functional scales. The proposed biomarker framework can guide implementation of more sensitive endpoints in future clinical trials and prove their utility in search for novel disease‐modifying therapies.
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Affiliation(s)
- Ulrike Bonati
- Division of Neuropediatrics University of Basel Children's Hospital Spitalstrasse 334056 Basel Switzerland.,Department of Neurology University of Basel Hospital Petersgraben 44031 Basel Switzerland
| | - Štefan Holiga
- Roche Pharma and Early Development Neuroscience, Ophthalmology and Rare Diseases Roche Innovation Center Basel F. Hoffmann-La Roche Ltd Grenzacherstrasse 1244070 Basel Switzerland.,Max Planck Institute for Human Cognitive and Brain Sciences Stephan str. 1A04103 Leipzig Germany
| | - Nicole Hellbach
- Roche Pharma and Early Development Neuroscience, Ophthalmology and Rare Diseases Roche Innovation Center Basel F. Hoffmann-La Roche Ltd Grenzacherstrasse 1244070 Basel Switzerland
| | - Céline Risterucci
- Roche Pharma and Early Development Neuroscience, Ophthalmology and Rare Diseases Roche Innovation Center Basel F. Hoffmann-La Roche Ltd Grenzacherstrasse 1244070 Basel Switzerland
| | - Tobias Bergauer
- Roche Pharma and Early Development Neuroscience, Ophthalmology and Rare Diseases Roche Innovation Center Basel F. Hoffmann-La Roche Ltd Grenzacherstrasse 1244070 Basel Switzerland
| | - Wakana Tang
- Roche Molecular Diagnostics Research Genomics & Oncology Roche Molecular Systems Inc.4300 Hacienda Dr Pleasanton 94588 California USA
| | - Patricia Hafner
- Division of Neuropediatrics University of Basel Children's Hospital Spitalstrasse 334056 Basel Switzerland.,Department of Neurology University of Basel Hospital Petersgraben 44031 Basel Switzerland.,University Clinics of Internal Medicine Kantonsspital Baselland Bruderholz 4101 Switzerland
| | - Alain Thoeni
- MIAC AG c/o University of Basel Hospital Mittlere-Strasse 834031 Basel Switzerland.,Department of Radiology University of Basel Hospital Petersgraben 44031 Basel Switzerland
| | - Oliver Bieri
- Department of Radiology University of Basel Hospital Petersgraben 44031 Basel Switzerland
| | - Irene Gerlach
- Roche Pharma and Early Development Neuroscience, Ophthalmology and Rare Diseases Roche Innovation Center Basel F. Hoffmann-La Roche Ltd Grenzacherstrasse 1244070 Basel Switzerland
| | - Anne Marquet
- Roche Pharma and Early Development Neuroscience, Ophthalmology and Rare Diseases Roche Innovation Center Basel F. Hoffmann-La Roche Ltd Grenzacherstrasse 1244070 Basel Switzerland
| | - Omar Khwaja
- Roche Pharma and Early Development Neuroscience, Ophthalmology and Rare Diseases Roche Innovation Center Basel F. Hoffmann-La Roche Ltd Grenzacherstrasse 1244070 Basel Switzerland
| | - Fabio Sambataro
- Roche Pharma and Early Development Neuroscience, Ophthalmology and Rare Diseases Roche Innovation Center Basel F. Hoffmann-La Roche Ltd Grenzacherstrasse 1244070 Basel Switzerland
| | - Alessandro Bertolino
- Roche Pharma and Early Development Neuroscience, Ophthalmology and Rare Diseases Roche Innovation Center Basel F. Hoffmann-La Roche Ltd Grenzacherstrasse 1244070 Basel Switzerland
| | - Juergen Dukart
- Roche Pharma and Early Development Neuroscience, Ophthalmology and Rare Diseases Roche Innovation Center Basel F. Hoffmann-La Roche Ltd Grenzacherstrasse 1244070 Basel Switzerland
| | - Arne Fischmann
- Department of Radiology University of Basel Hospital Petersgraben 44031 Basel Switzerland.,Hirslanden Klinik St. Anna St. Anna-Strasse 326006 Luzern Switzerland
| | - Dirk Fischer
- Division of Neuropediatrics University of Basel Children's Hospital Spitalstrasse 334056 Basel Switzerland.,Department of Neurology University of Basel Hospital Petersgraben 44031 Basel Switzerland
| | - Christian Czech
- Roche Pharma and Early Development Neuroscience, Ophthalmology and Rare Diseases Roche Innovation Center Basel F. Hoffmann-La Roche Ltd Grenzacherstrasse 1244070 Basel Switzerland
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11
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Schmidt S, Gocheva V, Zumbrunn T, Rubino-Nacht D, Bonati U, Fischer D, Hafner P. Treatment with L-citrulline in patients with post-polio syndrome: study protocol for a single-center, randomised, placebo-controlled, double-blind trial. Trials 2017; 18:116. [PMID: 28274276 PMCID: PMC5343398 DOI: 10.1186/s13063-017-1829-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 02/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-polio syndrome (PPS) is a condition that affects polio survivors years after recovery from an initial acute infection by the Poliomyelitis virus. Most often, patients who suffered from polio start to experience gradual new weakening in muscles, a gradual decrease in the size of muscles (muscle atrophy) and fatigue years after the acute illness. L-citrulline is known to change muscular metabolism synthesis by raising nitric oxide (NO) levels and increasing protein synthesis. This investigator-initiated, randomised, placebo-controlled, double-blind, trial aims to demonstrate that L-citrulline positively influences muscle function and increases muscular energy production in patients with PPS. METHODS/DESIGN Thirty ambulant PPS patients will be recruited in Switzerland. Patients will be randomly allocated to one of the two arms of the study (placebo:verum 1:1). After a 24-week run-in phase to observe natural disease history and progression, participants will be treated either with L-citrulline or placebo for 24 weeks. The primary endpoint is change in the 6-min Walking Distance Test. Secondary endpoints will include motor function measure, quantitative muscle force, quantitative muscle magnetic resonance imaging and magnetic resonance spectroscopy and serum biomarker laboratory analysis DISCUSSION: The aim of this phase IIa trial is to determine if treatment with L-citrulline shows a positive effect on clinical function and paraclinical biomarkers in PPS. If treatment with L-citrulline shows positive effects, this might represent a cost-efficient symptomatic therapy for PPS patients. TRIAL REGISTRATION ClinicalTrial.gov, ID: NCT02801071 . Registered on 6 June 2016.
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Affiliation(s)
- Simone Schmidt
- Division of Neuropediatrics, University of Basel Children’s Hospital, Spitalstrasse 33, Postfach 4031 Basel, Switzerland
- Division of Neurology, University Hospital Basel, Basel, Switzerland
| | - Vanya Gocheva
- Division of Neuropediatrics, University of Basel Children’s Hospital, Spitalstrasse 33, Postfach 4031 Basel, Switzerland
| | - Thomas Zumbrunn
- Department of Clinical Research, Clinical Trial Unit, University Hospital Basel, Basel, Switzerland
| | - Daniela Rubino-Nacht
- Division of Neuropediatrics, University of Basel Children’s Hospital, Spitalstrasse 33, Postfach 4031 Basel, Switzerland
| | - Ulrike Bonati
- Division of Neuropediatrics, University of Basel Children’s Hospital, Spitalstrasse 33, Postfach 4031 Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Dirk Fischer
- Division of Neuropediatrics, University of Basel Children’s Hospital, Spitalstrasse 33, Postfach 4031 Basel, Switzerland
- Division of Neurology, University Hospital Basel, Basel, Switzerland
- Division of Neurology, Medical University Clinic, Kantonsspital Baselland, Bruderholz, Switzerland
| | - Patricia Hafner
- Division of Neuropediatrics, University of Basel Children’s Hospital, Spitalstrasse 33, Postfach 4031 Basel, Switzerland
- Division of Neurology, Medical University Clinic, Kantonsspital Baselland, Bruderholz, Switzerland
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12
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Chen X, Siebourg-Polster J, Wolf D, Czech C, Bonati U, Fischer D, Khwaja O, Strahm M. Feasibility of Using Microsoft Kinect to Assess Upper Limb Movement in Type III Spinal Muscular Atrophy Patients. PLoS One 2017; 12:e0170472. [PMID: 28122039 PMCID: PMC5266257 DOI: 10.1371/journal.pone.0170472] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 01/05/2017] [Indexed: 11/19/2022] Open
Abstract
Although functional rating scales are being used increasingly as primary outcome measures in spinal muscular atrophy (SMA), sensitive and objective assessment of early-stage disease progression and drug efficacy remains challenging. We have developed a game based on the Microsoft Kinect sensor, specifically designed to measure active upper limb movement. An explorative study was conducted to determine the feasibility of this new tool in 18 ambulant SMA type III patients and 19 age- and gender-matched healthy controls. Upper limb movement was analysed elaborately through derived features such as elbow flexion and extension angles, arm lifting angle, velocity and acceleration. No significant differences were found in the active range of motion between ambulant SMA type III patients and controls. Hand velocity was found to be different but further validation is necessary. This study presents an important step in the process of designing and handling digital biomarkers as complementary outcome measures for clinical trials.
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Affiliation(s)
- Xing Chen
- Data Science, Roche Pharmaceutical Research and Early Development Informatics, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd., Basel, Switzerland
- * E-mail:
| | - Juliane Siebourg-Polster
- Translational Technologies and Bioinformatics, Pharmaceutical Sciences, Roche Pharmaceutical Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd., Basel, Switzerland
| | - Detlef Wolf
- Data Science, Roche Pharmaceutical Research and Early Development Informatics, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd., Basel, Switzerland
| | - Christian Czech
- Biomarker Experimental Medicine, Neuroscience, Roche Pharmaceutical Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd., Basel, Switzerland
| | - Ulrike Bonati
- Division of Neuropediatrics, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Neurology, University of Basel Hospital, Basel, Switzerland
| | - Dirk Fischer
- Division of Neuropediatrics, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Neurology, University of Basel Hospital, Basel, Switzerland
| | - Omar Khwaja
- Translational Medicine, Neuroscience and Rare Diseases, Roche Pharmaceutical Research and Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd., Basel, Switzerland
| | - Martin Strahm
- Data Science, Roche Pharmaceutical Research and Early Development Informatics, Roche Innovation Center Basel, F. Hoffmann-La Roche, Ltd., Basel, Switzerland
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13
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Hafner P, Bonati U, Rubino D, Gocheva V, Zumbrunn T, Gueven N, Fischer D. Treatment with L-citrulline and metformin in Duchenne muscular dystrophy: study protocol for a single-centre, randomised, placebo-controlled trial. Trials 2016; 17:389. [PMID: 27488051 PMCID: PMC4973063 DOI: 10.1186/s13063-016-1503-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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: 02/27/2016] [Accepted: 07/17/2016] [Indexed: 12/19/2022] Open
Abstract
Background Duchenne muscular dystrophy (DMD) is an X-linked recessive disease that affects 1 in 3500–6000 male births. Despite broad research aiming to improve muscle function as well as heart and brain function, sufficient therapeutic efficacy has not yet been achieved and current therapeutic management is still supportive. In a recent pilot trial, oral treatment with l-arginine and metformin showed consistent changes of muscular metabolism both in vitro and in vivo by raising NO levels and expression of mitochondrial proteins in the skeletal muscle tissue of patients with DMD. This randomised, double-blind, placebo-controlled trial aims to demonstrate the superiority of l-citrulline and metformin therapy over placebo in DMD patients with regard to the Motor Function Measure (MFM) D1 subscore (primary endpoint) as well as additional clinical and subclinical tests. Methods/Design A total of 40–50 ambulant patients with DMD will be recruited at the outpatient department of the University of Basel Children’s Hospital (Switzerland), as well as from the DMD patient registries of Switzerland, Germany and Austria. Patients will be randomly allocated to one of the two arms of the study and will receive either a combination of l-citrulline and metformin or placebo for 26 weeks. Co-medication with glucocorticoids is allowed. The primary endpoint is the change of the MFM D1 subscore from baseline to week 26 under l-citrulline and metformin therapy. Secondary endpoints will include the motor function measure (MFM) and its items and subscores, the 6-minute walking test, timed function tests and quantitative muscle testing. Furthermore, quantitative muscle MRI assessment to evaluate the muscle fat fraction as well as safety and biomarker laboratory analyses from blood will be included. For comparison, muscle metabolism and mitochondrial function will be analysed in 10–20 healthy age-matched male children. Discussion The aim of this study is to test if a 6-month treatment of a combination of l-citrulline and metformin is more effective than placebo in preventing loss of motor function and muscle degeneration in DMD. The MFM D1 subscore is used as a clinical outcome measure and a quantitative muscle MRI assessment as the surrogate outcome measure of fatty muscle degeneration. Trial registration ClinicalTrials.gov: NCT01995032. Registered on 20 November 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1503-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Patricia Hafner
- Division of Neuropaediatrics, University of Basel Children's Hospital, Basel, Switzerland. .,Division of Neurology, Medical University Clinic, Kantonsspital Baselland, Bruderholz, Switzerland. .,Division of Neuropaediatrics, University Children's Hospital, Spitalstrasse 33, Postfach, Basel, 4056, Switzerland.
| | - Ulrike Bonati
- Division of Neuropaediatrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Daniela Rubino
- Division of Neuropaediatrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Vanya Gocheva
- Division of Neuropaediatrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Thomas Zumbrunn
- Department of Clinical research, Clinical Trial Unit, University of Basel Hospital, Basel, Switzerland
| | - Nuri Gueven
- Pharmacy, School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Dirk Fischer
- Division of Neuropaediatrics, University of Basel Children's Hospital, Basel, Switzerland.,Division of Neurology, Medical University Clinic, Kantonsspital Baselland, Bruderholz, Switzerland.,Department of Neurology, University of Basel Hospital, Basel, Switzerland
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14
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Fischer D, Hafner P, Rubino D, Schmid M, Neuhaus C, Jung H, Bieri O, Haas T, Gloor M, Fischmann A, Bonati U. The 6-minute walk test, motor function measure and quantitative thigh muscle MRI in Becker muscular dystrophy: A cross-sectional study. Neuromuscul Disord 2016; 26:414-22. [PMID: 27209345 DOI: 10.1016/j.nmd.2016.04.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 11/17/2022]
Abstract
Becker muscular dystrophy (BMD) has an incidence of 1 in 16 000 male births. This cross-sectional study investigated the relation between validated functional scores and quantitative MRI (qMRI) of thigh muscles in 20 ambulatory BMD patients, aged 18.3-60 years (mean 31.2; SD 11.1). Clinical assessments included the motor function measure (MFM) and its subscales, as well as timed function tests such as the 6-minute walk test (6MWT) and the timed 10-m run/walk test. Quantitative MRI of the thigh muscles included the mean fat fraction (MFF) using a 2-point Dixon (2-PD) technique, and transverse relaxation time (T2) measurements. The mean MFM value was 80.4%, SD 9.44 and the D1 subscore 54.5%, SD 19.9. The median 6MWT was 195m, IQR 160-330.2. The median 10-m run/walk test was 7.4 seconds, IQR 6.1-9.3. The mean fat fraction of the thigh muscles was 55.6%, SD 17.4%, mean T2 relaxation times of all muscles: 69.9 ms, SD 14.4. The flexors had the highest MFF and T2 relaxation times, followed by the extensors and the adductors. MFF and global T2 relaxation times were highly negatively correlated with the MFM total, D1-subscore and 6MWT, and positively correlated with the 10 m run/walk test time (p < 0.01). Age was not correlated with MFF, global T2 relaxation time or clinical assessments. Both MFF and T2 measures in the thigh muscle were well correlated with clinical function in BMD and may serve as a surrogate outcome measure in clinical trials.
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Affiliation(s)
- Dirk Fischer
- Division of Neuropaediatrics, University of Basel Children's Hospital, Switzerland; University Clinic of Internal Medicine, Kantonsspital Baselland, Bruderholz, Switzerland; Department of Neurology, University of Basel Hospital, Switzerland
| | - Patricia Hafner
- Division of Neuropaediatrics, University of Basel Children's Hospital, Switzerland; University Clinic of Internal Medicine, Kantonsspital Baselland, Bruderholz, Switzerland
| | - Daniela Rubino
- Division of Neuropaediatrics, University of Basel Children's Hospital, Switzerland
| | - Maurice Schmid
- Division of Neuropaediatrics, University of Basel Children's Hospital, Switzerland
| | - Cornelia Neuhaus
- Therapy Department, University of Basel Children's Hospital, Switzerland
| | - Hans Jung
- Department of Neurology, University Hospital and University of Zurich, Switzerland
| | - Oliver Bieri
- Division of Radiological Physics, Department of Radiology, University of Basel Hospital, Switzerland
| | - Tanja Haas
- Division of Radiological Physics, Department of Radiology, University of Basel Hospital, Switzerland
| | - Monika Gloor
- Division of Radiological Physics, Department of Radiology, University of Basel Hospital, Switzerland
| | - Arne Fischmann
- Division of Neuroradiology, Institute of Radiology, University of Basel Hospital, Switzerland; Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - Ulrike Bonati
- Division of Neuropaediatrics, University of Basel Children's Hospital, Switzerland.
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15
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Hafner P, Bonati U, Erne B, Schmid M, Rubino D, Pohlman U, Peters T, Rutz E, Frank S, Neuhaus C, Deuster S, Gloor M, Bieri O, Fischmann A, Sinnreich M, Gueven N, Fischer D. Improved Muscle Function in Duchenne Muscular Dystrophy through L-Arginine and Metformin: An Investigator-Initiated, Open-Label, Single-Center, Proof-Of-Concept-Study. PLoS One 2016; 11:e0147634. [PMID: 26799743 PMCID: PMC4723144 DOI: 10.1371/journal.pone.0147634] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 01/05/2016] [Indexed: 12/31/2022] Open
Abstract
Altered neuronal nitric oxide synthase function in Duchenne muscular dystrophy leads to impaired mitochondrial function which is thought to be one cause of muscle damage in this disease. The study tested if increased intramuscular nitric oxide concentration can improve mitochondrial energy metabolism in Duchenne muscular dystrophy using a novel therapeutic approach through the combination of L-arginine with metformin. Five ambulatory, genetically confirmed Duchenne muscular dystrophy patients aged between 7–10 years were treated with L-arginine (3 x 2.5 g/d) and metformin (2 x 250 mg/d) for 16 weeks. Treatment effects were assessed using mitochondrial protein expression analysis in muscular biopsies, indirect calorimetry, Dual-Energy X-Ray Absorptiometry, quantitative thigh muscle MRI, and clinical scores of muscle performance. There were no serious side effects and no patient dropped out. Muscle biopsy results showed pre-treatment a significantly reduced mitochondrial protein expression and increased oxidative stress in Duchenne muscular dystrophy patients compared to controls. Post-treatment a significant elevation of proteins of the mitochondrial electron transport chain was observed as well as a reduction in oxidative stress. Treatment also decreased resting energy expenditure rates and energy substrate use shifted from carbohydrates to fatty acids. These changes were associated with improved clinical scores. In conclusion pharmacological stimulation of the nitric oxide pathway leads to improved mitochondria function and clinically a slowing of disease progression in Duchenne muscular dystrophy. This study shall lead to further development of this novel therapeutic approach into a real alternative for Duchenne muscular dystrophy patients.
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Affiliation(s)
- Patricia Hafner
- Division of Neuropaediatrics, University of Basel Children's Hospital, Basel, Switzerland.,Department of Neurology, University of Basel Hospital, Basel, Switzerland
| | - Ulrike Bonati
- Division of Neuropaediatrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Beat Erne
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Maurice Schmid
- Division of Neuropaediatrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Daniela Rubino
- Division of Neuropaediatrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Urs Pohlman
- Division of Neuropaediatrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Thomas Peters
- Interdisciplinary Center of Nutritional and Metabolic Diseases, St. Claraspital, Basel, Basel, Switzerland
| | - Erich Rutz
- Paediatric Orthopaedic Department, University of Basel Children's Hospital, Basel, Switzerland
| | - Stephan Frank
- Division of Neuropathology, Institute of Pathology, University of Basel Hospital, Basel, Switzerland
| | - Cornelia Neuhaus
- Therapy Department, University of Basel Children's Hospital, Basel, Switzerland
| | - Stefanie Deuster
- Hospital Pharmacy, University of Basel Hospital, Basel, Switzerland
| | - Monika Gloor
- Department of Radiology, Division of Radiological Physics, University of Basel Hospital, Basel, Switzerland
| | - Oliver Bieri
- Department of Radiology, Division of Radiological Physics, University of Basel Hospital, Basel, Switzerland
| | - Arne Fischmann
- Division of Neuroradiology, University of Basel Hospital, Basel, Switzerland
| | - Michael Sinnreich
- Department of Neurology, University of Basel Hospital, Basel, Switzerland.,Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Nuri Gueven
- Pharmacy, School of Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Dirk Fischer
- Division of Neuropaediatrics, University of Basel Children's Hospital, Basel, Switzerland.,Department of Neurology, University of Basel Hospital, Basel, Switzerland
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16
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Bonati U, Schmid M, Hafner P, Haas T, Bieri O, Gloor M, Fischmann A, Fischer D. Longitudinal 2-point dixon muscle magnetic resonance imaging in becker muscular dystrophy. Muscle Nerve 2015; 51:918-21. [PMID: 25736228 DOI: 10.1002/mus.24629] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2015] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Quantitative MRI techniques detect disease progression in myopathies more sensitively than muscle function measures or conventional MRI. To date, only conventional MRI data using visual rating scales are available for measurement of disease progression in Becker muscular dystrophy (BMD). METHODS In 3 patients with BMD (mean age 36.8 years), the mean fat fraction (MFF) of the thigh muscles was assessed by MRI at baseline and at 1-year follow-up using a 2-point Dixon approach (2PD). The motor function measurement scale (MFM) was used for clinical assessment. RESULTS The mean MFF of all muscles at baseline was 61.6% (SD 7.6). It increased by 3.7% to 65.3% (SD 4.7) at follow-up. The severity of muscle involvement varied between various muscle groups. CONCLUSIONS As in other myopathies, 2PD can quantify fatty muscle degeneration in BMD and can detect disease progression in a small sample size and at relatively short imaging intervals.
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Affiliation(s)
- Ulrike Bonati
- Division of Neuropaediatrics, University Children's Hospital Basel, Spitalstrasse 33, Basel, 4031, Switzerland
| | - Maurice Schmid
- Division of Neuropaediatrics, University Children's Hospital Basel, Spitalstrasse 33, Basel, 4031, Switzerland
| | - Patricia Hafner
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Tanja Haas
- Division of Radiological Physics, Department of Radiology, University of Basel Hospital, Basel, Switzerland
| | - Oliver Bieri
- Division of Radiological Physics, Department of Radiology, University of Basel Hospital, Basel, Switzerland
| | - Monika Gloor
- Division of Radiological Physics, Department of Radiology, University of Basel Hospital, Basel, Switzerland
| | - Arne Fischmann
- Division of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Dirk Fischer
- Division of Neuropaediatrics, University Children's Hospital Basel, Spitalstrasse 33, Basel, 4031, Switzerland.,Department of Neurology, University Hospital Basel, Basel, Switzerland.,University Clinic of Internal Medicine, Kantonsspital Baselland, Bruderholz, Switzerland
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Hafner P, Bonati U, Neuhaus C, Rutz E, Frank S, Erne B, Gloor M, Fischmann A, Sinnreich M, Fischer D. O7: Successful pilot trial of L-arginine and metformin in Duchenne’s muscular dystrophy. Clin Neurophysiol 2014. [DOI: 10.1016/s1388-2457(14)50113-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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18
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Bonati U, Bechtel N, Heinimann K, Rutz E, Schneider J, Frank S, Weber P, Fischer D. Congenital muscular dystrophy with dropped head phenotype and cognitive impairment due to a novel mutation in the LMNA gene. Neuromuscul Disord 2014; 24:529-32. [PMID: 24684859 DOI: 10.1016/j.nmd.2014.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [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: 11/22/2013] [Revised: 01/10/2014] [Accepted: 02/07/2014] [Indexed: 10/25/2022]
Abstract
Mutations in A-type nuclear lamins are known to cause a variety of diseases, which can affect almost all organs of the human body including striated muscle. For lamin-related congenital muscular dystrophy two different phenotypes are known to date. Here, we describe a 3-year-old, white Caucasian girl with a novel de novo mutation in the LMNA gene with marked hypotonia of neck and trunk muscles with dropped head posture, loss of cervical lordosis and marked joint laxity. In addition to this novel mutation, the patient also had cerebral white matter lesions on MRI and cognitive impairment on developmental testing. This is only the second A-type lamin-related congenital muscular dystrophy patient in which white matter lesions are described. Thus, white matter involvement might be a feature in A-type lamin-related congenital muscular dystrophy, warranting screening of these patients for both white matter lesions and cognitive impairment.
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Affiliation(s)
- Ulrike Bonati
- Division of Neuropaediatrics, University Children's Hospital Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland.
| | - Nina Bechtel
- Division of Neuropaediatrics, University Children's Hospital Basel, Switzerland
| | - Karl Heinimann
- Division of Medical Genetics, University Hospital Basel, Switzerland
| | - Erich Rutz
- Paediatric Orthopaedic Department, University Children's Hospital Basel, Switzerland
| | - Jacques Schneider
- Division of Neuroradiology, University Children's Hospital Basel, Switzerland
| | - Stephan Frank
- Institute of Pathology, Department of Neuropathology, Basel University Hospital, Switzerland
| | - Peter Weber
- Division of Neuropaediatrics, University Children's Hospital Basel, Switzerland
| | - Dirk Fischer
- Division of Neuropaediatrics, University Children's Hospital Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland
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19
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Hafner P, Bonati U, Fischmann A, Schneider J, Frank S, Morris-Rosendahl DJ, Dumea A, Heinimann K, Fischer D. Skeletal muscle MRI of the lower limbs in congenital muscular dystrophy patients with novel POMT1 and POMT2 mutations. Neuromuscul Disord 2014; 24:321-4. [PMID: 24556424 DOI: 10.1016/j.nmd.2014.01.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 01/06/2014] [Accepted: 01/20/2014] [Indexed: 12/20/2022]
Abstract
Alpha-dystroglycanopathies form a genetically heterogeneous group of congenital muscular dystrophies with a large variety of clinical phenotypes. Within this group mutations in the protein O-mannosyltransferase genes (POMT1 and POMT2) are known to cause a spectrum of CMD disorders including the Walker-Warburg Syndrome with severe brain and ocular malformations, and the limb girdle muscular dystrophy with and without mental retardation. In this case report the clinical phenotype and brain and muscle MRI findings of two siblings of 10 and 7years (male/female) homozygous for a novel mutation in the POMT1 gene (c.2220G>C, p.Trp740Cys) and a 10year old boy with two novel mutations in the POMT2 gene ((c.215G>A, p.Arg72His) and (c.713G>T, p.Gly238Val) are presented. Mutation detection was performed by direct sequencing of the FKRP, FKTN, POMT1 and POMT2 genes. T1-weighted axial muscle MRI of the lower limbs revealed diffuse fatty degeneration of thigh and calf muscles with predominance of gluteus maximus, adductor magnus, posterior thigh, medial gastrocnemius, and peroneus muscles, but no edematous changes. As a similar pattern of muscle involvement had been described in FKRP related α-dystroglycanopathy LGMD2I, we conclude that α-dystroglycanopathies may present with distinctive muscle MRI changes.
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Affiliation(s)
- Patricia Hafner
- Division of Neuropaediatrics, University of Basel Children's Hospital, Switzerland; Department of Neurology, University of Basel Hospital, Switzerland
| | - Ulrike Bonati
- Division of Neuropaediatrics, University of Basel Children's Hospital, Switzerland; Department of Neurology, University of Basel Hospital, Switzerland.
| | - Arne Fischmann
- Department of Radiology, Division of Neuroradiology, University of Basel Hospital, Switzerland
| | - Jacques Schneider
- Department of Radiology, University of Basel Children's Hospital, Switzerland
| | - Stephan Frank
- Division of Neuropathology, Institute of Pathology, University of Basel Hospital, Switzerland
| | | | - Anamaria Dumea
- Institute for Medical Genetics, University of Basel Children's Hospital, Switzerland
| | - Karl Heinimann
- Institute for Medical Genetics, University of Basel Children's Hospital, Switzerland
| | - Dirk Fischer
- Division of Neuropaediatrics, University of Basel Children's Hospital, Switzerland; Department of Neurology, University of Basel Hospital, Switzerland.
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Bonati U, Fisniku LK, Altmann DR, Yiannakas MC, Furby J, Thompson AJ, Miller DH, Chard DT. Cervical cord and brain grey matter atrophy independently associate with long-term MS disability. J Neurol Neurosurg Psychiatry 2011; 82:471-2. [PMID: 20710012 DOI: 10.1136/jnnp.2010.205021] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Vry J, Linder-Lucht M, Berweck S, Bonati U, Hodapp M, Uhl M, Faist M, Mall V. Altered cortical inhibitory function in children with spastic diplegia: a TMS study. Exp Brain Res 2008; 186:611-8. [PMID: 18214452 DOI: 10.1007/s00221-007-1267-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Accepted: 12/24/2007] [Indexed: 12/11/2022]
Abstract
Periventricular leukomalacia (PVL) is the most frequent cause of spastic diplegia. The movement disorder is attributed to damage to the corticospinal tract, but there is increasing evidence of additional cortical dysfunction associated with PVL. Aim of the present study was to evaluate the integrity of the corticospinal tract and cortical inhibitory function using transcranial magnetic stimulation. Fifteen children with bilateral PVL and spastic diplegia and twenty-two healthy children underwent single-pulse stimulations to the right tibial anterior muscle. We compared central motor conduction time and amplitudes of motor evoked potentials as markers for corticospinal integrity and the postexcitatory silent period (SP), representing cortical inhibitory interneurons. The patients' parameters of corticospinal tract function did not differ significantly from those in the control children. In contrast, the SP was significantly shortened in children with PVL (mean 25.6 +/- 6.9 ms; controls: mean 47.6 +/- 23.2 ms, P = 0.018). This suggests cortical involvement with reduced cortical inhibitory function in PVL. This could be due to impaired functioning of the cortical interneurons themselves, or to decreased input from activating fibres, e.g. thalamocortical or cortico-cortical connections.
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Affiliation(s)
- Julia Vry
- Department of Paediatrics and Adolescent Medicine, Division of Neuropaediatrics and Muscular Disorders, University Hospital Freiburg, Mathildenstrasse 1, 79106 Freiburg, Germany.
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