Research that will be presented in 2012 Annual Meeting of American Academy of Neurology
1) [P04.088] A Phase 2,
Randomized, Placebo-Controlled, Multiple Ascending-Dose Study of ACE-031, a
Soluble Activin Receptor Type IIB, in Boys with Duchenne Muscular Dystrophy (DMD)
Craig Campbell, London, ON, Canada, Diana
Escolar, Baltimore, MD, Jean Mah, Calgary, AB, Canada, Mark Tarnopolsky,
Hamilton, ON, Canada, Kathy Selby, Vancouver, BC, Canada, Hugh McMillan, Ottawa,
ON, Canada, Yijun Yang, Dawn Wilson, Rachel Barger, Matthew Sherman, Kenneth
Attie, Cambridge, MA
OBJECTIVE: To evaluate the safety, tolerability, pharmacokinetics, and
pharmacodynamic (PD) effects of ACE-031 in DMD. BACKGROUND: ACE-031 is a
soluble activin type IIB receptor (ActRIIB-IgG1) that binds negative regulators
of muscle, including myostatin and activin. In phase 1 studies in healthy
adults, ACE-031 treatment resulted in dose-dependent increases in lean mass.
DESIGN/METHODS: Ambulatory (30ft walk/run <12sec), steroid-treated DMD boys,
age ≥4yr, were randomized to 12 weeks treatment with either escalating doses of
ACE-031 or placebo (9:3 in each cohort), followed by 12-weeks follow-up. The
primary objective was safety/tolerability. PD endpoints included lean/fat/bone
mass (DXA), thigh muscle, fat volume (MRI), strength,
6-minute-walk-test-distance (6MWD), and other motor/pulmonary function tests.
RESULTS: Two cohorts completed treatment (C1: 0.5mg/kg SC q4weeks, C2:
1mg/kg SC q2weeks). Mean age was 10.3 years (range 6-17). There were no AEs that
were serious, severe, or resulted in discontinuation. Reversible telangiectasias
and mild epistaxis were reported in C2. Mean total body lean mass by DXA
increased 5.2% in C2 (p=0.015 vs baseline) vs 2.6% in placebo (p=0.20) after 12
weeks. Thigh MRI (C2) showed a trend for decreased muscle volume in placebo
group which was attenuated in ACE-031 group. The least-squares mean
Δ6MWD was +12meters in combined
ACE-031 groups vs -30meters in placebo group after 24 weeks (p=0.06, ANCOVA).
The %change in 6MWD correlated with that for 2MWD (r=0.67, p<0.001) and 10m
walk/run (r=-0.53, p=0.009) after 24 weeks. Dose-related trends for decreased
gain in fat mass and increased lumbar spine BMD by DXA were seen after 12 and 24
weeks. CONCLUSIONS: In this phase 2 study of ACE-031 in steroid-treated
DMD boys, reversible telangiectasias and mild epistaxis were reported at higher
dose. Significant dose-dependent increases in lean mass were observed. There
were trends for maintained 6MWD, decreased gain in fat mass, and increased
lumbar spine BMD with ACE-031 treatment. Supported by: MDA, PPMD.
2) [P04.084] Motor and Cognitive
Assessment of Infants and Young Boys with Duchenne Muscular Dystrophy; Results
from the Muscular Dystrophy Association DMD Clinical Research Center Network
Anne Connolly, Julaine Florence, Mary M.
Cradock, Elizabeth Malkus, Jeanine R. Schierbecker, Catherine Siener, Charlie O.
Wulf, Pallavi Anand, Saint Louis, MO, Linda Lowes, Lindsay N. Alfano, Laurence
Viollet-Callendret, Kevin Flanigan, Jerry Mendell, Columbus, OH, Craig McDonald,
Erica Goude , Linda Johnson, Alina Nicorici, Sacramento, CA, Peter Karachunski,
John Day, Joline Dalton, Minneapolis, MN, Janey M. Farber, Saint Paul, MN, Karen
K. Buser, Minneapolis, MN, Basil Darras, Susan O. Riley, Elizabeth Schriber,
Rebecca E. Parad, Boston, MA, Kate Bushby, Newcastle Upon Tyne, United Kingdom,
Michelle Eagle, Newcastle Upon Tyne, United Kingdom, MDA DMD Clinical Research
Network, Tucson, AZ
OBJECTIVE: To implement motor and cognitive assessments in infants and
young boys with Duchenne Muscular Dystrophy(DMD). BACKGROUND: Therapeutic
trials in DMD exclude young boys because traditional outcome measures rely on
cooperation. The Bayley Scales of Infant and Toddler Development(BAYLEY-III)
have been validated in both typically-developing(TD) children and those with
developmental disorders but have not been studied in DMD. Initial work in the
Hammersmith Functional Motor Scale Extended (HFMSE) and North Star Ambulatory
Assessment (NSAA) suggest these may be useful in this young DMD population.
DESIGN/METHODS: Clinical evaluators from six neuromuscular centers were
trained in the use of the BAYLEY-III, NSAA, and HFMSE. Infants and and young
boys with DMD(N=25) (mean=1.84 ± 0.7 years (range=0.37-2.99) were assessed with
the above measures. RESULTS: The Bayley-III mean motor composite score
was 83.5±12 with range 58-103 (TD 100±15). Gross motor function was more
severely involved than fine motor with mean scaled scores of 6.2±1.5 and 7.8±1.9
respectively (TD 10±3). The mean cognitive comprehensive score (N=25) was
89.6±8.7 with range of 65-115 (TD 100±15). The mean receptive and expressive
language scores (N=24) measured 7.1 and 7.9 respectively (TD 10±3). Age was
negatively associated with gross motor scores (linear regression slope p=0.008)
but not with cognitive and language scores. HFMSE was tested in 24 boys and
showed a mean score of 31±13. NSAA was performed in18 boys with a mean age of
2.2±years with a mean score of 12±5. CONCLUSIONS: These outcome
assessments of young infants and boys with DMD are possible in a multicenter
trial with careful clinical evaluator training. Ongoing studies will document
change over two years. Supported by: Muscular Dystrophy Association.
3) [P04.085] Outcomes Measure
Reliability in Non Ambulatory Boys and Men with Duchenne Muscular Dystrophy (DMD):
Results from the Muscular Dystrophy Association DMD Clinical Research Network
Julaine Florence, Anne Connolly, J. Philip
Miller, Elizabeth C. Malkus, Jeanine R. Schierbecker, Catherine A. Siener,
Charlie O. Wulf, Pallavi Anand, Saint Louis, MO, Craig McDonald, Erica Goude,
Linda Johnson, Alina Nicorici, Sacramento, CA, John Day, Peter Karachunski,
Joline Dalton, Minneapolis, MN , Jason M. Kelecic, Kelley Paulson, St. Paul, MN,
Cameron E. Naughton, Minneapolis, MN, Linda Lowes, Lindsay N. Alfano, Laurence
Viollet-Callendret, Kevin Flanigan, Jerry Mendell, Columbus, OH, Basil Darras,
Janet Quigley, Amy E. Pasternak, Elizabeth Shriber, Rebecca E. Parad, Boston,
MA, MDA DMD Clinical Research Network, Tucson, AZ
OBJECTIVE: To establish optimal and reliable assessments in
non-ambulatory boys and men with DMD. BACKGROUND: Therapeutic trials in
DMD most often exclude non-ambulatory individuals and consensus has not been
reached regarding which measures are most reliable and feasible.
DESIGN/METHODS: Clinical evaluators(CEs) from the five MDA-DMD CRN sites
were trained in all assessments. Ninety-three non-ambulatory boys/men with DMD
who were not on continuous ventilation (mean age 16.8±3.6 years) were assessed
twice(AM/PM) on one day with a battery of assessments. Reliability using
intra-class correlation coefficients(ICCs) was determined by comparing AM and PM
measures. Feasibility was determined by the percentage that could perform the
task. RESULTS: Forced Vital Capacity(FVC)(100% of subjects) showed mean
FVC 47±23% predicted with an ICC of 0.97. Manual muscle testing was performed
for shoulder abduction (88% of subjects; ICC=0.95), elbow flexion (96.8% of
subjects; ICC=0.98), wrist flexion (70% of subjects; ICC=0.92) and wrist
extension (96% of subjects; ICC=0.89). Hand Held myometrywas performed for
supine elbow flexion (71% of subjects; ICC=0.93), supine elbow extension (70% of
subjects; ICC=0.94), grip (97% of subject; 0.92), pinch grip(95% of subjects;
ICC=0.84), and key grip (99% of subjects; ICC=0.93). Upper extremity active
range of motion(ROM) ICCs ranged from 0.89-0.99 and passive ROM ranged from 0.71
to 0.97. Nine-hole peg was performed in 77% of subjects with ICC ranging from
0.96-0.97 for dominant and non-dominant hands. Brooke upper extremity scale was
performed on 100% of subjects with an ICC=0.99. Egen Klassifikation(EK) scale
was performed in 100% of subjects with ICCs on individual questions ranging from
0.93 to 0.99. Jebsen-Taylor Hand Function test was performed in 84% of subjects
with ICCs of individual tasks ranging from 0.64 to 0.98. CONCLUSIONS:
This study demonstrates excellent reliability across most measures with
well-trained CEs from five centers. Ongoing studies will test sensitivity to
change across time. Supported by: Muscular Dystrophy Association.
4) [P04.087] Guidelines and
Outcomes; Standardizing Care for Duchenne Muscular Dystrophy
Michele Scully, Rochester, NY, Valerie Cwik,
Tucson, AZ, Bruce Marshall, Bethesda, MD, Emma Ciafaloni, Rochester, NY, Thomas
Getchius, Saint Paul, MN, Robert Griggs, Rochester, NY
OBJECTIVE: To review evidence-based and consensus guidelines for the
treatment of Duchenne Muscular Dystrophy (DMD) and consider how outcome measures
could standardize and improve patient care. BACKGROUND: There are no
evidence-based quality care indicators to standardize outcomes across Muscular
Dystrophy Association (MDA) clinics. We reviewed the Cystic Fibrosis (CF) model
for standardizing CF clinic outcomes and consider potential outcomes to assess
the quality of care in DMD clinics. For forty years, the CF foundation has
maintained a nationwide patient registry and acquired patient data from each CF
clinic. The data, analyzed yearly, is reviewable on the CF website. Comparing
individual and national clinic outcomes challenges clinics to improve clinical
care. This data also provides potential patient populations for future
investigations, including clinical trials. DESIGN/METHODS: We reviewed:
published guidelines and consensus statements on the care of DMD; current
efforts to obtain outcomes from DMD clinics; standardized data obtained annually
from CF clinics; and published approaches to improving outcomes by attention to
the fidelity of health care delivery. RESULTS: There are multiple
approaches within the DMD field for surveillance and collection of patient
information, including MDSTARNet, Parent Project Muscular Dystrophy, and MDA DMD
Clinical Research Network. Based on CF analyzed data, a similar patient registry
and nationwide reporting of standard outcomes across MDA clinics appears
feasible. Monitoring data including molecular diagnosis, age at loss of
ambulation, FVC, and survival, could provide metrics for quality of care.
CONCLUSIONS: There are logistic challenges to reporting nationwide outcomes;
however the influence this model has had on outcomes for CF patients has changed
survival. In 2009, the median life expectancy for a patient with CF was 35.9
years, compared to 27 years in 1985. Implementation of clinical data monitoring
in MDA clinics will determine if similar benefit accrues in patients with
Duchenne Muscular Dystrophy.
5) [S15.003] Natural History of
Cardiomyopathy in Duchenne Muscular Dystrophy and the Effects of Angiotensin-Converting
Enzyme Inhibitor with or without β-Blocker
Philip T. Thrush, Laurence Viollet, Kevin
Flanigan, Jerry Mendell, Hugh Allen, Columbus, OH
OBJECTIVE: To prospectively examine the natural history of cardiomyopathy
(CM) in Duchenne muscular dystrophy (DMD) patients & assess responses to
treatment utilizing angiotensin-converting enzyme inhibitors (ACEI) with or
without concomitant β-blocker
(BB). BACKGROUND: Cardiomyopathy is an invariable consequence of DMD.
Suggested treatments include ACEI and/or BB, but few large series are reported.
We present 65 DMD patients with CM treated with ACEI or ACEI+BB, including their
natural history & therapeutic responses. DESIGN/METHODS: Serial
echocardiograms were performed and reported for natural history analysis prior
to initiation of therapy when available. Adequate ejection fractions (EF) were
obtained in 45 patients at initiation of therapy (EF<55%). Twenty patients were
excluded due to pre-existing ACEI therapy (n=11), inadequate follow-up (n=8), or
inadequate echocardiogram (n=1). ACEI dosage adjustments were made if a
continued decrease in EF was noted. BB therapy initiated when average heart rate
on Holter >100 beats/min. Data analyzed using paired t-test & linear regression.
RESULTS: Natural history data (n=24) demonstrated decreased EF over time
(r2=0.22). At ACEI therapy initiation, the mean age was 14.7 ± 4.4
years & mean EF was 44.3 ± 8.3%. BB therapy was used in 25/45 patients. Mean age
for ACEI+BB group was 16.1 ± 3.9 years. Both groups demonstrated significant
improvement compared to natural history (p≤0.0001 for ACEI, p<0.001 for ACEI+BB).
No significant difference noted between treatment groups. CONCLUSIONS:
Patients with DMD demonstrated gradual decline in myocardial function. Treatment
with ACEI or ACEI+BB resulted in significant improvement compared to the natural
history. No significant difference was noted in EF improvement between treatment
groups. Treatment with ACEI or ACEI+BB can delay progression of CM. Supported
by: Data collection was made possible by the Muscular Dystrophy Association &
Wellstone Muscular Dystrophy Cooperative Research Center (NIH sponsored) and led
to creation of the MDA DMD Clinical Network. Mutational analysis for most
patients performed as part of the United Dystrophinopathy Project-supported by
NINDS (R01 NS043264)[K.M.F.].
6)
[S15.002] Osteopontin in Duchenne Muscular Dystrophy
Elena Pegoraro, Luca Bello, Luisa Piva, Andrea
Barp, Mario Ermani, Padova, Italy, Luisa Politano, Naples, Italy, Eugenio
Mercuri, Roma, Italy, Stefano Previtali, Yvan Torrente, Milan, Italy, Claudio
Bruno, Carlo Minetti, Genova, Italy, Angela Berardinelli, Pavia, Italy, Giacomo
Comi, Milano, Italy, Adele D'Amico, Rome, Italy, Gianni Soraru', Padova, Italy ,
Sonia Messina, Messina, Italy, Tiziana Mongini, Torino, Italy, Enrico Bertini,
Rome, Italy, Alessandra Ferlini, Ferrara, Italy, Francesca Gualandi, Genova,
Italy, Roberta Battini, Pisa, Italy, Patrizia Boffi, Turin, Italy, Marika Pane,
Roma, Italy, Giuseppe Vita, Messina, Italy, Eric Hoffman, Washington, DC,
Corrado Angelini, Padova, Italy
OBJECTIVE: To test the effect of the SPP1 rs28357094 in a longitudinal
cohort of ambulatory DMD patients and to dissect the molecular mechanisms of
increased disease severity associated with the G allele at rs28357094.
BACKGROUND: Osteopontin (OPN coded by the SPP1 gene) is a secreted
glycoprotein expressed by multiple cell types including myoblasts. In mdx
muscle OPN modulates inflammation and fibrosis via a reduction of transforming
growth factor-b (TGFB). In Duchenne muscular dystrophy (DMD) a polymorphism in
the SPP1 promoter region (rs28357094) is a determinant of disease
progression. DESIGN/METHODS: 80 DMD patients were genotyped at rs28357094
and stratified in TT vs TG/GG according to a dominant model. Genotypes were
compared to phenotypes using the North Star Ambulatory Assessment (NSAA) and the
6 Minute Walk Test (6MWT) score at T0 and T12. Muscle biopsies from selected
patients were studied for quantification of TGFB and transforming growth
factor-b receptor-2 (TGFBR2) mRNA and SPP1 mRNA and protein,
muscle histology and infiltrating inflammatory cells. A polymorphism in the
TGFBR2 gene (rs4522809 ) was genotyped in the patients. RESULTS:
Paired t-test showed a significant difference in both NSAA (p=0.013) and 6MWT
(p=0.03) between baseline and follow-up after 12 months in DMD patients carrying
the G allele. The difference was not significant in the T subgroup. OPN was
upregulated in DMD muscle. No significant differences in osteopontin mRNA or
protein expression nor in TGFB and TGFBR2 mRNA between G and T
genotype at rs28357094 were found. An increase in CD4+ and CD68 cells in the
patients carrying the T allele at rs28357094 was observed. TGFBR2
rs4522809 polymorphism predicted SPP1 mRNA level. CONCLUSIONS:
SPP1 genotype is a strong disease modifier in DMD and may be relevant as
covariate in DMD clinical trials. OPN modulates inflammatory changes and
TGFBR2 genotype predicts osteopontin in DMD muscle
7) [PD6.004] Overexpression of
Human Alpha7 Integrin as a Potential Therapy for Duchenne Muscular Dystrophy
Kristin N. Heller, Chrystal L. Montgomery, Kim
Shontz, Vinod Malik, Paul Janssen, K. Reed Clark, Louise Rodino-Klapac, Jerry
Mendell, Columbus, OH
OBJECTIVE: To overexpress a7 integrin as a potential therapy for the
treatment of Duchenne muscular dystrophy. BACKGROUND: Duchenne Muscular
Dystrophy (DMD) is a severe muscle disease caused by mutations in the DMD
gene. Dystrophin provides a link from the extracellular matrix to the actin
cytoskeleton, stabilizing the sarcolemma during muscle activity. a7b1 integrin
is a laminin receptor on skeletal muscle that serves a similar functional role.
Transgenic double knockout mice (mdx/utr-/-) overexpressing a7 show significant
improvement in life-span, kyphosis and muscle histology. We performed a
pre-clinical study to address the potential of gene transfer of ha7 delivered by
adeno-associated virus (AAV) under control of a muscle specific promoter (MCK)
to avoid off targeted effects. Transfer of the a7 gene potentially avoids an
immune response encountered with mini-dystrophin gene transfer (Mendell JR et al
N Engl J Med 2010). DESIGN/METHODS: We have generated rAAV8.MCK.human
α7 integrin and delivered it
to the lower limb muscle of mdx mice through isolated limb perfusion (Rodino-Klapac
et al 2007). In mdx mice, we measured human (as opposed to mouse) α7
as a biomarker of gene transfer and assessed muscle histopathology, force
generation and protection against eccentric contraction. RESULTS: We have
demonstrated fifty-two percent of fibers in the TA and EDL overexpressing human
α7 integrin. The increase in human α7
integrin in skeletal muscle significantly protected against eccentric
contraction induced injury. Force generation was not increased. CONCLUSIONS:
a7 integrin gene transfer protects the dystrophin-deficient muscle fiber against
the deleterious effects of contraction induced injury. Overtime this reduces
segmental necrosis and preserves muscle fibers. We are currently treating mdx/utrn-/-
mice to determine if there is a similar improvement in muscle physiology and
further investigating the mechanism that is involved in the protection from
eccentric contraction induced injury.
8)
[P04.086] Delayed Recognition of Dysphagia and Malnutrition among Teenaged Boys
with Duchenne Muscular Dystrophy
Aimee Gasior, Douglas Sproule, New York, NY
OBJECTIVE: To evaluate the relationship between onset, recognition, and
intervention for weight loss among teenaged boys with Duchenne muscular
dystrophy (DMD) by treating physicians at a tertiary pediatric neuromuscular
center. BACKGROUND: DMD is a neuromuscular disease leading to progressive
weakness and loss of ambulation. While excessive weight is common early in the
disease, gradual weight loss ensues in later stages. Weight loss in DMD has been
attributed to muscle wasting and feeding difficulties, and malnutrition due to
weakness of chewing and swallowing may anticipate frank dysphagia by years. We
sought to ascertain the relationship and timing of weight loss and clinically
recognized dysphagia in the DMD population. DESIGN/METHODS: This was a
retrospective chart review of 60 boys with DMD, aged ≥10 years. Weight was
obtained during routine clinical care and Z-scores were determined based on
established normative values for age and gender. Age at malnourishment (defined
as having weight Z-score ≤-2 or experiencing a drop in Z-score of ≥1 from
baseline), and age at weight loss (drop in Z-score of ≥0.5) were determined.
Ages at clinician-documented concern of malnutrition or weight loss, swallow
evaluation, and gastrostomy were recorded. RESULTS: Malnourishment is
common among older boys, affecting 5% of boys age 10-11 and 67.1% of boys 20 and
older. Weight loss and malnourishment occurred at approximately the same age
(174.45 and 174.6 months, respectively), reflecting a rapid decline in weight
after long periods of relative stability. Initial clinician-documented concern
of weight loss or malnutrition occurred at a mean age of 184.7 months,
approximately 10 months after onset of weight loss. CONCLUSIONS: Our
results suggest that boys with DMD enter into an energy deficit related to
feeding dysfunction before the development of overt dyphagia and clinically
obvious malnutrition, resulting in weight loss that persists for months to years
before clinical recognition and management. Supported by: American Academy of
Neurology.
9) [P02.001] Functional Outcome
Measures Correlated with Strength in Becker Muscular Dystrophy
Lindsay Alfano, Linda Lowes, Laurence Viollet,
Kevin Flanigan, Jerry Mendell, Columbus, OH
OBJECTIVE: To determine the relationship between quadriceps strength and
performance on functional outcome measures in subjects with Becker muscular
dystrophy (BMD). BACKGROUND: BMD is characterized by progressive muscle
weakness. Upcoming treatment trials are designed to improve quadriceps muscle
strength in these patients. However, the correlation of quadriceps strength to
performance on functional outcomes has not been evaluated in BMD. Determination
of the proper outcome measures is critical to the success of future
interventions. DESIGN/METHODS: 24 subjects with BMD underwent strength
testing of quadriceps and hamstrings muscles. Performance on the modified Timed
Up & Go (mTUG), Berg Balance Scale (BBS), timed 4 stairs, curb steps, and 10
meter, 2 and 6 minute walk tests was recorded in one study session. RESULTS:
Performance on the BBS was most highly correlated with quadriceps strength in
BMD (r=0.648, p=0.012), followed by stepping up on curbs (r=0.612, p=0.02),
timed 4 stairs (r=-0.554, p=0.026), and mTUG (r=-0.431, p=0.045). Distance
walked in 2 (r=0.385, p=0.063) and 6 (r=0.378, p=0.068) minutes was not
significantly correlated with quadriceps strength in this population, nor was
performance on the 10 meter walk test (r=-0.294, p=0.571). CONCLUSIONS:
Functional performance relates to distribution of muscle weakness and is disease
specific. Selection of appropriate outcome measures should be investigated based
on targeted intervention and must be established prior to clinical trials. In
patients with BMD, performance on the BBS, stair climbing with and without upper
extremity support, and the mTUG are most highly correlated with quadriceps
strength, the target of current follistatin gene therapy. It is also of note
that BMD function and strength correlations differ from those in DMD and sIBM.
Supported by: Parent Project Muscular Dystrophy and The Myositis Association
10)
[S15.004] Results from a National Cross-Sectional Study of Disease-Burden in
Facioscapulohumeral Muscular Dystrophy (FSHD)
Chad Heatwole, Rochester, NY, Rita Bode,
Chicago, IL, William Martens, Michael McDermott, Richard Moxley, Christine
Quinn, Alrabi Tawil, Rochester, NY, Nan Rothrock, Chicago, IL, Barbara Vickrey,
Los Angeles, CA, David Victorson, Evanston, IL, Nicholas Johnson, Rochester, NY
OBJECTIVE: To assess: 1) The most critical symptoms and disease
manifestations in FSHD patients; and, 2) The modifying factors that are
associated with these symptoms. BACKGROUND: FSHD is a dominantly
inherited multisystem disease capable of impairing the physical, mental, and
social health of patients. The identification of the symptoms and disease
manifestations that are most significant to patients' health and the
relationship between the severity of these manifestations and other patient
characteristics are currently lacking. These data are necessary to develop valid
disease-specific patient-reported outcome measures for use in future FSHD
clinical trials. DESIGN/METHODS: A cross-sectional study of 328
genetically or clinically confirmed adult FSHD patients from the National
Registry of FSHD patients between September and December 2010. The prevalence
and relative impact score of 250 critical symptoms and 15 disease themes
previously identified through FSHD qualitative interviews were assessed.
Responses were categorized by age, gender, education level, and duration of
symptoms. RESULTS: FSHD participants from 46 states provided over 48,000
symptom rating responses to address the relative frequency and importance of
each FSHD symptom. Problems with shoulders or arms (96.9%), inability to do
activities (94.7%), fatigue (93.8%), back, chest, or abdomen weakness (93.8%),
and limitations with mobility or walking (93.6%) were the symptomatic themes
with the highest frequency in FSHD. Participants identified problems with
shoulders or arms and limitations with mobility or walking as the symptomatic
themes with the greatest impact on their lives. Significant associations were
found between demographic data and the prevalence and relative impact of
specific FSHD symptoms on patients' lives. CONCLUSIONS: In this national
cross-sectional study patients with FSHD identified the symptoms of highest
frequency and greatest impact. These symptoms, some under-recognized, vary based
on patient age, gender, and duration of symptoms. Fortunately many, perhaps all
symptoms, may be amenable to future therapeutic intervention. Supported by: The
National Institute of Arthritis and Musculoskeletal and Skin Disorders
(1K23AR055947), the NIH supported Senator Paul D. Wellstone Muscular Dystrophy
Cooperative Research Center (U54NS48843-01), the Muscular Dystrophy Association,
and the University of Rochester Clinical Translational Science Institute.
11)
[P04.082] Focal Presentations of Facioscapulohumeral Dystrophy
Anhar Hassan, Gainesville, FL, Lyell Jones,
Margherita Milone, Neeraj Kumar, Rochester, MN
OBJECTIVE: To identify additional focal presentations of FSHD.
BACKGROUND: Facioscapulohumeral dystrophy (FSHD) is an autosomal dominant
myopathy, classically presenting with facial and shoulder girdle weakness.
Recently, monomelic lower limb presentations of genetically confirmed FSHD have
been reported. DESIGN/METHODS: A retrospective review of our academic
center medical record database of all FSHD cases seen from 1996 to 2011. Of 139
cases identified, 8 had DNA confirmation with a focal presentation. Demographic
and clinical data was abstracted. RESULTS: There were 8 cases (4 male)
with mean age at onset 39 years (range 18-63) and age at diagnosis 45 years
(range 20-74). Presenting symptoms were monomelic lower limb atrophy (3);
unilateral shoulder atrophy (3); and axial weakness (2). Examination showed
isolated focal weakness in five. CK was normal or mildly elevated. All had a
single family member with “weakness”. Co-existent unusual symptoms included
dyspnea (2), S1 radicular pain with calf atrophy (2), peripheral neuropathy (1)
and post-traumatic onset (1). EMG showed myopathic changes in all, apart from
one case with severe denervation later followed by myopathic changes. DNA
analysis showed D4Z4 EcoRI fragment size ranging from 20 to 37 kilobases.
CONCLUSIONS: The clinical phenotype of FSHD should be expanded to include
focal atrophy with myopathic EMG findings; axial weakness; or dyspnea at
presentation. These cases are challenging due to lack of typical FSHD signs and
coexistent symptoms suggestive of an alternative diagnosis.
12) [P05.186] Identifying High
Impact Symptoms and Issues in Congenital and Juvenile Myotonic Dystrophy
Nicholas Johnson, Elizabeth Luebbe, Eileen
Eastwood, Nancy Chin, Richard Moxley, Chad Heatwole, Rochester, NY
OBJECTIVE: To assess the symptoms impacting health related quality of
life (HRQOL) in congenital and juvenile onset (CMD/JMD) Myotonic Dystrophy.
BACKGROUND: Myotonic Dystrophy type-1 is a multisystemic, autosomal dominant
disorder. Significant expansion of the trinucleotide repeat mutation may result
in the onset of symptoms in infancy (CMD) or childhood (JMD). There is minimal
data at this point with regards to HRQOL in CMD/JMD patients. DESIGN/METHODS:
We conducted in-depth individual patient and parent interviews with 7 CMD
patient-parent dyads and 5 JMD patient-parent dyads for a total of 20 children
and 12 parents. Children were over the age of 8 and had a wide range of
disability. Each interview focused on identifying the issues that have the
greatest impact on patient HRQOL. Each interview was recorded, transcribed,
coded, and analyzed using a qualitative framework technique, triangulation, and
three investigator consensus approach. RESULTS: 32 patient-parent
interviews were conducted. 195 critical symptoms of importance were identified.
These symptoms were categorized into 20 themes that represent the physical,
mental, social, and disease-specific HRQOL of the CMD/JMD populations. A
disease-specific HRQOL model was created for CMD/JMD representing the most
relevant issues for this population. Categories in this model included: 1)
Mobility and ambulation; 2) Proximal leg weakness; 3) Truncal muscle weakness;
4) Fine motor and upper extremity function; 5) Emotional distress; 6) Cognitive
impairment; 7) Social role dissatisfaction; 8) Social role limitation; 9)
Genetic issues; 10) Activity impairment specific to CMD/JMD; 11) Sleep
disturbance; 12) Fatigue; 13) Pain; 14) Myotonia; 15) Gastrointestinal
dysfunction; 16) Problems swallowing or choking; 17) Central sensory impairment;
18)Communication difficulties; 19) Incontinence; and 20) Impaired body image.
CONCLUSIONS: There are multiple themes and symptoms that impact CMD/JMD
HRQOL. These issues must be carefully examined to develop a disease specific
patient-reported outcome measure and functional rating scale that represents the
most critical areas of CMD/JMD health.
13) [S15.005] Anoctamin 5
Mutations Are a Frequent Cause of Limb Girdle Muscular Dystrophy and of the
Miyoshi-Type Muscular Dystrophy in the Netherlands
Marianne De Visser, Anneke J. van der Kooi, W.
H. J. P. Linssen, Amsterdam, Netherlands, Ieke H. B. Ginjaar, Leiden,
Netherlands, John Wokke, Utrecht, Netherlands, Pieter Van Doorn, Rotterdam,
Netherlands
OBJECTIVE: To perform Anoctamin 5 (ANO) mutation analysis, neurological
and cardiological examination in the genetically undiagnosed remainder of the
Dutch limb girdle muscular dystrophy (LGMD) cohort encompassing 105 patients
from 68 families and in a proportion of a cohort of 22 patients from 16 families
with a Miyoshi-type muscular dystrophy (MMD) in which no dysferlin mutations
were found. BACKGROUND: ANO 5 mutations have recently been found to cause
LGMD2L, MMD3 and asymptomatic hyperCKemia. DESIGN/METHODS: Neurological
examination, cardiological investigations (i.e. electrocardiography, Holter
monitoring, echocardiography), serum creatine kinase (sCK) activity assessments
and ANO 5 mutation analysis were performed in LGMD and MMD patients. RESULTS:
32 LGMD index patients and 12 MMD3 patients from 8 kindreds were examined. ANO 5
mutations were found in 13 sporadic LGMD cases (8 males). Age at onset ranged
from 21-57 years, age at examination from 26-69. Symmetrical proximal leg muscle
weakness had been the first manifestation. Rhabdomyolysis attacks were mentioned
in one patient, and three had cardiological abnormalities, including
intraventricular septum thickening (2) and hypertrophic cardiomyopathy (1). SCK
was 10-25 times the upper limit of normal (ULN). In 8 patients (all male) from 6
MMD families mutations were identified. Age at onset ranged from 18-51 years and
age at examination from 30-67. Uni- or bilateral calf muscle weakness had been
the presenting symptom in 7 patients and one had been asymptomatic at time of
diagnosis. SCK was 20-40 times ULN. None had associated symptoms and
cardiological examination was normal. Exon 5 c.191dupA was the most frequently
observed mutation and in addition novel mutations were identified.
CONCLUSIONS: 1. LGMD 2L is found in 16% of the Dutch LGMD families and MMD3
in 40% of the MMD families.
2. In three LGMD2L patients heart involvement was found and in none of the MMD3
patients.
14) [S15.006] Limb Girdle Muscular
Dystrophy Type 2L (Anoctamin 5 Deficiency): Cardiac Involvement and
Characterization of the Skeletal Muscle Phenotype
John Vissing, Nanna Witting, Helle P. Lauritsen,
Morten Duno, Copenhagen, Denmark
OBJECTIVE: To test the prevalence of the newly discovered limb girdle
muscular dystrophy type 2L (LGMD2L) in Denmark, and further characterize the
phenotype. BACKGROUND: Mutations in the anoctamin 5 gene causes LGMD2L,
which was first described in 2010. Two existing reports on small LGMD2L cohorts,
suggest that LGMD2L may be a relatively common cause of LGMD2. Less than 30
patients have been reported so far. It appears that the disease, like LGMD2B (dysferlinopathy)
may present as either classical LGMD2 or as a distal myopathy (MMD3), primarily
involving the posterior calf musculature. In this study, we determined the
prevalence of anoctamin 5 deficiency in a cohort of patients with unclassified
LGMD2, hyperCKemia or distal myopathy. DESIGN/METHODS: All unclassified
LGMD2 patients (26 out of 161), unexplained hyperCKemia (15 patients) and distal
myopathies (5 patients) were tested for mutations in ANO5. All mutation-positive
patients underwent a clinical exam, echocardiography and 48-h Holter monitoring.
RESULTS: Ten of 26 unclassified LGMD2 patients, 2 of the 15 hyperCKemia
patients and 4 of 5 distal myopathy patients had LGMD2L. All patients carried
the common c.191dupA mutation on at least one allele. Echocardiograhies were
unremarkable, but Holter monitoring showed a 2.5-fold increase in premature
ventricular contractions, which predicts an increased risk of cardiovascular
disease. Only 2 of the 16 patients were women. In distal forms, the medial
gastrocnemius muscle was the preferentially affected muscle, but the phenotype
converges into a LGMD2 phenotype in all patients with time. Calpain 3 expression
on Western blots was decreased in about half the patients. CONCLUSIONS:
This study suggests that LGMD2L (16 patients) is the third commonest LGMD2 type
in Denmark, only surpassed by LGMD2I (64 patients) and LGMD2A (22 patients). The
study demonstrates for the first time that cardiac involvement may occur in this
disease, and suggests a regular electrocardiographic follow-up of these
patients.
15) [P04.083] Patient-Reported
Disease Burden and Progression in Genetically Confirmed Participants in a
National Facioscapulohumeral Muscular Dystrophy Registry
Jeffrey Statland, William Martens, Alrabi Tawil,
Rochester, NY
OBJECTIVE: To determine disease progression in a genetically defined
population of facioscapulohumeral muscular dystrophy (FSHD) patients.
BACKGROUND: Recent breakthroughs in the molecular pathophysiology of FSHD
have identified potential therapeutic targets. Consequently, an accurate
understanding of disease progression in FSHD is crucial for the design of future
clinical trials. DESIGN/METHODS: De-identified data from 343 genetically
confirmed FSHD patients with an average 6 years of follow up (range 1-9) was
analyzed from the National Registry of FSHD Patients and Family Members.
Measures of disease included patient-reported symptoms, extra-muscular
manifestations, use of assisted devices, pain, and a patient reported functional
rating scale (4-8 mild, 9-13 moderate, 14-19 severe). RESULTS: Registry
participants were 51% female, primarily Caucasian, non-Hispanic, with a mean age
of 51 years. The median D4Z4 fragment size was 25 kb. The initial age of symptom
onset was 22 years, and mean time until diagnosis 10 years. At baseline 91% had
facial weakness, 70% arm involvement, and 67% leg involvement. 41% used an ankle
brace, leg brace, cane, or walker. 24% used a wheelchair at some point during
the day, with a mean age at first use of 42 years. 4% used a breathing machine,
18% reported hearing loss, 7% used hearing aids, and 1% reported a retinal
hemorrhage or detachment, but no history of Coat's disease. The average
self-reported total impairment score was 10.4 (moderately impaired). At follow
up 11% of device-free patients started to use an ankle brace, leg brace, cane or
walker. 22% started to use a wheelchair at some point during the day. And the
self-reported total impairment score increased by 0.78. CONCLUSIONS:
Genetically confirmed Registry participants are moderately impaired, demonstrate
slow but steady progression of disease, and represent a valuable resource for
future FSHD clinical trials. Supported by: NIH Experimental Therapeutics in
Neurological Disorders grant #T32 NS07338-20 (PI, R. Griggs).
16) [P05.190] Is There a
Difference in Gastric Emptying between Myotonic Dystrophy Patients with and
without Gastrointestinal Symptoms? An Analysis Using the 13C-Acetate
Breath Test
Yuji Tanaka, Tomohiro Kato, Hiroshi Nishida,
Megumi Yamada, Akihiro Koumura, Takeo Sakurai, Akio Kimura, Isao Hozumi,
Hisataka Moriwaki, Takashi Inuzuka, Gifu City, Japan
OBJECTIVE: To clarify gastric emptying of patients with myotonic
dystrophy (MyD). BACKGROUND: Gastrointestinal symptoms are frequent
complaint in patients with MyD and may be associated with reduced
gastrointestinal motility as dysfunction of smooth muscle. However, it is few
report of gastric emptying in MyD patients. In the present study, we
investigated gastric emptying in MyD patients using the 13C-acetate
breath test (13C-ABT). DESIGN/METHODS: We investigated gastric
emptying in 19 MyD patients and 20 healthy volunteers. The MyD patients were
divided into two groups: 7 patients with gastrointestinal symptoms and 12
patients without gastrointestinal symptoms. Gastric emptying was estimated by
the 13C-ABT [the half emptying time (HET), the peak time of the
13C %-dose-excess curve (Tmax)], with expirations collected every 10
minutes for 4 hours after a test meal and analyzed for 13CO2
using an IR spectrophotometer. Informed consent was obtained from each subject
prior to participation in this study. The study protocol was approved by the
Ethical Committee of our institution and carried out in accordance with the 1975
Declaration of Helsinki. RESULTS: 1) The HET and Tmax of gastric emptying
as assessed using the 13C-ABT was significantly delayed in MyD
patients with and without gastrointestinal symptoms as compared to the controls
(P<0.05). 2) The HET and Tmax were significantly delayed in MyD patients with
gastrointestinal symptoms as compared to those without gastrointestinal symptoms
(P<0.05). 3) There was a significant correlation between the HET and Tmax of MyD
patients with gastrointestinal symptoms and duration of the disease.
CONCLUSIONS: The results demonstrated that gastric emptying of the MyD
patients was delayed, even those without gastrointestinal symptoms. The gastric
emptying was delayed in MyD patients with gastrointestinal symptoms as compared
to those without gastrointestinal symptoms. Delayed gastric emptying is one of
constitutional symptoms of the MyD patients.
17) [P05.184] Symptoms of Myotonia
as Reported by Patients with Myotonic Dystrophy Type 1: Location, Description
and Severity- Implications for Clinical Trials
Shree Pandya, Katy Eichinger, Nuran Dilek,
Jeanne Dekdebrun, William Martens, Chad Heatwole, Charles Thornton, Richard
Moxley, Rochester, NY
OBJECTIVE: This study documents patient-reported descriptions of the
location and severity of myotonia in patients with DM1. BACKGROUND:
Myotonia is a cardinal disease manifestation in myotonic dystrophy type 1
(DM-1). Clinicians identify and grade myotonia based upon the tests they perform
rather than asking patients to describe and rate their symptoms related to
myotonia. DESIGN/METHODS: Data were gathered as part of a disease
progression study. Patients were asked to fill out a survey that included
questions about symptom/s of myotonia - Y/N, the body area affected, a
description of the symptoms and the severity of the symptoms using a visual
analog scale. Patients also filled out the Individualised Quality of Life (INQoL)
instrument which includes questions about myotonia and the impact of myotonia on
their health related quality of life. RESULTS: Of the 71 patients in the
current cohort 65 (91.5%) report problems related to myotonia. Patients used
terms like myotonia, cramps and tightness (51%). They also described important
associated symptoms [weakness (30%); pain (11%); and, other (8%)]. The majority
of myotonia related symptoms were associated with hand function (63%) and
approximately 10% each described symptoms in face/tongue/jaw functions,
calf/thighs/legs and back/neck. The severity scores for myotonia on the VAS
were: back/neck 67; calf/thighs/legs 65; hands/fingers 57; and face/tongue/jaw
37. CONCLUSIONS: To our knowledge this is the first study that has
directly asked DM1 patients to describe their symptoms related to myotonia.
Along with symptoms related to myotonia, DM1 patients reported other associated
symptoms. This suggests that many patients associate myotonia with other disease
manifestations. For this reason prior to using any patient reported outcome
measure of myotonia in clinical trials, it will be essential to assure that
patients are able to differentiate the symptoms of myotonia from other
manifestations of this multisystem disorder. Supported by: U54NS048843 from the
National Institute of Neurological Disorders and Stroke.
18) [P05.187] Relationships
between Upper Extremity Strength and the Purdue Pegboard Test and the Jebsen-Taylor
Hand Function Test in Patients with Myotonic Dystrophy Type 1
Katy Eichinger, Nuran Dilek, Jeanne Dekdebrun,
William Martens, Chad Heatwole, Charles Thornton, Richard T. Moxley, Shree
Pandya, Rochester, NY
OBJECTIVE: To document the relationship between measures of upper
extremity strength and hand function in patients with myotonic dystrophy type
1(DM1). BACKGROUND: Distal weakness is a common feature in patients with
(DM1). The assessment of hand function in this patient population is just
beginning to be explored. Measurements of upper extremity strength and hand
function have demonstrated good reliability; however, the relationship between
strength and function is unknown. DESIGN/METHODS: Patients with DM1
participating in a longitudinal study performed strength tests of the upper
extremity including manual muscle testing (MMT) and quantitative muscles testing
(QMT). MMT included shoulder abduction, elbow flexion and extension, wrist
flexion and extension, and short and long finger flexors of the thumb and first
two digits. QMT included shoulder abduction, elbow flexion, elbow extension and
grip. Patients also performed the Purdue Pegboard Test (PPT) and the Jebsen-Taylor
Hand Function Test (JTHFT). RESULTS: Data from 71 genetically confirmed
patients with DM1 were analyzed using Spearman's rho. Statistically significant
(p<.0001) relationships were documented between upper extremity MMT and the PPT
(r=0.48); upper extremity QMT and overall JTHFT (r=-0.52). The relationships
between QMT and the 3 of 7 total subtests of the JTHFT were found to be
significant with lifting heavy objects being the most significant. (r= -0.58).
CONCLUSIONS: Moderate relationships exist between upper extremity
strength tests and hand function tests. The PPT correlates better with MMT which
included several distal hand muscles and hence captures fine motor function
deficits. The JTHFT correlated better with QMT and the most significant
correlation was with lifting heavy objects and this may reflect more the
proximal strength deficits. Patients need to be followed longitudinally to
document which of these tests is able to reflect changes over time. Supported
by: Award number U54NS048843 from the National Institute of Neurological
Disorders and Stroke.
19) [PD6.003] Role of RNA and
MBNL1 Nuclear Foci in Pathomolecular Mechanism in Myotonic Dystrophy Type 1 and
Type 2
Giovanni Meola, Milan, Italy, Valentina Renna,
Enrico Bugiardini, San Donato Mil., MI, Italy, Marzia Giagnacovo, Carlo
Pellicciari, Pavia, Italy, Manuela Malatesta, Verona, Italy, Rosanna Cardani,
Milan, Italy
OBJECTIVE: To study RNA and MBNL1 nuclear foci in myotonic dystrophies to
elucidate their role in pathomolecular mechanism. BACKGROUND: Myotonic
dystrophies (DM1 and DM2) are multisystemic RNA-mediated diseases. The presence
of the CTG or CCTG expansion, leads to nuclear accumulation of expanded RNAs
which interact with RNA binding proteins, such as MBNL1. The nuclear
sequestration of MBNL1 appears to be involved in splicing defects of genes
directly related to the DM phenotypes. However, the mechanisms underlying
nuclear retention of expanded RNAs and their aggregation into nuclear foci are
still not well understood. A recent study has revealed that CUG-foci are
constantly aggregating and disaggregating structures, and that MBNL1 is directly
involved in this process. DESIGN/METHODS: FISH in combination with
MBNL1-immunofluorescence was performed on: 1) 3 DM2 skin fibroblast cultures to
investigate the fate of MBNL1 foci in proliferating and in non-cycling cells; 2)
muscle biopsies from 3 DM2 patients who underwent 2 biopsies at different years
of age and from 3 DM1 patients for morphometric measurements of nuclear RNA and
MBNL1 foci. RESULTS: Nuclear MBNL1 foci do not associate with chromosomes
at mitosis, and remain in the cytoplasm at cytodieresis, being disassembled in
early G1 and re-formed in the nucleus, at each cell cycle. In senescent
fibroblasts the nuclear foci increase in number and size indicating that in
non-dividing cells the sequestration of factors for RNA processing would be
continuous and progressive. Interestingly, foci in DM2 muscle become larger with
increasing patient's age thus suggesting that a relationship may exist between
the amount of foci and the severe phenotype. CONCLUSIONS: However,
despite DM1 phenotype is more severe than DM2 one, RNA and MBNL1 foci appear to
be smaller in DM1 than in DM2 muscle. This suggests that DM pathomechanism is
more complex and that other processes might be involved.
Supported by: by AFM, CMN and FMM.
20) [P05.189] Application of
Digital Accelerometry for Swallow Imaging (DASI) for Dysphagia Evaluation and
Treatment in a Series of Myotonic Dystrophy Type 1 (DM1) Patients
Lia-Ana Farkas, Lane Entrekin, Norma Milstead,
Kristin Mosman, Kiera Berggren, Jacinda Sampson, Salt Lake City, UT
OBJECTIVE: To use digital accelerometry for swallow imaging (DASI) for
evaluation and treatment of dysphagia in DM1 patients. BACKGROUND:
Dysphagia is a potentially life threatening complication of DM1 patients.
DESIGN/METHODS: Patients with DM1 and history of aspiration or dysphagia
underwent a formal swallow evaluation +/- modified barium swallow (MBS). We used
noninvasive DASI technology with software designed for swallow imaging and
calculation of key parameters of swallow biomechanics. Trials included
spontaneous and instructed dry and wet swallows with different consistencies. We
analyzed shape, amplitude, timing, frequency and jitter looking for swallow
movement dysfunction. DASI biofeedback: Patients observed swallow traces on the
computer screen and were coached in improving strength, duration and timing of
swallow. RESULTS: Case 1: A 24-year old man with congenital DM1,
dysphagia, and repeated hospitalizations for aspiration pneumonia had a MBS
showing aspiration of pyriform sinus residue. DASI evaluation showed excessive
pre/post-swallow laryngeal movement, decreased pharyngeal phase control with
multiple small amplitude peaks. DASI Treatment: Patient improved swallow
strenght and control of pharyngeal movement. Case 2: A 46 year-old man with
adult-onset DM1 and choking episodes was hospitalized with pneumonia and placed
on a ventilator. MBS showed aspiration during/after the swallow with delayed
cough. DASI evaluation showed low amplitude and frequency of swallow with
increased jitter and frequent coughing. DASI Treatment: Patient improved swallow
strength. Case 3: A 33 year-old female with adult-onset DM1 reported dysphagia.
Clinical swallow evaluation showed oral residue, reduced hyolaryngeal excursion,
and throat clearing. DASI evaluation showed reduced amplitude and increased
jitter, with extraneous, inefficient lingual/hyolaryngeal movements. DASI
Treatment: Reduced extraneous laryngeal movements and improved control of
swallow. CONCLUSIONS: DASI is an adjunct in dysphagia evaluation in DM1.
DASI biofeedback is helpful in gaining increased swallow function through Active
Repetitive Motion Therapy which is instructive for reducing extraneous,
inefficient laryngeal movements and can be personalized according to the patient
physical and mental status. Supported by: DASI
equipment on loan from Elixir Therapeutics.
21) [P05.185] Correlation between
Biomarkers and Surrogate Markers in Patients with Myotonic Dystrophy Type 1
(DM-1): Data from the Study of Pathogenesis and Progression in DM (STOPP DM)
Shree Pandya, Katy Eichinger, Nuran Dilek,
Jeanne Dekdebrun, William Martens, Chad Heatwole, Charles Thornton, Richard
Moxley, Rochester, NY
OBJECTIVE: To document correlations between biomarkers (muscle mass and
strength measures) and surrogate markers (function and health related quality of
life (HRQoL measures) in patients with DM-1. BACKGROUND: Research funding
agencies and regulatory agencies are increasingly requiring investigators to
validate and use outcome measures that patients feel have a direct relationship
to their well being and performance. DESIGN/METHODS: Patients
participating in the STOPP DM study at our institution undergo assessments of:
muscle mass ( DXA), manual muscle testing (MMT) on 38 muscles, quantitative
muscle tests (QMT) on 14 muscles, function testing – 6 and 2 minute walk tests
(6MWT& 2MWT), run/walk 30', ascend/descend 4 stairs, rise from a chair, Purdue
pegboard test (PPT), Jebsen Taylor Hand function test (JTHFT); and complete,
HRQOL surveys (Short Form 36 & Individualised Quality of Life-INQoL). Data from
patients who have undergone all the above evaluations at baseline were analyzed
using Pearson correlation coefficients. Statistical significance was set at
p<.001. RESULTS: To date 71(46F) patients average age 46.9yrs (18-69)
have enrolled in the study. Significant correlations (p<.0001) were documented
between muscle strength (MMT) and function tests- 6MWT (r=0.65), 2MWT(r=0.64),
go 30' (r=-0.61), ascend/descend stairs (r=- 0.0.53/-0.51) and rise from chair
(r=- 0.44). There were also significant correlations between strength (MMT/QMT)
and INQoL weakness score (r=-0.65/r=-0.51) and SF-36 physical function score
(r=0.58/r=0.46). Correlations were even higher if only the lower extremity
strength scores were used. CONCLUSIONS: We have documented significant
relationships between measures of muscle strength, function and quality of life
in patients with DM-1. These correlations and subsequent longitudinal analyses
of our findings at 12 and 36 months in the STOPP DM cohort will provide
necessary guidance in selecting appropriate outcome measures for future
therapeutic trial phases. Supported by: U54NS048843 from the National Institute
of Neurological Disorders and Stroke.
22) [P05.188] Video Hand Opening
Time (vHOT) in Myotonic Dystrophy Type 1 (DM1)
Araya Puwanant, Jeffrey Statland, Nuran Dilek,
Richard Moxley, Charles Thornton, Rochester, NY
OBJECTIVE: To evaluate test-retest reliability of vHOT in DM1.
BACKGROUND: Delayed release of the handgrip is a common symptom in DM1,
reflecting myotonia plus a variable contribution of finger extensor weakness.
Previous methods to quantify myotonia required sophisticated equipment and
labor-intensive analysis. Video recording coupled with blinded review is an
accepted procedure to evaluate motor performance in clinical trials.
DESIGN/METHODS: vHOT recordings were made using a standardized procedure in
20 individuals with DM1. Subjects were asked to perform maximal handgrip for 5
seconds, followed by rapid extension of fingers without shaking of the hand.
Each participant completed 3 trials with a 10-minute rest between trials. vHOT
was recorded on 2 consecutive days by the same evaluator. vHOT recordings were
later reviewed using the standard video editing software by 2 blinded raters.
Time for maximal hand opening was measured separately for the thumb and long
finger. RESULTS: The mean vHOT was 4.6 ± 5.6 seconds. vHOT was longer for
the thumb than the long finger. The correlation of vHOT between trials on the
same day (r = 0.94-0.97) was better than for trials on the separate days (r =
0.88). There is no evidence for “warm-up” in successive trials. The ICC for
test-retest concordance for the same rater on 2 successive days was 0.71. The
ICC for concordance between 2 raters was 0.96. CONCLUSIONS: vHOT provides
a simple low-cost method to assess grip myotonia and finger extension. The
inter-rater reliability is excellent and the test-retest reliability is
moderate, reflecting the physiologic variability of myotonia over time. vHOT may
provide a suitable endpoint for studies of disease progression and therapeutic
response in DM1. Supported by: NIH U54NS48843.
23) [S15.001] Defining Dystrophin-Specific
T Cells in DMD Population
Laurence Viollet, Katie Campbell, William
Bremer, Chelsea Rankin, Christopher Shilling, Kevin Flanigan, Christopher
Walker, Jerry Mendell, Columbus, OH
OBJECTIVE: To determine the frequency of DMD patients with cellular
immunity to dystrophin. BACKGROUND: Duchenne muscular dystrophy (DMD) is
the most severe childhood form of muscular dystrophy. It is caused by mutation
of the DMD gene. Studies attempting to replace the dystrophin gene using adeno-associated
virus revealed pre-existing dystrophin-specific T cells that demonstrated an
amnestic response upon gene transfer. Analysis revealed an HLA-restricted, exon
specific response targeted to revertant fibers. DESIGN/METHODS:
Seventy-six DMD patients were enrolled in this study. Six BMD (Becker MD, a
milder form of DMD) and nine healthy subjects were used as controls. Age and
corticosteroids (prednisone or deflazacort) regimen were recorded. Peripheral
blood mononuclear cells were isolated and stimulated with peptide pools specific
to dystrophin. Detection of IFN-γ
was measured by ELISpot assays. RESULTS: 52.9% (9/17) of DMD
steroid-naïve patients exhibited an immune response. The response was blunted by
steroid treatment: prednisone 25% (6/24); deflazacort 17.2% (5/29). In
comparison, only one BMD subject had a response (16.6%, 1/6) and no response was
found in normal controls. DMD patients and normal controls were around the same
age (11.9 ± 4.6 years) while BMD subjects were older (20.5 ± 9.6 years). Thirty
adult controls (age range 21-45) from a previous study did not show any immune
response either. In three DMD groups, patients with an immune response were
slightly older than the ones with no response. However, dosage of steroids and
duration of treatment were not statistically different between responders or
not. CONCLUSIONS: These results show that corticosteroids may have a
protective effect on dystrophin-specific T cell response in DMD patients. This
may be related to steroid responsiveness in this disease. In addition, immune
response should be assessed prior and throughout therapeutic clinical trials
since it may influence outcomes. Supported by: NIH.
24) [S49.005] Moderate Walking
Distances and Velocity Correlate with Function Comparable to 6 Minute Walk Test
Linda Lowes, Lindsay Alfano, Laurence Viollet,
Kevin Flanigan, Jerry Mendell, Columbus, OH
OBJECTIVE: To evaluate the utility of different walking tests in
neuromuscular disease. BACKGROUND: Many different timed walking tests
have been shown to be accurate, reproducible, and simple to administer (10 meter
walk (10mw), and the 2-minute (2MWT), 6-minute (6MWT) and 12-minute walk
distance). Recently the 6 MWT has emerged as the gold standard for use in
clinical trials. DESIGN/METHODS: A total of 196 subjects (n= Duchenne
Muscular Dystrophy (DMD) =85; Becker Muscular Dystrophy BMD=24; Inclusion Body
Myositis (IBM) = 87) performed a variety of timed walking tests (10mw, distances
walked in minute increments from 1-6 minutes). Walking ability was compared to
quadriceps strength and the modified Timed Up & Go (mTUG), stepping up on curbs,
stair climbing, and the North Star Ambulatory Assessment (NASA). RESULTS:
Test/retest reliability is excellent for timed walking of any distance (range r
=0. 898-0.972, p=.000). In BMD and IBM, the 2MWT was most highly correlated with
performance on other strength and functional outcomes (BMD: stairs r=-0.836,
Berg Balance Scale(BBS) r=0.891,; IBM: stairs r=-0.748, quadriceps strength
r=0.585,(all p<0.001) compared to the 6MWT (BMD: stair climbing r=-0.836, BBS
r=0.853; IBM: stairs r=-0.652, quadriceps strength r=0.558, (all p<0.001). In
DMD, all distances were moderately to highly correlated with other functional
outcomes (r=0.562-0.951, p<0.01), however, the 3MWT, 4MWT, and 5MWT were highly
correlated consistently across outcomes (3MWT: 10mw r=-0.948, NASA r=0.871,
stairs r=-0.768, p<0.001; 4MWT: 10mw r=-0.951, North Star r=0.879, stairs
r=-0.766, p<0.001; 5MWT: 10mw r=-0.950, NASA r=0.891, stairs r=-0.784, p<0.001).
CONCLUSIONS: A fixed walking distance such as 6 minutes is not necessary
to assess function in patients with neuromuscular disease. Shorter distances
enable more individuals to participate and require less time. Comparison to
previously reported studies is possible by converting the distance walked to
velocity. Supported by: Parent Project Muscular
Dystrophy. The Myositis Association.
25) [P01.116] Congenital
Megaconial Myopathy Due to a Novel Defect in the Choline Kinase beta (CHKB)
Gene
Purificacion Gutierrez Rios, New York, NY, Arun
Asha Kalra, Shreveport, LA, Jon Wilson, Kurenai Tanji, H. Akman, Estela Area,
Eric Schon, Salvatore DiMauro, New York, NY
OBJECTIVE: To describe the first American patient with mutations in the
gene encoding choline kinase beta (CHKB), a novel cause of congenital
muscular dystrophy with giant and displaced muscle mitochondria. BACKGROUND:
Mutations in CHKB have been described in 15 children with congenital
muscular dystrophy and mental retardation. The morphologic hallmark was the
presence in muscle of giant mitochondria (megaconial myopathy) displaced to the
periphery of the fibers (Mitsuhashi et al, 2011). DESIGN/METHODS: Here we
describe a 2-year-old African American boy with weakness and psychomotor delay.
At 22 months, he was not able to sit up and did not utter any intelligible word.
He was severely hypotonic and had multiple dysmorphic features. Serum CK was
elevated but lactate was normal. EMG showed a myopathic pattern and brain MRI
revealed diffuse atrophy. RESULTS: Both histochemistry and electron
microscopy of a muscle biopsy showed greatly enlarged mitochondria, which were
pushed to the periphery of the fibers. Biochemical analysis revealed severely
decreased cytochrome c oxidase activity (30% of normal). The patient
harbored a novel homozygous CHKB mutation (E392X). CONCLUSIONS:
Besides confirming the phenotype of CHKB mutations, we propose that this
disorder affects the MAM (mitochondria-associated-membrane) and the impaired
phospholipid metabolism in MAM causes both the abnormal size and the
displacement of muscle mitochondria. Supported by: NIH Grant HD32062 and by the
Marriott Mitochondrial Disorders Clinical Research Fund (MMDCRF).
EAS is supported by the Ellison Foundation.
26) [P04.081] Expression of
microRNAs in the Histopathological Stages of LGMD2A (Calpainopathy)
Xiomara Rosales, Vinod Malik, Amita Sneh, Lei
Chen, Janaiah Kota, Sarah Lewis, Julie Gastier-Foster, Caroline Astbury, Robert
Pyatt, Shalini Reshmi, Louise Rodino-Klapac, Reed Clark, Jerry Mendell, Zarife
Sahenk, Columbus, OH
OBJECTIVE: To examine expression of regulatory microRNAs in pathological
stages of LGMD2A muscle to gain insight into disease pathogenesis.
BACKGROUND: Recent in vitro studies have suggested that CAPN3 deficiency
leads initially to accelerated myofiber formation followed by a depletion of the
satellite cell pool. In normal muscle, upregulation of miR-1 facilitates
transition from proliferating satellite cells to differentiating myogenic
progenitors. DESIGN/METHODS: A fully characterized LGMD2A cohort (n = 45)
had muscle biopsies (n = 39) with quantification of miR-1 expression (n = 12)
and Pax 7, a satellite cell biomarker. RESULTS: Three groups of patients
clustered by age, duration of disease and clinical severity. Group 1: prominent
inflammation (n =8) with eosinophilia (n = 5). Group 2 (n=8): minimal
inflammatory infiltrate, accompanied scattered fibers undergoing necrosis and
regeneration with minimal focal perivascular fibrosis. Group 3 (n=23): prominent
endomysial and perimysial fibrosis, rare necrosis/regeneration without
inflammation. A continuum of changes was revealed by age and symptoms duration:
group 1= age 13.4 ± 7.1; duration 4.6 ± 3.7 yrs; group 2 = age 25.9 ± 9.1;
duration 10.9 ± 5.6 yrs; and group 3 = age 33.9 ± 11.8; duration 17.6 ± 9.3 yrs.
Contrary to expectations, a significant increase of Pax7-positive satellite
cells was seen in all samples with the greatest increase in the fibrotic group.
Findings correlated with significant reduction in miR-1 in fibrotic group
compared to others. CONCLUSIONS: The histopathological analysis
identified 3 distinct stages of pathological changes representing a continuum of
the disease correlating with age and disease duration. Pax7-positive satellite
cell number was elevated even in the advanced dystrophic stage where reduced
miR-1 failed to promote transition to satellite cell differentiation. This
provides a potential entrée for treatment with miR-1 overexpression to
facilitate satellite cell differentiation, skeletal muscle maturation, and
promotion of normal muscle growth and regeneration. Supported by: NIH NIAMS U54
AR050733-05, Jesse's Journey, and the muscular Dystrophy Association.
27) [P04.089] Reducing Skeletal
Muscle Fibrosis with AAV-Delivered miR-29
Eric Meadows, Janaiah Kota, Sarah Lewis, Zarife
Sahenk, Reed Clark, Jerry Mendell, Louise Rodino-Klapac, Columbus, OH
OBJECTIVE: To demonstrate the degree of muscle fibrosis in mdx:utrophin
heterozygote (mdx:utrn+/-) mice and in dystrophin-deficient
patient-derived muscle biopsies, and correlate changes with microRNA-29 isoforms
(miR-29a, miR-29b, and miR-29c). BACKGROUND: Duchenne muscular dystrophy
(DMD) is a X-linked, inherited disease caused by dystrophin deficiency that
results in progressive muscle weakness, endomysial inflammation, and fibrotic
scarring. Muscle fibrosis impairs blood flow, excluding endomysial-derived
constituents important for muscle repair and regeneration, anti-oxidation, and
vascular-derived metabolites. In addition, fibrosis is a critical factor
contributing to early loss of ambulation through limb contractures. Irrespective
of the success of gene restoration using currently tested clinical approaches
functional improvement for patients mandates reduction of muscle fibrosis. The
gene regulator microRNA-29 is an ideal candidate for reducing muscle fibrosis.
DESIGN/METHODS: Connective tissue was quantified from muscle biopsies of
dystrophin-deficient patients and the mdx:utrn+/- mouse model,
which exhibits increased endomysial fibrosis, using Sirius Red-stained sections
analyzed by NIH ImageJ Software. 5'-nuclease assays were used to measure miR-29
expression levels and correlate with demonstrated levels of fibrosis.
RESULTS: In the mdx:utrn+/- mouse, endomysial connective
tissue levels were uniformly increased 2 to 4-fold in the diaphragm,
gastrocnemius, and quadriceps muscles at 3 and 6-months of age. A 4-fold
increase in fibrosis was also observed in muscle biopsies from dystrophin-deficient
patients. We correlated these findings with the downregulation of miR-29a and
miR-29c in the mouse disease model to approximately 60% of wild-type in most of
the tested groups, and in patient biopsies to less than 50% of normal controls.
CONCLUSIONS: Demonstration of increased fibrosis and decreased miR-29
expression in mdx:utrn+/- mice and dystrophin-deficient
patients validates the mouse model as being representative of the human disease.
In addition, these data provide a rationale for overexpression of these miR-29
isoforms to reduce fibrosis in translational, pre-clinical studies in
mdx:utrn+/- mice in preparation for clinical trials.
28) [SC02.004] Adeno-Associated
Viral (AAV)-Mediated Follistatin (FS) Gene Transfer Toxicology Studies in
Preparation for Phase I Clinical Trial
Janaiah Kota, Christopher Shilling, Chrystal
Montgomery, Sarah Lewis, Adam Bevan, Kim Shontz, Yuuki Kaminoh, Xiomara Rosales,
Laurence Viollet, Kevin Flanigan, Reed Clark, Brian Kaspar, Zarife Sahenk, Jerry
Mendell, Columbus, OH
OBJECTIVE: Establish safety of rAAV.CMV.FS gene transfer by intramuscular
(i.m.) injection for improving quadriceps strength in preparation for phase I
clinical trial. BACKGROUND: FS is a potent myostatin inhibitor that
increases muscle size and strength in mice and non-human primates when secreted
by muscle following delivery by AAV. Safety concerns have included impeded
release of pituitary-gonadal axis hormones and general organ toxicity. In this
study we used a non-tissue binding FS isoform (FS344) to address these safety
concerns in mice at viral doses 10-fold greater than those planned for clinical
use. DESIGN/METHODS: Mice were randomized to three experimental arms with
bilateral i.m. injections to quadriceps muscle of rAAV1.CMV.FS344 equal to
highest clinical dose (2.0e12 vg/kg) or 10-fold higher (2.0e13 vg/kg). Animals
were followed to sacrifice time points at 6-,12-,24-, and 36-weeks (5
animals/sex/cohort/timepoint) post-injection (p.i.). Outcomes included:
bodyweight, hematology, chemistry panels, pituitary-gonadal hormones; immune
studies, and histopathology of 24 organs from each animal. RESULTS: No
treatment-related adverse clinical or toxicology signs were observed and viral
DNA in non-injected tissues dissipated by 24 weeks. Within 6 weeks, high dose
animals showed scattered focal infiltrates of inflammatory cells corresponding
to T-cell immunity to AAV1 identified by IFN-γ
ELISpot, but no other pathology was observed. Wet weights of quadriceps
increased by 3.5-fold at 36 weeks p.i. in high dose animals. Muscle fiber
hypertrophy was observed at 6 weeks and fiber diameter increased by 50% compared
to controls by 36 weeks. Hypertrophic-multinucleated fibers were observed at 12
weeks p.i. with increased density of PAX7 positive nuclei. CONCLUSIONS:
This study shows rAAV1.CMV.FS344 is safe and well tolerated at the proposed
clinical doses and causes satellite cell proliferation and significant muscle
hypertrophy by fusion with differentiated satellite cells. Early transient
inflammation in muscle is related to immune response to AAV1. These results
support this approach for clinical trial use. Supported by: Grants from The
Myositis Association and Parent Project Muscular Dystrophy, Inc; and support
from the Foundation at Nationwide Children's Hospital.
29) [PD6.005] Adeno-Associated
Viral (AAV)-Mediated Follistatin (FS) Gene Transfer Toxicology Studies in
Preparation for Phase I Clinical Trial
Janaiah Kota, Christopher Shilling, Chrystal
Montgomery, Sarah Lewis, Adam Bevan, Kim Shontz, Yuuki Kaminoh, Xiomara Rosales,
Laurence Viollet, Kevin Flanigan, Reed Clark, Brian Kaspar, Zarife Sahenk, Jerry
Mendell, Columbus, OH
OBJECTIVE: Establish safety of rAAV.CMV.FS gene transfer by intramuscular
(i.m.) injection for improving quadriceps strength in preparation for phase I
clinical trial. BACKGROUND: FS is a potent myostatin inhibitor that
increases muscle size and strength in mice and non-human primates when secreted
by muscle following delivery by AAV. Safety concerns have included impeded
release of pituitary-gonadal axis hormones and general organ toxicity. In this
study we used a non-tissue binding FS isoform (FS344) to address these safety
concerns in mice at viral doses 10-fold greater than those planned for clinical
use. DESIGN/METHODS: Mice were randomized to three experimental arms with
bilateral i.m. injections to quadriceps muscle of rAAV1.CMV.FS344 equal to
highest clinical dose (2.0e12 vg/kg) or 10-fold higher (2.0e13 vg/kg). Animals
were followed to sacrifice time points at 6-,12-,24-, and 36-weeks (5
animals/sex/cohort/timepoint) post-injection (p.i.). Outcomes included:
bodyweight, hematology, chemistry panels, pituitary-gonadal hormones; immune
studies, and histopathology of 24 organs from each animal. RESULTS: No
treatment-related adverse clinical or toxicology signs were observed and viral
DNA in non-injected tissues dissipated by 24 weeks. Within 6 weeks, high dose
animals showed scattered focal infiltrates of inflammatory cells corresponding
to T-cell immunity to AAV1 identified by IFN-γ
ELISpot, but no other pathology was observed. Wet weights of quadriceps
increased by 3.5-fold at 36 weeks p.i. in high dose animals. Muscle fiber
hypertrophy was observed at 6 weeks and fiber diameter increased by 50% compared
to controls by 36 weeks. Hypertrophic-multinucleated fibers were observed at 12
weeks p.i. with increased density of PAX7 positive nuclei. CONCLUSIONS:
This study shows rAAV1.CMV.FS344 is safe and well tolerated at the proposed
clinical doses and causes satellite cell proliferation and significant muscle
hypertrophy by fusion with differentiated satellite cells. Early transient
inflammation in muscle is related to immune response to AAV1. These results
support this approach for clinical trial use. Supported by: Grants from The
Myositis Association and Parent Project Muscular Dystrophy, Inc; and support
from the Foundation at Nationwide Children's Hospital.