Diagnosis and Treatment of the Cardiovascular Consequences of Fabry Disease

Fabry Disease (FD) has been a diagnostic challenge since it was first recognised in 1898, with patients traditionally suffering from considerable delay before a diagnosis is made. Cardiac involvement is the current leading cause of death in FD. A combination of improved enzyme assays, availability of genetic profiling, together with more organised clinical services for rare diseases, has led to a rapid growth in the prevalence of FD. The earlier and more frequent diagnosis of asymptomatic individuals before development of the phenotype has focussed attention on early detection of organ involvement and closer monitoring of disease progression. The high cost of enzyme replacement therapy at a time of constraint within many health economies moreover, has challenged clinicians to target treatment effectively. This article provides an outline of FD for the general physician and summarises the aetiology and pathology of FD, the cardiovascular (CV) consequences thereof, modalities used in diagnosis, and then discusses current indications for treatment, including pharmacotherapy and device implantation

(Acetato-κO)(2,5,5,7,9,12,12,14-octa­methyl-1,4,8,11-tetra­aza­cyclo­tetra­decane-κ4 N,N′,N′′,N′′′)zinc perchlorate

The ZnII atom in the cation of the title salt, [Zn(C2H3O2)(C18H40N4)]ClO4, is five-coordinated by the four N atoms of the macrocycle and the O atom of the monodentate acetate ligand. The N4O donor set is based on a trigonal bipyramid with two N atoms occupying axial positions [N—Zn—N = 170.89 (16)°]. The perchlorate anions are associated with the cations via N—H⋯O hydrogen bonds; intra­molecular N—H⋯O(acetate) inter­actions are also observed. The neutral aggregates are connected into an helical chain along the b axis via N—H⋯O(acetate) hydrogen bonds. The perchlorate anion was found to be disordered about a pseudo-threefold axis: the major component of the disorder had a site occupancy factor of 0.692 (11)

cis-(Nitrato-κ2 O,O′)(2,5,5,7,9,12,12,14-octa­methyl-1,4,8,11-tetra­aza­cyclo­tetra­decane-κ4 N,N′,N′′,N′′′)cadmium nitrate hemihydrate

The CdII atom in the title complex, [Cd(NO3)(C18H40N4)]NO3·0.5H2O, is coordinated within a cis-N4O2 donor set provided by the tetra­dentate macrocyclic ligand and two O atoms of a nitrate anion; the coordination geometry is distorted octa­hedral. The lattice water mol­ecule is located on a twofold rotation axis. N—H⋯O hydrogen bonds and weak C—H⋯O inter­actions link the complex cations into a supra­molecular layer in the bc plane. Layers are connected by O—H⋯O hydrogen bonds between the lattice water mol­ecule and the non-coordinating nitrate anion, as well as by weak C—H⋯O contacts

trans-(5,7,7,12,14,14-Hexamethyl-1,4,8,11-tetra­aza­cyclo­tetra­deca-4,11-diene-κ4 N,N′,N′′,N′′′)bis­(nitrito-κN)cobalt(III) perchlorate hemihydrate

The asymmetric unit of the title CoIII complex, [Co(NO2)2(C16H32N4)]ClO4·0.5H2O, comprises two complex cations, two perchlorate anions and a water mol­ecule of crystallization. The CoIII atoms exist within distorted octa­hedral N6 geometries defined by four N atoms of the macrocycle ligand and trans-N atoms derived from the nitrite anions. Systematic variations in the Co—N bond lengths are correlated with the presence of intra­molecular N—H⋯O(nitrite) hydrogen bonds. In the crystal, water-O—H⋯O(perchlorate) hydrogen bonds, involving one of the independent perchlorate anions only, lead to supra­molecular chains along the b-axis direction. The three-dimensional architecture is consolidated by numerous C—H⋯O inter­actions. The crystal studied was a non-merohedral, racemic twin

Dichlorido[(4E,11E)-5,7,12,14-tetra­benzyl-7,14-dimethyl-1,4,8,11-tetra­aza­cyclo­tetra­deca-4,11-diene]cobalt(III) perchlorate

The CoIII atom in the title complex, [CoCl2(C40H48N4)]ClO4, is octa­hedrally coordinated within a trans-Cl2N4 donor set provided by the tetra­dentate macrocylic ligand and two chloride ions. The N—H atoms, which are orientated to one side of the N4 plane, form hydrogen bonds with chloride ions and perchlorate-O atoms. These along with C—H⋯O inter­actions consolidate the three-dimensional crystal structure. One of the benzene rings was disordered. This was resolved over two positions with the major component of the disorder having a site-occupancy factor of 0.672 (4)

Exercise training alone or in combination with high-protein diet in patients with late onset Pompe disease: results of a cross over study

15noBACKGROUND: Late onset Pompe disease (LOPD) is a lysosomal neuromuscular disorder which can progressively impair the patients' exercise tolerance, motor and respiratory functions, and quality of life. The available enzyme replacement therapy (ERT) does not completely counteract disease progression. We investigated the effect of exercise training alone, or associated with a high-protein diet, on the exercise tolerance, muscle and pulmonary functions, and quality of life of LOPD patients on long term ERT. METHODS: The patients were asked to participate to a crossover randomized study comprehending a control period (free diet, no exercise) followed by 2 intervention periods: exercise or exercise + diet, each lasting 26 weeks and separated by 13 weeks washout periods. Exercise training included moderate-intensity aerobic exercise on a cycle ergometer, stretching and balance exercises, strength training. The diet was composed by 25-30% protein, 30-35% carbohydrate and 35-40% fat. Before and after each period patients were assessed for: exercise tolerance test on a cycle-ergometer, serum muscle enzymes, pulmonary function tests and SF36 questionnaire for quality of life. Compliance was evaluated by training and dietary diaries. Patients were contacted weekly by researchers to optimize adherence to treatments. RESULTS: Thirteen LOPD patients, median age 49 ± 11 years, under chronic ERT (median 6.0 ± 4.0 years) were recruited. Peak aerobic power (peak pulmonary O2 uptake) decreased after control, whereas it increased after exercise, and more markedlyafter exercise + diet. Serum levels of lactate dehydrogenase (LDH) significantly decreased after exercise + diet; both creatine kinase (CK) and LDH levels were significantly reduced after exercise + diet compared to exercise. Pulmonary function showed no changes after control and exercise, whereas a significant improvement of forced expiratory volume in 1 sec (FEV1) was observed after exercise + diet. SF36 showed a slight improvement in the "mental component" scale after exercise, and a significant improvement in "general health" and "vitality" after exercise + diet. The compliance to prescriptions was higher than 70% for both diet and exercise. CONCLUSIONS: Exercise tolerance (as evaluated by peak aerobic power) showed a tendency to decrease in LOPD patients on long term ERT. Exercise training, particularly if combined with high-protein diet, could reverse this decrease and result in an improvement, which was accompanied by improved quality of life. The association of the two lifestyle interventions resulted also in a reduction of muscle enzyme levels and improved pulmonary function.openopenSechi A.; Zuccarelli L.; Grassi B.; Frangiamore R.; De Amicis R.; Marzorati M.; Porcelli S.; Tullio A.; Bacco A.; Bertoli S.; Dardis A.; Biasutti L.; Pasanisi M.B.; Devigili G.; Bembi B.Sechi, A.; Zuccarelli, L.; Grassi, B.; Frangiamore, R.; De Amicis, R.; Marzorati, M.; Porcelli, S.; Tullio, A.; Bacco, A.; Bertoli, S.; Dardis, A.; Biasutti, L.; Pasanisi, M. B.; Devigili, G.; Bembi, B

Comprehensive Evaluation of Plasma 7-Ketocholesterol and Cholestan-3β,5α,6β-Triol in an Italian Cohort of Patients Affected by Niemann-Pick Disease due to NPC1 and SMPD1 Mutations

: Niemann-Pick C disease (NPCD) is a rare autosomal recessive neurovisceral disorder with a heterogeneous clinical presentation. Cholestan-3β,5α,6β-triol and 7-ketocholesterol have been proposed as biomarkers for the screening of NPCD. In this work, we assessed oxysterols levels in a cohort of Italian patients affected by NPCD and analyzed the obtained results in the context of the clinical, biochemical and molecular data. In addition, a group of patients affected by Niemann-Pick B disease (NPBD) were also analyzed. NPC patients presented levels of both oxysterols way above the cut off value, except for 5 siblings presenting the variant biochemical phenotype who displayed levels of 3β,5α,6β-triol below or just above the cut-off value; 2 of them presented also normal levels of 7-KC. Both oxysterols were extremely high in a patient presenting the neonatal systemic lethal phenotype. All NPB patients showed increased oxysterols levels. In conclusion, the reported LC-MS/MS assay provides a robust non-invasive screening tool for NPCD. However, false negative results can be obtained in patients expressing the variant biochemical phenotype. These data strengthen the concept that the results should always be interpreted in the context of the patients' clinical picture and filipin staining and/or genetic studies might still be undertaken in patients with normal levels of oxysterols if symptoms are highly suggestive of NPCD. Both oxysterols are significantly elevated in NPB patients; thus a differential diagnosis should always be performed in patients presenting isolated hepatosplenomegaly, a common clinical sign of both NPCD and NPBD

Delphi consensus on the current clinical and therapeutic knowledge on Anderson-Fabry disease

BACKGROUND: Management of Anderson-Fabry disease (AFD) is contentious, particularly regarding enzyme replacement therapy (ERT). We report results of a Delphi consensus panel on AFD management. METHODS: A survey to gauge consensus among AFD experts was distributed online and responses were analysed. Statements on: 1) diagnosis; 2) when starting ERT; 3) management of ERT infusion and adverse reactions; and 4) follow-up/monitoring response to therapy and progression of disease were included. Responses without consensus were discussed with an enlarged panel and modified to reach consensus. RESULTS: 15 experts responded to the survey. After plenary discussion among the enlarged panel, consensus was reached on most statements. Key points were the use of a target organ biopsy to show Gb3 deposits in symptomatic women with negative molecular analysis, the need for ERT in symptomatic women and in all patients with persistent signs and symptoms±organ damage. It was agreed to assess vital signs before ERT administration and use a 0.2μL filter on infusion to reduce the risk of adverse reactions, that serum should be drawn prior to the first infusion for anti-agalsidase antibody analysis to have a baseline value if a subsequent adverse reaction appears, and that pre-medication is required in those with prior infusion reactions. Holter ECG monitoring, cardiac and brain MRI, renal parameters, and abdominal ultrasound were considered important for the assessment of disease progression and response at ERT. CONCLUSIONS: This consensus supplies guidance to healthcare providers on best practice in the management of patients with AFD and indicates a need for more guidanc

Position statement on the role of healthcare professionals, patient organizations and industry in European Reference Networks

A call from the EU for the set-up of European Reference Networks (ERNs) is expected to be launched in the first quarter of 2016. ERNs are intended to improve the care for patients with low prevalent or rare diseases throughout the EU by, among other things, facilitating the pooling and exchange of experience and knowledge and the development of protocols and guidelines. In the past, for example where costly orphan drugs have been concerned, industry has played an important role in facilitating consensus meetings and publication of guidelines. The ERNs should provide a unique opportunity for healthcare professionals and patients to lead these activities in an independent way. However, currently costs for networking activities are not to be covered by EU funds and alternative sources of funding are being explored. There is growing concern that any involvement of the industry in the funding of ERNs and their core activities may create a risk of undue influence. To date, the European Commission has not been explicit in how industry will be engaged in ERNs. We believe that public funding and a conflict of interest policy are needed at the level of the ERNs, Centers of Expertise (CEs), healthcare professionals and patient organizations with the aim of maintaining scientific integrity and independence. Specific attention is needed where it concerns the development of clinical practice guidelines. A proposal for a conflict of interest policy is presented, which may support the development of a framework to facilitate collaboration, safeguard professional integrity and to establish and maintain public acceptability and trust among patients, their organizations and the general public