Post-intervention Status in Patients With Refractory Myasthenia Gravis Treated With Eculizumab During REGAIN and Its Open-Label Extension

OBJECTIVE: To evaluate whether eculizumab helps patients with anti-acetylcholine receptor-positive (AChR+) refractory generalized myasthenia gravis (gMG) achieve the Myasthenia Gravis Foundation of America (MGFA) post-intervention status of minimal manifestations (MM), we assessed patients' status throughout REGAIN (Safety and Efficacy of Eculizumab in AChR+ Refractory Generalized Myasthenia Gravis) and its open-label extension. METHODS: Patients who completed the REGAIN randomized controlled trial and continued into the open-label extension were included in this tertiary endpoint analysis. Patients were assessed for the MGFA post-intervention status of improved, unchanged, worse, MM, and pharmacologic remission at defined time points during REGAIN and through week 130 of the open-label study. RESULTS: A total of 117 patients completed REGAIN and continued into the open-label study (eculizumab/eculizumab: 56; placebo/eculizumab: 61). At week 26 of REGAIN, more eculizumab-treated patients than placebo-treated patients achieved a status of improved (60.7% vs 41.7%) or MM (25.0% vs 13.3%; common OR: 2.3; 95% CI: 1.1-4.5). After 130 weeks of eculizumab treatment, 88.0% of patients achieved improved status and 57.3% of patients achieved MM status. The safety profile of eculizumab was consistent with its known profile and no new safety signals were detected. CONCLUSION: Eculizumab led to rapid and sustained achievement of MM in patients with AChR+ refractory gMG. These findings support the use of eculizumab in this previously difficult-to-treat patient population. CLINICALTRIALSGOV IDENTIFIER: REGAIN, NCT01997229; REGAIN open-label extension, NCT02301624. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that, after 26 weeks of eculizumab treatment, 25.0% of adults with AChR+ refractory gMG achieved MM, compared with 13.3% who received placebo

Minimal Symptom Expression' in Patients With Acetylcholine Receptor Antibody-Positive Refractory Generalized Myasthenia Gravis Treated With Eculizumab

The efficacy and tolerability of eculizumab were assessed in REGAIN, a 26-week, phase 3, randomized, double-blind, placebo-controlled study in anti-acetylcholine receptor antibody-positive (AChR+) refractory generalized myasthenia gravis (gMG), and its open-label extension

Novel OPA1 mutation featuring spastic paraparesis and intestinal dysmotility

A 58-year-old man with optic atrophy, spastic paraparesis, axonal sensorimotor peripheral neuropathy and intestinal dysmotility harbors a novel heterozygous missense mutation in the mitochondrial import signal peptide of OPA1. The case underscores the role of OPA1 in the pathogenesis of spastic paraparesis, so far reported only in very few cases, and it adds intestinal dysmotility to the spectrum of adult-onset clinical manifestation of OPA1-associated disease

Metabolic syndrome and peripheral neuropathy

Diabetic peripheral neuropathy and metabolic syndrome (MetS) are both global health challenges with well‐established diagnostic criteria and significant impacts on quality of life. Clinical observations, epidemiologic evidence, and animal models of disease have strongly suggested MetS is associated with an elevated risk for cryptogenic sensory peripheral neuropathy (CSPN). MetS neuropathy preferentially affects small unmyelinated axons early in its course, and it may also affect autonomic and large fibers. CSPN risk is linked to MetS and several of its components including obesity, dyslipidemia, and prediabetes. MetS also increases neuropathy risk in patients with established type 1 and type 2 diabetes. In this review we present animal data regarding the role of inflammation and dyslipidemia in MetS neuropathy pathogenesis. Several studies suggest exercise‐based lifestyle modification is a promising treatment approach for MetS neuropathy.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/166416/1/mus27086.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/166416/2/mus27086_am.pd

FGF23, a novel muscle biomarker detected in the early stages of ALS

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease characterized by progressive muscle weakness. Skeletal muscle is a prime source for biomarker discovery since it is one of the earliest sites to manifest disease pathology. From a prior RNA sequencing project, we identified FGF23 as a potential muscle biomarker in ALS. Here, we validate this finding with a large collection of ALS muscle samples and found a 13-fold increase over normal controls. FGF23 was also increased in the SOD1 G93A mouse, beginning at a very early stage and well before the onset of clinical symptoms. FGF23 levels progressively increased through end-stage in the mouse. Immunohistochemistry of ALS muscle showed prominent FGF23 immunoreactivity in the endomysial connective tissue and along the muscle membrane and was significantly higher around grouped atrophic fibers compared to non-atrophic fibers. ELISA of plasma samples from the SOD1 G93A mouse showed an increase in FGF23 at end-stage whereas no increase was detected in a large cohort of ALS patients. In conclusion, FGF23 is a novel muscle biomarker in ALS and joins a molecular signature that emerges in very early preclinical stages. The early appearance of FGF23 and its progressive increase with disease progression offers a new direction for exploring the molecular basis and response to the underlying pathology of ALS

Comprehensive immune profiling reveals substantial immune system alterations in a subset of patients with amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease with a median lifespan of 2-3 years after diagnosis. There are few meaningful treatments that alter progression in this disease. Preclinical and clinical studies have demonstrated that neuroinflammation may play a key role in the progression rate of ALS. Despite this, there are no validated biomarkers of neuroinflammation for use in clinical practice or clinical trials. Biomarkers of neuroinflammation could improve patient management, provide new therapeutic targets, and possibly help stratify clinical trial selection and monitoring. However, attempts to identify a singular cause of neuroinflammation have not been successful. Here, we performed multi-parameter flow cytometry to comprehensively assess 116 leukocyte populations and phenotypes from lymphocytes, monocytes, and granulocytes in a cohort of 80 ALS patients. We identified 32 leukocyte phenotypes that were altered in ALS patients compared to age and gender matched healthy volunteers (HV) that included phenotypes of both inflammation and immune suppression. Unsupervised hierarchical clustering and principle component analysis of ALS and HV immunophenotypes revealed two distinct immune profiles of ALS patients. ALS patients were clustered into a profile distinct from HVs primarily due to differences in a multiple T cell phenotypes, CD3+CD56+ T cells and HLA-DR on monocytes. Patients clustered into an abnormal immune profile were younger, more likely to have a familial form of the disease, and survived longer than those patients who clustered similarly with healthy volunteers (344 weeks versus 184 weeks; p = 0.012). The data set generated from this study establishes an extensive accounting of immunophenotypic changes readily suitable for biomarker validation studies. The extensive immune system changes measured in this study indicate that normal immune homeostatic mechanisms are disrupted in ALS patients, and that multiple immune states likely exist within a population of patients with ALS

Transforming Growth Factor Beta (TGF-β) Is a Muscle Biomarker of Disease Progression in ALS and Correlates with Smad Expression.

We recently identified Smads1, 5 and 8 as muscle biomarkers in human ALS. In the ALS mouse, these markers are elevated and track disease progression. Smads are signal transducers and become activated upon receptor engagement of ligands from the TGF-β superfamily. Here, we sought to characterize ligands linked to activation of Smads in ALS muscle and their role as biomarkers of disease progression. RNA sequencing data of ALS muscle samples were mined for TGF-β superfamily ligands. Candidate targets were validated by qRT-PCR in a large cohort of human ALS muscle biopsy samples and in the G93A SOD1 mouse. Protein expression was evaluated by Western blot, ELISA and immunohistochemistry. C2C12 muscle cells were used to assess Smad activation and induction. TGF-β1, 2 and 3 mRNAs were increased in ALS muscle samples compared to controls and correlated with muscle strength and Smads1, 2, 5 and 8. In the G93A SOD1 mouse, the temporal pattern of TGF-β expression paralleled the Smads and increased with disease progression. TGF-β1 immunoreactivity was detected in mononuclear cells surrounding muscle fibers in ALS samples. In muscle cells, TGF-β ligands were capable of activating Smads. In conclusion, TGF-β1, 2 and 3 are novel biomarkers of ALS in skeletal muscle. Their correlation with weakness in human ALS and their progressive increase with advancing disease in the ALS mouse suggest that they, as with the Smads, can track disease progression. These ligands are capable of upregulating and activating Smads and thus may contribute to the Smad signaling pathway in ALS muscle

Different immunophenotypic biomarkers associate with clinical parameters in the two ALS immune profiles.

<p>Immune phenotypes were plotted against ALSFRS-R score or slope (ALSFRS-R points/month). XY graphs of correlations show p-value and Spearman r value. Lines represent the best fit resulting from linear regression analysis. Closed circles represent healthy volunteers, open squares represent ALS patients in Profile 1, and open diamonds represent ALS patients in Profile 2. <b>A.</b> Correlations of selected immunophenotypes to ALSFRS-R score in Profile 1 patients (top row) versus Profile 2 (bottom row). <b>B.</b> Correlations of selected immunophenotypes to slope in ALS Profile 1 patients. <b>C.</b> Survival curves of patients in each profile sub-grouped by cut-off values for PD-1⁺ CD4⁺ T cells. 19.7% was the cut-off value representing the median value for Profile 1 patients (Hi PD-1≥ 19.7; Lo PD-1< 19.7) and 19.5% was the cut-off value for Profile 2 patients. For CD3⁺CD56⁺ T cells, 104.62 cells/μl was used as a cut-off value for Profile 2 patients and 28.21 cells/μl was used for Profile 1. <b>D.</b> CD4⁺CD45RA⁺ naïve T cells show dissimilar age related associations between Profile 2 ALS patients, Profile 1 ALS patients, and healthy volunteers.</p

Role of Biotransformation of <i>Acacia nilotica</i> Metabolites by <i>Aspergillus subolivaceus</i> in Boosting <i>Lupinus termis</i> Yield: A Promising Approach to Sustainable Agriculture

Biotransformation plays a significant role in sustainable agriculture. This process involves utilizing microorganisms, such as bacteria and fungi, to transform organic compounds and metabolites into bioactive compounds which have beneficial effects on plant growth, yield, and soil characters. Accordingly, the present study aims to explore the role of biotransformation of Acacia nilotica metabolites by Aspergillus subolivaceus in boosting L. termis yield, as an important strategy in agricultural sustainability. A pilot experiment was performed on five fungal strains (Fusarium oxysporium A. aculeatus, Aspergillus. subolivaceus, Rhizopus oryzae and Trichoderma viride) which were grown on different parts of plants (A. nilotica leaves; green tea leaves, green pepper fruits and pomegranate fruits), and the results indicated that the most active metabolite for the growth of L. termis seeds was the fungal metabolite of A. subolivaceus growing on A. nilotica. More specifically, we assess how metabolites produced by Aspergillus subolivaceus using A. nilotica leaves affect the biochemical properties and chemical composition of L. termis seeds. A. subolivaceus was grown on leaves from A. nilotica to obtain metabolites and fractionated into four extracts. Two concentrations of each extract were examined by pretreating the seeds of L. termis. The study found that all four extracts contributed to an increase in yield and some biochemical properties of the yielded seeds. The best results were obtained by treating the L. termis seeds with an extract obtained from diethyl ether, which led to a significant increase in total nitrogen, amino nitrogen, glucose and protein contents of the seeds. According to 1H NMR guided GC/MS analysis, our results showed an increase in phytochemicals such as terpenes, fatty materials, and flavonoids including 3′,4′,7-trimethoxyquercetin and 4-methyl-p-menth-8-en-3-one, which have not been stated before from A. nilotica suggesting that biotransformation may have occurred due to the presence of A. subolivaceus

Two immune profiles of ALS patients reveal significant phenotypic differences.

<p>Leukocyte phenotypes from HVs and ALS patients sub-grouped into Profiles 1 and 2 were compared. <b>A.</b> Box-and-whisker plots of total white blood cells (WBCs) and mononuclear cells (MNCs) are shown. The boxes indicate the 25-75^th percentile, the horizontal line indicates the median, and the whiskers represent minimum and maximum values. <b>B.</b> Pie graphs depicting the peripheral blood leukocyte compartment of the three groups. The HV pie graph was set to 100% and the other pie graphs were sized in relation to the HV. <b>C.</b> Box-and-whisker plots of immunophenotypes associated with principal components. *** = p value <0.001, and * = p value <0.05.</p