Function In Duchenne Muscular Dystrophy Research Articles

Meaningful changes in motor function in Duchenne muscular dystrophy (DMD): A multi-center study.

Evaluations of treatment efficacy in Duchenne muscular dystrophy (DMD), a rare genetic disease that results in progressive muscle wasting, require an understanding of the 'meaningfulness' of changes in functional measures. We estimated the minimal detectable change (MDC) for selected motor function measures in ambulatory DMD, i.e., the minimal degree of measured change needed to be confident that true underlying change has occurred rather than transient variation or measurement error. MDC estimates were compared across multiple data sources, representing >1000 DMD patients in clinical trials and real-world clinical practice settings. Included patients were ambulatory, aged ≥4 to <18 years and receiving steroids. Minimal clinically important differences (MCIDs) for worsening were also estimated. Estimated MDC thresholds for >80% confidence in true change were 2.8 units for the North Star Ambulatory Assessment (NSAA) total score, 1.3 seconds for the 4-stair climb (4SC) completion time, 0.36 stairs/second for 4SC velocity and 36.3 meters for the 6-minute walk distance (6MWD). MDC estimates were similar across clinical trial and real-world data sources, and tended to be slightly larger than MCIDs for these measures. The identified thresholds can be used to inform endpoint definitions, or as benchmarks for monitoring individual changes in motor function in ambulatory DMD.

Tamoxifen may contribute to preserve cardiac function in Duchenne muscular dystrophy

Duchenne muscular dystrophy is life-limiting. Cardiomyopathy, which mostly ensues in the second decade of life, is the main cause of death. Treatment options are still limited. The TAMDMD (NCT03354039) trial assessed motor function, muscle strength and structure, laboratory biomarkers, and safety in 79 ambulant boys with genetically confirmed Duchenne muscular dystrophy, 6.5–12 years of age, receiving either daily tamoxifen 20 mg or placebo for 48 weeks. In this post-hoc analysis, available echocardiographic data of ambulant patients recruited at one study centre were retrieved and compared before and after treatment. Data from 14 patients, median 11 (interquartile range, IQR, 11–12) years of age was available. Baseline demographic characteristics were similar in participants assigned to placebo (n = 7) or tamoxifen (n = 7). Left ventricular end-diastolic diameter in the placebo group (median and IQR) was 39 (38–41) mm at baseline and 43 (38–44) mm at study end, while it was 44 (41–46) mm at baseline and 41 (37–46) mm after treatment in the tamoxifen group. Left ventricular fractional shortening in the placebo group was 35% (32–38%) before and 33% (32–36%) after treatment, while in the tamoxifen group it was 34% (33–34%) at baseline and 35% (33–35%) at study end. No safety signals were detected.Conclusion: This hypothesis-generating post-hoc analysis suggests that tamoxifen over 48 weeks is well tolerated and may help preserving cardiac structure and function in Duchenne muscular dystrophy. Further studies are justified.ClinicalTrials.gov Identifier: EudraCT 2017–004554–42, NCT03354039What is known:• Duchenne muscular dystrophy (DMD) is life-limiting. Cardiomyopathy ensues in the second decade of life and is the main cause of death. Treatment options are still limited.• Tamoxifen reduced cardiac fibrosis in mice and improved cardiomyocyte function in human-induced pluripotent stem cell-derived cardiomyocytes.What is new:• In this post-hoc analysis of the TAMDMD trial among 14 boys, median 11 years of age, treated with either tamoxifen or placebo for 48 weeks, treatment was well-tolerated.• A visual trend of improved left-ventricular dimensions and better systolic function preservation generates the hypothesis of a potential beneficial effect of tamoxifen in DMD cardiomyopathy.

Relationship Between Hand Strength and Function in Duchenne Muscular Dystrophy and Spinal Muscular Atrophy: Implications for Clinical Trials.

Measurement of muscle strength and motor function is recommended in clinical trials of neuromuscular diseases, but the loss of hand strength at which motor function is impacted is not documented. To establish the relationship between hand strength and function, and to determine the strength threshold that differentiates normal and abnormal hand function in individuals with Duchenne Muscular Dystrophy (DMD) or Spinal Muscular Atrophy (SMA). Maximal handgrip and key pinch strength were measured with the MyoGrip and MyoPinch dynamometers, respectively. Hand function was assessed using the MoviPlate, the Motor Function Measure items for distal upper limb (MFM-D3-UL) and the Cochin Hand Function Scale (CHFS). Data from 168 participants (91 DMD and 77 SMA, age 6-31 years) were analyzed. Relationships between strength and function were significant (P < 0.001). Hand function was generally preserved when strength was above the strength threshold determined by Receiver-Operating Characteristic (ROC) analysis: For MFM-D3-UL, the calculated handgrip strength thresholds were 41 and 13% of the predicted strength for a healthy subject (% pred) and the key pinch strength thresholds were 42 and 26% pred for DMD and SMA, respectively. For the MoviPlate, handgrip strength thresholds were 11 and 8% pred and key pinch strength thresholds were 21 and 11% pred for DMD and SMA, respectively. For participants with sub-threshold strength, hand function scores decreased with decreasing strength. At equal % pred strength, individuals with SMA had better functional scores than those with DMD. Hand function is strength-dependent for most motor tasks. It declines only when strength falls below a disease-specific threshold. Therefore, therapies capable of maintaining strength above this threshold should preserve hand function.

Appendicular lean mass index and motor function in ambulatory patients with Duchenne muscular dystrophy.

Appendicular lean mass index (ALMI) has been linked to motor function in patients with Duchenne muscular dystrophy (DMD). However, quantification of the relationship between ALMI and disease-specific clinical outcome assessment trajectories is needed. The purpose of this study was to determine associations between dual-energy x-ray absorptiometry (DXA) derived estimates of ALMI and motor function in ambulatory patients with DMD. A retrospective analysis of longitudinal clinical visit data from 137 glucocorticoid-treated patients with DMD collected via structured motor assessment protocol evaluated associations between ALMI and motor function indexed by the North Star Ambulatory Assessment (NSAA) and 10 Meter Walk/run Test (10MWT). Body composition was assessed using DXA. ALMI was calculated by dividing arm and leg lean mass by height in m2; fat mass index (FMI) was calculated by dividing whole body fat mass by height in m2. Linear mixed-effects models were used to estimate associations between ALMI and motor function, controlling for age and FMI. The full prediction model (age, age,2 ALMI, and FMI) explained 57% of the variance in NSAA scores and 63% of the variance in 10MWT speed. A 1 kg/m2 higher ALMI value predicted a 5.4-point higher NSAA score (p < .001) and 0.45 m/s faster 10MWT speed (p < .001). A 1 kg/m2 higher FMI value predicted a 1.5-point lower NSAA score (p < .001) and 0.14 meters/second slower 10MWT speed (p < .001). DXA-derived estimates of ALMI and FMI are associated with motor function in DMD and may explain variation in DMD disease progression.

TRIM Enhances Dystrophic Muscle Function 70 Days Post Treatment

Background: Duchenne Muscular Dystrophy (DMD) is associated with limb muscle dysfunction caused by progressive weakness and degeneration of skeletal muscle. Current FDA-approved therapeutic strategies are less effective than originally hoped. Our alternative approach was to develop a novel biomaterial, Time Release Ion Matrix (TRIM), shown to release angiogenic ions and enhance muscle structure and function at 14 days post injection (dpi) in dystrophic (D2. mdx) mice. However, the long-term effects of TRIM are unknown. Hypothesis: At 70 days post injection in D2. mdx mice TRIM will: 1) enhance isometric force and myofiber cross-sectional area (CSA) of the tibialis anterior (TA) muscle; and 2) promote vascular endothelial growth factor (VEGF) availability and muscle vascularity. Methods: The right and left TA of adult male D2. mdx mice (n=6-7, age 5 months) were injected with saline alone (control) or 250 μg of TRIM suspended in saline. At 70 dpi, the left TA was isolated for in situ muscle force measurements and histological analysis; the right TA was frozen for biochemical analysis. Muscle cross-sections were immunostained for laminin (myofiber borders), DAPI (nuclei), and CD31 (endothelial cells). An ELISA for VEGF was performed on homogenates of frozen muscles. Results: TA’s injected with TRIM increased peak isometric force (means ± SE: TRIM 70.9 ± 1.8 g; Saline, 65.9 ± 1.1 g; P= 0.04). TRIM-treated TA’s had a 2.2-fold increase in relative frequency of myofibers &gt;1000 μm2 (TRIM, 31.8 ± 3.7%; Saline, 14.4 ± 1.9%; P= 0.001), and reduced the frequency of myofibers &lt;400 μm2 by 32% (TRIM, 38.6% ± 2.8; Saline, 56.5% ± 3.5; P= 0.001). DAPI staining revealed a 50% increase in central myonuclei indicative of regenerated myofibers (TRIM, 30.2 ± 1.7%; Saline, 20.2 ± 1.3%; P=0.0006). Microvessel area (CD31 staining; μm2) was 2.1-fold greater in treated TA’s (TRIM, 135.6 ± 8.7 μm2; Saline, 63.6 ± 4.5 μm2; P=0.0001). In muscle homogenates, TRIM increased [VEGF] (TRIM, 139 ± 10%; Saline, 100 ± 6%; P= 0.009) Conclusion: Results support the hypothesis that 70 days following injection of TRIM into the TA of dystrophic mice, muscle force and myofiber CSA are enhanced. Moreover, TRIM enhances VEGF with increased vascularity, suggesting that the angiogenic effects of TRIM complement those on myogenesis and contractile function towards restoring muscle structure and function in DMD. University of Missouri Coulter Biomedical Accelerator (SSS), Texas A&amp;M Department of Kinesiology and Sport Management (ABM). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Decreasing microtubule detyrosination modulates Nav1.5 subcellular distribution and restores sodium current in mdx cardiomyocytes.

The microtubule (MT) network plays a major role in the transport of the cardiac sodium channel Nav1.5 to the membrane, where the latter associates with interacting proteins such as dystrophin. Alterations in MT dynamics are known to impact on ion channel trafficking. Duchenne muscular dystrophy (DMD), caused by dystrophin deficiency, is associated with an increase in MT detyrosination, decreased sodium current (INa), and arrhythmias. Parthenolide (PTL), a compound that decreases MT detyrosination, has shown beneficial effects on cardiac function in DMD. We here investigated its impact on INa and Nav1.5 subcellular distribution. Ventricular cardiomyocytes (CMs) from wild-type (WT) and mdx (DMD) mice were incubated with either 10 µM PTL, 20 µM EpoY, or dimethylsulfoxide (DMSO) for 3-5 h, followed by patch-clamp analysis to assess INa and action potential (AP) characteristics in addition to immunofluorescence and stochastic optical reconstruction microscopy (STORM) to investigate MT detyrosination and Nav1.5 cluster size and density, respectively. In accordance with previous studies, we observed increased MT detyrosination, decreased INa and reduced AP upstroke velocity (Vmax) in mdx CMs compared to WT. PTL decreased MT detyrosination and significantly increased INa magnitude (without affecting INa gating properties) and AP Vmax in mdx CMs, but had no effect in WT CMs. Moreover, STORM analysis showed that in mdx CMs, Nav1.5 clusters were decreased not only in the grooves of the lateral membrane (LM; where dystrophin is localized) but also at the LM crests. PTL restored Nav1.5 clusters at the LM crests (but not at the grooves), indicating a dystrophin-independent trafficking route to this subcellular domain. Interestingly, Nav1.5 cluster density was also reduced at the intercalated disc (ID) region of mdx CMs, which was restored to WT levels by PTL. Treatment of mdx CMs with EpoY, a specific MT detyrosination inhibitor, also increased INa density, while decreasing the amount of detyrosinated MTs, confirming a direct mechanistic link. Attenuating MT detyrosination in mdx CMs restored INa and enhanced Nav1.5 localization at the LM crest and ID. Hence, the reduced whole-cell INa density characteristic of mdx CMs is not only the consequence of the lack of dystrophin within the LM grooves but is also due to reduced Nav1.5 at the LM crest and ID secondary to increased baseline MT detyrosination. Overall, our findings identify MT detyrosination as a potential therapeutic target for modulating INa and subcellular Nav1.5 distribution in pathophysiological conditions.

Quantifying Variability in Motor Function in Duchenne Muscular Dystrophy: UK Centiles for the NorthStar Ambulatory Assessment, 10 m Walk Run Velocity and Rise from Floor Velocity in GC Treated Boys.

In this paper, we present the UK centiles for the North Star Ambulatory Assessment (NSAA), the 10 m walk/run time (10MWR) and velocity (10MWRV), and the rise from floor time (RFF) and velocity (RFFV) created from a cohort of glucocorticoid treated DMD boys between the age of 5 and 16 years. Participants were included from the UK NorthStar registry if they had initiated steroids (primarily deflazacorts/prednisolone, intermittent/daily) and were not enrolled in an interventional trial. Assessments were included if the participant had a complete NSAA, the timed tests had been completed or the corresponding items were 0, or the participant was recorded as non-ambulant, in which case the NSAA was assumed 0. We analysed 3987 assessments of the NSAA collected from 826 participants. Of these, 1080, 1849 and 1199 were imputed as 0 for the NSAA, RFFV and 10MWRV respectively. The 10th, 25th, 50th, 75th and 90th centiles were presented. The NSAA centiles showed a peak score of 14, 20, 26, 30 and 32 respectively, with loss of ambulation at 10.7, 12.2 and 14.3 years for the 25th, 50th and 75th centiles, respectively. The centiles showed loss of rise from floor at 8.6, 10.1 and 11.9 years and a loss of 10MWR of 0 at 8.9, 10.3 and 13.8 years for the 25th, 50th and 75th centiles, respectively. The centiles were pairwise less correlated than the raw scores, suggesting an increased ability to detect variability in the DMD cohort. The NSAA, 10MWR and RFF centiles may provide insights for clinical monitoring of DMD boys, particularly in late ambulatory participants who are uniformly declining. Future work will validate the centiles in national and international natural history cohorts.

Comparison of Low-intensity Aerobic Exercise with Assisted Bicycle Exercise on Quality of Life and Lung Function in Duchenne Muscular Dystrophy

Comparison of Low-intensity Aerobic Exercise with Assisted Bicycle Exercise on Quality of Life and Lung Function in Duchenne Muscular Dystrophy

Abbreviated cardiac magnetic resonance imaging versus echocardiography for interval assessment of systolic function in Duchenne muscular dystrophy: patient satisfaction, clinical utility, and image quality.

Poor acoustic windows make interval assessment of systolic function in patients with (Duchenne Muscular Dystrophy) DMD by echocardiography (echo) difficult. Cardiac magnetic resonance imaging (CMR) can be challenging in DMD patients due to study duration and patient discomfort. We developed an abbreviated CMR (aCMR) protocol and hypothesized that aCMR would compare favorably to echo in image quality and clinical utility without significant differences in exam duration, patient satisfaction, and functional measurements. DMD patients were recruited prospectively to undergo echo and aCMR. Modalities were compared with a global quality assessment score (GQAS), clinical utility score (CUS), and patient satisfaction score (PSS). Results were compared using Wilcoxon signed-rank tests, Spearman correlations, intraclass correlations, and Bland-Altman analyses. Nineteen DMD patients were included. PSS scores and exam duration were equivalent between modalities, while CUS and GQAS scores favored aCMR. ACMR scored markedly higher than echo in RV visualization and assessment of atrial size. Older age was negatively correlated with echo GQAS and CUS scores, as well as aCMR PSS scores. Higher BMI was positively correlated with aCMR GQAS scores. Nighttime PPV requirement and non-ambulatory status were correlated with worse echo CUS scores. Poor image quality precluding quantification existed in five (26%) echo and zero (0%) aCMR studies. There was moderate correlation between aCMR and echo for global circumferential strain and left ventricular four chamber global longitudinal strain. The aCMR protocol resulted in improved clinical relevance and quality scores relative to echo, without significant detriment to patient satisfaction or exam duration.

Association between neurodevelopmental impairments and motor function in Duchenne muscular dystrophy.

We explored various prognostic factors of motor outcomes in corticosteroid-naive boys with Duchenne Muscular Dystrophy (DMD). The associations between parent-reported neurodevelopmental concerns (speech delay, speech and language difficulties (SLD), and learning difficulties), DMD mutation location, and motor outcomes (6-minute walk distance (6MWD), North Star Ambulatory Assessment (NSAA) total score, 10-meter walk/run velocity, and rise from floor velocity) were studied in 196 corticosteroid-naive boys from ages 4 to less than 8 years. Participants with SLD walked 25.8 fewer meters in 6 minutes than those without SLD (p = 0.005) but did not demonstrate statistical differences in NSAA total score, 10-meter walk/run velocity, and rise from floor velocity. Participants with distal DMD mutations with learning difficulties walked 51.8 fewer meters in 6 minutes than those without learning difficulties (p = 0.0007). Participants with distal DMD mutations were slower on 10-meter walk/run velocity, and rise from floor velocity (p = 0.02) than those with proximal DMD mutations. Participants with distal DMD mutations, who reported speech delay or learning difficulties, were slower on rise from floor velocity (p = 0.04, p = 0.01) than those with proximal DMD mutations. The mean NSAA total score was lower in participants with learning difficulties than in those without (p = 0.004). Corticosteroid-naive boys with DMD with distal DMD mutations may perform worse on some timed function tests, and that those with learning difficulties may perform worse on the NSAA. Pending confirmatory studies, our data underscore the importance of considering co-existing neurodevelopmental symptoms on motor outcome measures.

PCR174 Characterizing Progressive Disease Burden amid Heterogeneity: Data Visualizations for Ambulatory Motor Function in Duchenne Muscular Dystrophy (DMD)

DMD is an X-linked recessive disorder that causes progressive loss of muscle function in affected patients. Given variation in ages at symptom onset and rates of motor function decline, we aimed to develop data visualizations characterizing typical patterns of disease progression amid heterogeneity.

Timed Release Ion Matrix Enhances Muscle Force in Dystrophic Mice

Background: Duchenne Muscular Dystrophy (DMD) is an x-linked, recessive chromosomal mutation of the gene dystrophin, affecting 1 in 3,500 males. DMD is associated with limb muscle dysfunction from repetitive damage to myofibers beginning at 2 years of age. In healthy muscle, dystrophin is responsible for maintaining the sarcolemma through the dystrophin-glycoprotein complex, while muscle with dystrophin deficiencies seen in DMD patients experience severe sarcolemmal disruption following muscle contraction. Despite major advances in genetic engineering, the functional outcomes of FDA-approved therapeutic strategies have failed to enhance the function of dystrophin-deficient myofibers. We have taken an alternative approach to apply a novel biomaterial, Time Release Ion Matrix (TRIM), that has the potential to release ions favorable to regeneration, restoring muscle structure and function in DMD mice. Hypothesis: We hypothesized that muscle force and myofiber cross-sectional area (CSA) of the tibialis anterior muscle (TA) in an established mouse model of muscle dystrophy [D2.B10 mdx (DBA. mdx)] would be enhanced 14 days post-injection of TRIM. Methods: The left TA of adult male DBA. mdx mice (n=3-9, age 6-7 months) was injected with 250 μg of TRIM suspended in saline or saline alone (vehicle control). At 14 days post injection, the TA muscle was isolated for in situ muscle force measurements using direct electrical stimulation. The TA was then removed and frozen in optimal cutting temperature compound (OCT) for histological analysis. Muscle cross-sections (thickness, 10 μm) were labeled with laminin to identify myofiber borders and myosin heavy chain as a marker of myofibers able to generate force. Images were analyzed using Nikon NIS-Elements software. To simulate body fluid, 300 mg of TRIM was suspended in physiological salt solution (PSS) for 120 hours. Results: The dissolution of TRIM in PSS over 120 hours was 40% (179 mg remaining). Peak isometric force of TAs injected with TRIM (60.0 ± 2.3 g) was 11% greater compared to saline alone (52.4 ± 2.4 g) (means ± SE, n=6-9 per group; P=0.048). There were fewer small diameter myofibers (&lt; 400 μm2) in TAs injected with TRIM (10 ± 7%) compared to saline controls (24 ± 5 %) (n=3/group; P=0.03). Conclusion: 14 days following injection of TRIM into the TA of dystrophic mice, muscle force and myofiber CSA were enhanced by 11 and 14% respectively. We suggest that TRIM may be an effective treatment to restore muscle function in DMD and serve as a powerful tool for discovering therapeutic targets against DMD. University of Missouri Coulter Biomedical Accelerator (SSS, ABM), Texas A&amp;M Department of Kinesiology and Sport Management (JAK, ABM) This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

DMD Genotypes and Motor Function in Duchenne Muscular Dystrophy: A Multi-institution Meta-analysis With Implications for Clinical Trials.

Clinical trials of genotype-targeted treatments in Duchenne muscular dystrophy (DMD) traditionally compare treated patients with untreated patients with the same DMD genotype class. This avoids confounding of drug efficacy by genotype effects but also shrinks the pool of eligible controls, increasing challenges for trial enrollment in this already rare disease. To evaluate the suitability of genotypically unmatched controls in DMD, we quantified effects of genotype class on 1-year changes in motor function endpoints used in clinical trials. More than 1,600 patient-years of follow-up (>700 patients) were studied from 6 real-world/natural history data sources (UZ Leuven, PRO-DMD-01 shared by CureDuchenne, iMDEX, North Star UK, Cincinnati Children's Hospital Medical Center, and the DMD Italian Group), with genotypes classified as amenable to skipping exons 44, 45, 51, or 53, or other skippable, nonsense, and other mutations. Associations between genotype class and 1-year changes in North Star Ambulatory Assessment total score (ΔNSAA) and in 10-m walk/run velocity (Δ10MWR) were studied in each data source with and without adjustment for baseline prognostic factors. The studied genotype classes accounted for approximately 2% of variation in ΔNSAA outcomes after 12 months, whereas other prognostic factors explained >30% of variation in large data sources. Based on a meta-analysis across all data sources, pooled effect estimates for the studied skip-amenable mutation classes were all small in magnitude (<2 units in ΔNSAA total score in 1-year follow up), smaller than clinically important differences in NSAA, and were precisely estimated with standard errors <1 unit after adjusting for nongenotypic prognostic factors. These findings suggest the viability of trial designs incorporating genotypically mixed or unmatched controls for up to 12 months in duration for motor function outcomes, which would ease recruitment challenges and reduce numbers of patients assigned to placebos. Such trial designs, including multigenotype platform trials and hybrid designs, should ensure baseline balance between treatment and control groups for the most important prognostic factors, while accounting for small remaining genotype effects quantified in this study.

Effect of respiratory muscle training using Ultrabreathe device on pulmonary function in Duchenne Muscular Dystrophy through telephysiotherapy

Background. Duchenne Muscular Dystrophy (DMD), an X linked disorder resulting in respiratory insufficiency, caused by progressive respiratory muscle weakness particularly in diaphragm. During this pandemic, Telerehabilitation played a major role among patients, especially disabled children. OBJECTIVE: To find out the effect on the pulmonary function in DMD children by training the respiratory muscles by telephysiotherapy. Methodology. Non Experimental design, Case series- pre and post test type. Convenient sampling, sample size was 5. Boys and girls between 9 and 16 years of age were included in the study. Procedure. 5 subjects were selected based on the inclusion and exclusion criteria and were trained for one minute with minimum resistance using ultrabreathe through Telephysiotherapy which is repeated for 3 times in a session with a rest period of 20–30 seconds for six weeks. Outcome measure. Pulmonary Function test. Results. The results of this study shows increased mean value of post test Tidal volume, Forced Vital Capacity, Inspiratory time/Respiration time and Tidal Volume / Inspiration time compared with pre test, whereas other parameters like Duration of Inspiration, Total Lung Volume, Inspiratory Capacity, Forced Expiratory Volume1 does not increased. Conclusion This study concluded that the Duchenne Muscular Dystrophy children improved in Tidal Volume, Forced Vital Capacity, Tidal Volume/Inspiration Time, and Inspiration Time/Respiration Time whereas all other parameters such as Duration of Inspiration, Total lung volume, Inspiratory capacity and Forced Expiratory volume1 maintained after 6 weeks of respiratory muscles training with ultrabreathe device.

Calcium handling maturation and adaptation to increased substrate stiffness in human iPSC-derived cardiomyocytes: The impact of full-length dystrophin deficiency.

Cardiomyocytes differentiated from human induced Pluripotent Stem Cells (hiPSC- CMs) are a unique source for modelling inherited cardiomyopathies. In particular, the possibility of observing maturation processes in a simple culture dish opens novel perspectives in the study of early-disease defects caused by genetic mutations before the onset of clinical manifestations. For instance, calcium handling abnormalities are considered as a leading cause of cardiomyocyte dysfunction in several genetic-based dilated cardiomyopathies, including rare types such as Duchenne Muscular Dystrophy (DMD)-associated cardiomyopathy. To better define the maturation of calcium handling we simultaneously measured action potential and calcium transients (Ca-Ts) using fluorescent indicators at specific time points. We combined micropatterned substrates with long-term cultures to improve maturation of hiPSC-CMs (60, 75 or 90 days post-differentiation). Control-(hiPSC)-CMs displayed increased maturation over time (90 vs 60 days), with longer action potential duration (APD), increased Ca-T amplitude, faster Ca-T rise (time to peak) and Ca-T decay (RT50). The progressively increased contribution of the SR to Ca release (estimated by post-rest potentiation or Caffeine-induced Ca-Ts) appeared as the main determinant of the progressive rise of Ca-T amplitude during maturation. As an example of severe cardiomyopathy with early onset, we compared hiPSC-CMs generated from a DMD patient (DMD-ΔExon50) and a CRISPR-Cas9 genome edited cell line isogenic to the healthy control with deletion of a G base at position 263 of the DMD gene (c.263delG-CMs). In DMD-hiPSC-CMs, changes of Ca-Ts during maturation were less pronounced: indeed, DMD cells at 90 days showed reduced Ca-T amplitude and faster Ca-T rise and RT50, as compared with control hiPSC-CMs. Caffeine-Ca-T was reduced in amplitude and had a slower time course, suggesting lower SR calcium content and NCX function in DMD vs control cells. Nonetheless, the inotropic and lusitropic responses to forskolin were preserved. CRISPR-induced c.263delG-CM line recapitulated the same developmental calcium handling alterations observed in DMD-CMs. We then tested the effects of micropatterned substrates with higher stiffness. In control hiPSC-CMs, higher stiffness leads to higher amplitude of Ca-T with faster decay kinetics. In hiPSC-CMs lacking full-length dystrophin, however, stiffer substrates did not modify Ca-Ts but only led to higher SR Ca content. These findings highlighted the inability of dystrophin-deficient cardiomyocytes to adjust their calcium homeostasis in response to increases of extracellular matrix stiffness, which suggests a mechanism occurring during the physiological and pathological development (i.e. fibrosis).

Respiratory Function and Sleep Disordered Breathing in Pediatric Duchenne Muscular Dystrophy.

The decline of respiratory function in Duchenne muscular dystrophy (DMD) is associated with sleep disordered breathing (SDB) and alteration of nocturnal gas exchange, first manifesting as nocturnal hypoventilation (NH). However, the correlation between the pulmonary function measured by spirometry (PFT) and the onset of SDB with or without NH is unclear. The aims of this study are to identify the prevalence and features of SDB and to investigate the relationship between lung function determined by forced vital capacity (FVC) and sleep abnormalities in a large pediatric DMD population. This was a retrospective, single-center cohort study. FVC% predicted (FVC%) was calculated using predicted equations from the Global Lung Function Initiative. NH was defined by transcutaneous (tc) CO2 &gt;50 mm Hg for &gt;25% of total sleep time (TST), borderline NH by a mean tcCO2 between 45 and 50 mm Hg or tcCO2&gt;50 mm Hg for ≤25% of TST, and clinically meaningful obstructive sleep apnea (OSA) by obstructive apnea-hypopnea index &gt;5. The sensitivity, specificity, and positive and negative predictive values of FVC &lt; 50% to indicate the presence of nocturnal hypoventilation were calculated. One hundred thirty-four patients underwent 284 sleep studies and 1222 PFT. The mean (SD) age at the first and the last sleep study was 12.9 (2.7) and 14.3 (2.6) years, respectively. Borderline NH (n = 31) was detected in both ambulant and early-nonambulant participants, while 100% of NH cases (n = 14) were nonambulant. NH was detected in 4 of the 14 patients despite an FVC &gt;50%. Seventeen of the 26 patients with OSA presented with concomitant NH or borderline NH. FVC &lt;50% was associated with NH indicating a sensitivity and specificity of 73% and 86%, respectively. Positive and negative predictive values were 32% and 97%, respectively. PFT showed a nonlinear, sudden FVC% decline in 18% of cases. FVC% &lt;50 was associated with NH in close to a third of patients. CO2 elevation can be associated with obstructive/pseudo-obstructive events and was also observed in early nonambulant cases or in the presence of FVC &gt;50%. These results are relevant for the clinical management of SDB.

Comparison of the effect of three steroid regimens on cardiac function in Duchenne muscular dystrophy

BackgroundSteroid therapy of patients with Duchenne muscular dystrophy (DMD) delays the onset of cardiac dysfunction. ObjectiveThe aim of this study was to compare the effects of 3 different steroid regimens on cardiac function assessed by echocardiography. MethodsPatients diagnosed with DMD, between 8 and 23 years of age were reviewed between January 2000 and September 2018. Participants were classified into four groups. Control group (no steroid treatment), Prednisone 10 mg/kg/weekend day, Prednisone 0.40 mg - 0.75 mg/kg/day and Deflazacort 0.9 mg/kg/day.Demographic data, echocardiographic measurements of shortening fraction (FS) and left ventricular end diastolic diameter z-score were collected and compared between cohorts. ResultsDevelopment of cardiac dysfunction in groups receiving prednisone daily or 3 day prednisone was less common in comparison to the control group (p = 0.005). No patient on the Deflazacort group had abnormal left ventricular FS. There was no difference in the age of initiation of steroid therapy among groups (p = 0.08). Age of development of systolic dysfunction by echocardiography between daily prednisone and weekend prednisone was not significantly different (p = 0.07). There was no difference in the number of patients developing of cardiac dysfunction between patients receiving prednisone daily or 3 day prednisone (p = 0.4). The entire cohort (77 patients) demonstrated a decline in the cardiac function over time. ConclusionsOur study confirms the delay in development of left ventricular dysfunction related to steroid therapy. Deflazacort seems to show a significant beneficial effect on cardiac function, compared to daily and weekend prednisone therapies.

Longitudinal changes in cardiac function in Duchenne muscular dystrophy population as measured by magnetic resonance imaging

BackgroundThe lack of dystrophin in cardiomyocytes in Duchenne muscular dystrophy (DMD) is associated with progressive decline in cardiac function eventually leading to death by 20–40 years of age. The aim of this prospective study was to determine rate of progressive decline in left ventricular (LV) function in Duchenne muscular dystrophy (DMD) over 5 years.MethodsShort axis cine and grid tagged images of the LV were acquired in individuals with DMD (n = 59; age = 5.3–18.0 years) yearly, and healthy controls at baseline (n = 16, age = 6.0–18.3 years) on a 3 T MRI scanner. Grid-tagged images were analyzed for composite circumferential strain (ℇcc%) and ℇcc% in six mid LV segments. Cine images were analyzed for left ventricular ejection fraction (LVEF), LV mass (LVM), end-diastolic volume (EDV), end-systolic volume (ESV), LV atrioventricular plane displacement (LVAPD), and circumferential uniformity ratio estimate (CURE). LVM, EDV, and ESV were normalized to body surface area for a normalized index of LVM (LVMI), EDV (EDVI) and ESV (ESVI).ResultsAt baseline, LV ℇcc% was significantly worse in DMD compared to controls and five of the six mid LV segments demonstrated abnormal strain in DMD. Longitudinal measurements revealed that ℇcc% consistently declined in individuals with DMD with the inferior segments being more affected. LVEF progressively declined between 3 to 5 years post baseline visit. In a multivariate analysis, the use of cardioprotective drugs trended towards positively impacting cardiac measures while loss of ambulation and baseline age were associated with negative impact. Eight out of 17 cardiac parameters reached a minimal clinically important difference with a threshold of 1/3 standard deviation.ConclusionThe study shows a worsening of circumferential strain in dystrophic myocardium. The findings emphasize the significance of early and longitudinal assessment of cardiac function in DMD and identify early biomarkers of cardiac dysfunction to help design clinical trials to mitigate cardiac pathology. This study provides valuable non-invasive and non-contrast based natural history data of cardiac changes which can be used to design clinical trials or interpret the results of current trials aimed at mitigating the effects of decreased cardiac function in DMD.

Predicting Trajectories of Ambulatory Function in Duchenne Muscular Dystrophy (DMD) (P13-13.006)

Predicting Trajectories of Ambulatory Function in Duchenne Muscular Dystrophy (DMD) (P13-13.006)

Clinical Issues in Indication, Correction, and Outcomes of the Surgery for Neuromuscular Scoliosis: Narrative Review in Pedicle Screw Era.

Surgical treatment for neuromuscular scoliosis has evolved with pedicle screw instrumentation and the improvement of perioperative management. We aimed to review recent papers related to posterior surgical correction with a pedicle screw system for neuromuscular scoliosis, particularly cerebral palsy and muscular dystrophy, in terms of indication, correction method, and outcomes. The most remarkable change was the posterior-only operation with all-pedicle screw fixations. With this change, operation time, blood loss, and postoperative complications decreased. Furthermore, spinal osteotomy could be performed with the pedicle screw system for severe scoliosis. S2-alar-iliac screws demonstrated favorable outcomes in terms of stability and complication, but a question remains about saving the mobile segment for sitting balance, interaction between the hip and spine, effect to the sagittal balance, and proximal junctional problem. The quality of life improvement was more definite in patients with cerebral palsy. The improvement of respiratory function in Duchenne muscular dystrophy was not certain, although an increase of spinal height, thoracic cavity size, and absolute forced vital capacity have been reported. Further prospective studies or randomized clinical trials are needed to evaluate the long-term outcomes of lumbosacral fixation, preservation of the lumbosacral joint, or functional improvement considering the different etiology.