Claudia Godi

Gene therapy augments the efficacy of hematopoietic cell transplantation and fully corrects mucopolysaccharidosis type I phenotype in the mouse model

Type I mucopolysaccharidosis (MPS I) is a lysosomal storage disorder caused by the deficiency of α-L-iduronidase, which results in glycosaminoglycan accumulation in tissues. Clinical manifestations include skeletal dysplasia, joint stiffness, visual and auditory defects, cardiac insufficiency, hepatosplenomegaly, and mental retardation (the last being present exclusively in the severe Hurler variant). The available treatments, enzyme-replacement therapy and hematopoietic stem cell (HSC) transplantation, can ameliorate most disease manifestations, but their outcome on skeletal and brain disease could be further improved. We demonstrate here that HSC gene therapy, based on lentiviral vectors, completely corrects disease manifestations in the mouse model. Of note, the therapeutic benefit provided by gene therapy on critical MPS I manifestations, such as neurologic and skeletal disease, greatly exceeds that exerted by HSC transplantation, the standard of care treatment for Hurler patients. Interestingly, therapeutic efficacy of HSC gene therapy is strictly dependent on the achievement of supranormal enzyme activity in the hematopoietic system of transplanted mice, which allows enzyme delivery to the brain and skeleton for disease correction. Overall, our data provide evidence of an efficacious treatment for MPS I Hurler patients, warranting future development toward clinical testing.

Ocular Adnexal Lymphoma: Diffusion-weighted MR Imaging for Differential Diagnosis and Therapeutic Monitoring

PURPOSE To describe the magnetic resonance (MR) imaging and diffusion-weighted (DW) imaging features of ocular adnexal lymphomas (OALs), to determine the diagnostic accuracy of apparent diffusion coefficient (ADC) for discriminating OALs from other orbital mass lesions, and to assess whether variations in ADC constitute a reliable biomarker of OAL response to therapy. MATERIALS AND METHODS Institutional ethical committee approval and informed consent were obtained. In this prospective study, 114 white subjects (65 females and 49 males) were enrolled. Thirty-eight patients with histopathologically proved OAL underwent serial MR and DW imaging examination of the orbits. ADCs of OALs were compared with those of normal orbital structures, obtained in 18 healthy volunteers, and other orbital mass lesions, prospectively acquired in 58 patients (20 primary non-OAL neoplasms, 15 vascular benign lesions, 12 inflammatory lesions, 11 metastases). Interval change in ADC of OALs before and after treatment was analyzed in 29 patients. Analysis of covariance and a paired t test were used for statistical analysis. RESULTS Baseline ADCs in OALs were lower than those in normal structures and other orbital diseases (P < .001). An ADC threshold of 775 x 10(-6) mm(2)/sec resulted in 96% sensitivity, 93% specificity, 88% positive predictive value, 98.2% negative predictive value, and 94.4% accuracy in OAL diagnosis. Following appropriate treatment, 10 (34%) of 29 patients showed OAL volumetric reduction, accompanied (n = 7) or preceded (n = 3) by an increase in ADC (P = .005). Conversely, a further reduction of ADC was observed in the seven patients who experienced disease progression (P < .05). CONCLUSION ADC permits accurate diagnosis of OALs. Interval change in ADC after therapy represents a helpful tool for predicting therapeutic response.

Intra-arterial transplantation of HLA-matched donor mesoangioblasts in Duchenne muscular dystrophy

Intra‐arterial transplantation of mesoangioblasts proved safe and partially efficacious in preclinical models of muscular dystrophy. We now report the first‐in‐human, exploratory, non‐randomized open‐label phase I–IIa clinical trial of intra‐arterial HLA‐matched donor cell transplantation in 5 Duchenne patients. We administered escalating doses of donor‐derived mesoangioblasts in limb arteries under immunosuppressive therapy (tacrolimus). Four consecutive infusions were performed at 2‐month intervals, preceded and followed by clinical, laboratory, and muscular MRI analyses. Two months after the last infusion, a muscle biopsy was performed. Safety was the primary endpoint. The study was relatively safe: One patient developed a thalamic stroke with no clinical consequences and whose correlation with mesoangioblast infusion remained unclear. MRI documented the progression of the disease in 4/5 patients. Functional measures were transiently stabilized in 2/3 ambulant patients, but no functional improvements were observed. Low level of donor DNA was detected in muscle biopsies of 4/5 patients and donor‐derived dystrophin in 1. Intra‐arterial transplantation of donor mesoangioblasts in human proved to be feasible and relatively safe. Future implementation of the protocol, together with a younger age of patients, will be needed to approach efficacy.

Magnetic resonance imaging with diffusion-weighted imaging in the evaluation of thyroid-associated orbitopathy: getting below the tip of the iceberg.

AbstractObjectivesTo compare extraocular muscles (EOMs) T2, post-contrast T1 (T1Gad) signal intensity ratios (SIRs) and normalized-apparent diffusion coefficient (n-ADC) values in patients with thyroid-associated orbitopathy (TAO) at different phases of activity and severity and correlate MRI modifications to clinical evolution during follow-up.MethodsA total of 74 TAO patients were classified as active or inactive on the basis of the clinical activity score (CAS). Severity of EOM impairment was evaluated by assigning a functional score to each rectus. T2, T1Gad SIRs and n-ADC of EOMs were compared in patients with active inflammation, those with inactive disease and 26 healthy controls, and correlated with clinical scores. MRI parameter variation was correlated with clinical modifications during follow-up.ResultsAll MRI parameters in TAO EOMs were significantly higher than in healthy subjects and correlated with muscle dysfunction and CAS. EOMs of active patients showed higher T2 and T1Gad SIRs than those with inactive disease. The T2 SIR and n-ADC of normally functioning TAO EOMs were higher than those of healthy controls. SIRs decreased in clinically improved and clinically stable EOMs after therapy.ConclusionsT2 SIR, T1Gad SIR and n-ADC are objective measures of activity and severity of EOMs in TAO patients. MRI shows clinically silent muscle involvement and modifications.Key Points• MRI and DWI measures are objective, quantitative parameters of TAO activity and severity • MRI and DWI measures significantly correlate with clinical scores in TAO patients • MRI and DWI can identify clinically silent inflammation of deep orbital structures • MRI and DWI can depict subclinical modifications during follow-up • MRI and DWI may aid clinicians in choosing the most appropriate treatment

Growth defects and impaired cognitive-behavioral abilities in mice with knockout for Eif4h, a gene located in the mouse homolog of the Williams-Beuren syndrome critical region

Protein synthesis is a tightly regulated, energy-consuming process. The control of mRNA translation into protein is fundamentally important for the fine-tuning of gene expression; additionally, precise translational control plays a critical role in many cellular processes, including development, cellular growth, proliferation, differentiation, synaptic plasticity, memory, and learning. Eukaryotic translation initiation factor 4h (Eif4h) encodes a protein involved in the process of protein synthesis, at the level of initiation phase. Its human homolog, WBSCR1, maps on 7q11.23, inside the 1.6 Mb region that is commonly deleted in patients affected by the Williams-Beuren syndrome, which is a complex neurodevelopmental disorder characterized by cardiovascular defects, cerebral dysplasias and a peculiar cognitive-behavioral profile. In this study, we generated knockout mice deficient in Eif4h. These mice displayed growth retardation with a significant reduction of body weight that began from the first week of postnatal development. Neuroanatomical profiling results generated by magnetic resonance imaging analysis revealed a smaller brain volume in null mice compared with controls as well as altered brain morphology, where anterior and posterior brain regions were differentially affected. The inactivation of Eif4h also led to a reduction in both the number and complexity of neurons. Behavioral studies revealed severe impairments of fear-related associative learning and memory formation. These alterations suggest that Eif4h might contribute to certain deficits associated with Williams-Beuren syndrome.

Chromogranin-A production and fragmentation in patients with Takayasu arteritis

BackgroundChromogranin-A (CgA) is a secretory protein processed into peptides that regulate angiogenesis and vascular cells activation, migration and proliferation. These processes may influence arterial inflammation and remodelling in Takayasu arteritis (TA).MethodsPlasma levels of full-length CgA (CgA439), CgA fragments lacking the C-terminal region (CgA-FRs) and the N-terminal fragment, CgA1–76 (vasostatin-1, VS-1) were analysed in 42 patients with TA and 20 healthy age-matched controls. Vascular remodelling was longitudinally assessed by imaging. CgA peptides were related to markers of systemic and local inflammation, disease activity and vascular remodelling.ResultsLevels of CgA-FRs and VS-1 were increased in TA. Treatment with proton-pump inhibitors (PPIs) and arterial hypertension partially accounted for CgA levels and high inter-patient variability. CgA439, CgA-FRs and VS-1 levels did not reflect disease activity or extent. Markers of systemic or local inflammation correlated with higher CgA-FRs and VS-1 in normotensive patients and with higher CgA439 in hypertensive patients. Treatment with non-biologic anti-rheumatic agents was associated with increased CgA-FRs and a distinctive regulation of CgA processing. Reduced blood levels of anti-angiogenic CgA peptides were associated with vascular remodelling in the groups of patients on PPIs and with arterial hypertension.ConclusionsThe plasma levels of CgA fragments are markedly increased in TA as a consequence of disease- and therapy-related variables. Anti-angiogenic forms of CgA may limit vascular remodelling. Given the effect of the various CgA peptides, it is advisable to limit the therapeutic prescriptions that might influence CgA-derived peptide levels to clearly agreed medical indications until further data become available.

Longitudinal MRI quantification of muscle degeneration in Duchenne muscular dystrophy

The aim of this study was to evaluate the usefulness of magnetic resonance imaging (MRI) in detecting the progression of Duchenne muscular dystrophy (DMD) by quantification of fat infiltration (FI) and muscle volume index (MVI, a residual‐to‐total muscle volume ratio).

Glioma imaging in Europe: A survey of 220 centres and recommendations for best clinical practice

ObjectivesAt a European Society of Neuroradiology (ESNR) Annual Meeting 2015 workshop, commonalities in practice, current controversies and technical hurdles in glioma MRI were discussed. We aimed to formulate guidance on MRI of glioma and determine its feasibility, by seeking information on glioma imaging practices from the European Neuroradiology community.MethodsInvitations to a structured survey were emailed to ESNR members (n=1,662) and associates (n=6,400), European national radiologists’ societies and distributed via social media.ResultsResponses were received from 220 institutions (59% academic). Conventional imaging protocols generally include T2w, T2-FLAIR, DWI, and pre- and post-contrast T1w. Perfusion MRI is used widely (85.5%), while spectroscopy seems reserved for specific indications. Reasons for omitting advanced imaging modalities include lack of facility/software, time constraints and no requests. Early postoperative MRI is routinely carried out by 74% within 24–72 h, but only 17% report a percent measure of resection. For follow-up, most sites (60%) issue qualitative reports, while 27% report an assessment according to the RANO criteria. A minority of sites use a reporting template (23%).ConclusionClinical best practice recommendations for glioma imaging assessment are proposed and the current role of advanced MRI modalities in routine use is addressed.Key Points• We recommend the EORTC-NBTS protocol as the clinical standard glioma protocol.• Perfusion MRI is recommended for diagnosis and follow-up of glioma.• Use of advanced imaging could be promoted with increased education activities.• Most response assessment is currently performed qualitatively.• Reporting templates are not widely used, and could facilitate standardisation.

Novel Angiographic Scores for evaluation of Large Vessel Vasculitis

Arterial involvement is the cardinal feature of large-vessel vasculitis (LVV) and prevention of disease progression is the principal therapeutic goal. However, development of tools for its evaluation represents a major unmet need. To address this, a widely-applicable imaging tool for LVV, analysing arterial involvement in 17 arterial territories, has been developed and validated. Individual stenosis and dilation scores were generated and combined in a composite score. The methodology was validated cross-sectionally and longitudinally in 131 patients, 96 Takayasu arteritis (TA), 35 large-vessel giant-cell arteritis (LV-GCA). In total, 4420 arterial segments from 260 imaging studies were evaluated. The new scores allowed quantitative grading of LVV arterial involvement with high consistency, revealing inter-patient differences. TA had higher stenosis and composite scores and lower dilation scores than LV-GCA. Baseline stenotic and composite scores reflected arterial damage rather than disease-activity. Longitudinal changes in all three scores correlated with disease activity and mirrored arterial disease evolution, reflecting both progressive injury and lesion improvement. Increases ≥1 in any score were specific for arterial disease progression. The scores objectively quantify arterial involvement in LVV, providing precise definition of disease phenotype and evolution. We propose that they represent novel vascular outcome measures essential for future clinical trials.

Exome sequencing reveals a novel homozygous mutation in ACP33 gene in the first Italian family with SPG21

SPG21, also known as Mast Syndrome (MIM 248900), is an ultra-rare autosomal recessive complicated form of hereditary spastic paraparesis (HSP) characterized by slowly progressive spasticity with dementia, occurring with high frequency in the Old Order Amish [1]. After the first Amish family, a single Japanese family with two affected members was reported [2]. Here we describe an Italian family with a single affected member carrying a novel homozygous single base deletion in the acidic cluster protein 33, ACP33 gene (SPG21) and presenting with a phenotype characterized by cognitive decline prevailing on the spastic paraparesis component. Difficulties at school and motor problems were noted in the patient since childhood. By the early 20s, mental function declined with progressive speech limitation, as well as evidence of clear executive dysfunctions and subtle personality disturbances. At neurological examination at 39 years of age, a spastic paraparesis was evident, with clear pyramidal signs apart from extensor plantar response. Extrapyramidal features like lack of facial expression, apathy, segmental dystonic torticollis and paucity of arm swing during gait were noted. The incoordination was minimal. Over a 2 year follow-up the motor abilities were identical, whereas cognitive decline mildly progressed with muteness, mental and behavioral rigidity with irritability and attitudes among the oppositional and renunciation, and a wide social closure. Brain MRI revealed thin corpus callosum and non-specific periventricular white matter hyperintensities (Fig. 1a, b).The patient had previously been tested for mutations in few common forms of HSP (SPG4, SPG7, SPG11, SPG15) with negative results. After informed consent, the proband of this family (Fig. 1c) together with the unaffected mother and sister underwent whole exome sequencing performed at the Illumina NextSeq 500 platform). Variants not present at single-nucleotide polymorphism databases and fitting a recessive model were prioritized for further analysis. A novel homozygous single base deletion c.118delC, was identified in the ACP33 gene (SPG21) (Fig. 1d) in the proband and confirmed by Sanger sequencing. The proband’s mother and sister were both carriers, while the father was not available for analysis. However, based on family reports the father was healthy. The single base deletion leads to early truncation of the ACP33/maspardin protein (308 aa), p.R40EfsTer27 at the N-terminal of the alpha–beta hydrolase domain (20-269 aa) (Fig. 1e).This is the only functional domain of maspardin with a protein–protein interaction activity [3, 4]. A role for maspardin in normal and EGF-induced growth and maturation of primary cortical neurons in SPG21 mice was demonstrated [5, 6]. Electronic supplementary material The online version of this article (doi:10.1007/s00415-017-8558-0) contains supplementary material, which is available to authorized users.