Slumdog Milionaire: Breakthrough in Muscular Dystrophy

Inspired by the book, 'Loveleen Tandan', director Danny Boyle produced the oscar-winning film we now know of as 'Slumdog Millionaire'. The story centers on a Mumbai teen who enters India's version of 'Who Wants to Be a Millionaire' and the moments in his upbringing in the slums of India which helped him become the first winner of a billion rupees. When this happens he is then accused of cheating because how is it possible for someone like Jamal to know the answers to such questions? Jamal Malik is dragged for a brutal questioning before he can answer his final question to win a million dollars. Thus he is promptly arrested, abused, and thoroughly investigated.

INTRODUCTION:

Duchenne muscular dystrophy (DMD) was first described by the French neurologist Guillaume Benjamin Amand Duchenne in the 1860s, but until the 1980s, little was known about the cause of any kind of muscular dystrophy. In 1986, MDA-supported researchers identified a particular gene on the X chromosome that, when flawed (or mutated), leads to DMD. In 1987, the protein associated with this gene was identified and named dystrophin. Lack of the dystrophin protein in muscle cells causes them to be fragile and easily damaged.DMD has an X-linked recessive inheritance pattern and is passed on by the mother, who is referred to as acarrier. [A] 

Muscular dystrophy is a group of diseases that cause progressive weakness and loss of muscle mass. In muscular dystrophy, abnormal genes (mutations) interfere with the production of proteins needed to form healthy muscle. Various forms of muscular dystrophy exist. Symptoms typically appear during childhood and mostly in boys. Although there is no cure, medications and therapy treatments help manage symptoms and slow down the progression of the disease. The main sign of muscular dystrophy is progressive muscle weakness. Specific signs and symptoms begin at different ages and in different muscle groups, depending on the type of muscular dystrophy. [A]

Duchenne muscular dystrophy is the most common form of muscular dystrophy. Although girls can be carriers and mildly affected, it's much more common in boys. About one-third of boys with Duchenne muscular dystrophy (DMD) don't have a family history of the disease, possibly because the gene involved may be subject to sudden abnormal change (spontaneous mutation). Symptoms include Frequent falls, Difficulty rising from a lying or sitting up position, Trouble running and jumping, Waddling gait, Walking on the toes, Large calf muscles, Muscle pain and stiffness, and Learning disabilities.[A]

 
Some of the many forms of Muscular Dystrophy include Myotonic (or 'Steinert's Disease' which is characterized by the inability to relax muscles at will following contractions. Myotonic Muscular Dystrophy is the most common form of adult-onset MD. Muscles in the face and neck are affected first.), Facioscapulohumeral ("FSHD" muscles in face and shoulders weaken), Congenital (affects both boys and girls. It is apparent at birth or before two years of age. other sub-forms progress slowly and cause mild disability verses others which progress rapidly, causing severe impairment), and Limb-Girdle (hip and shoulder muscles affected first. experience difficulty lifting front part of foot causing frequent trips while walking. onset usually begins in childhood or teen years).[A]

BACKGROUND INFORMATION:

Muscular dystrophy (MD) is a group of more than 30 inherited diseases. They all cause muscle weakness and muscle loss. Some forms of MD appear in infancy or childhood. Others may not appear until middle age or later. The different types can vary in whom they affect, which muscles they affect, and what the symptoms are. All forms of MD grow worse as the person's muscles get weaker. Most people with MD eventually lose the ability to walk. There is no cure for muscular dystrophy. Treatments can help with the symptoms and prevent complications. They include physical and speech therapy, orthopedic devices, surgery, and medications. Some people with MD have mild cases that worsen slowly. Others cases are disabling and severe. [B]

For diagnosis purposes physicians will begin with a medical history and physical examination. Next patient may be recommended to take enzyme tests, electromyography, genetic testing, muscle biopsy, heart-monitoring tests, and/or lung-monitoring tests. Damaged muscles release enzymes, such as creatine kinase (CK), into your blood. In a person who hasn't had a traumatic injury, high blood levels of CK suggest a muscle disease — such as muscular dystrophy. This is why enzyme tests are recommended by physicians.[B]

With electromyography an electrode needle is inserted into the muscle to be tested. Electrical activity is measured as you relax and as you gently tighten the muscle. Changes in the pattern of electrical activity can confirm a muscle disease. Genetic testing such as blood samples check for possible mutations in some genes that cause different types of Muscular Dystrophy. Tests in which a small piece of muscle is removed by an incision or a hollow needle is known as muscle biopsy. An analysis of this biopsy of the tissue sample can distinguish muscular dystrophies from other muscle diseases. Lastly, heart-monitoring tests check a patients heart function in particular those with myotonic muscular dystrophy.[B]

Although there is no cure, treatments have been created to help prevent or reduce joint or spinal problems. These treatments help patients remain mobile as long as possible. Treatment options include medications, physical and occupational therapy, and surgical  or other procedures.[B]

Eteplirsen (Exondys 51), the first medication to be approved by the Food and Drug Administration specifically to treat Duchenne muscular dystrophy. It was approved conditionally in 2016 and will continue to be evaluated during an additional two years of use. Although the medication appears safe, it's not clear how effective the drug is. It's definitely not a cure for DMD, but it may increase muscle strength in some people treated with the drug. Eteplirsen acts on specific gene variants that affect approximately one in seven people with DMD. [B]

 

Corticosteroids can strengthen muscles and delay certain types of MD. Prednisone is an example of such corticosteroids. The con to such medications tend to cause weight gain, weakened bones, and increase fracturing risks. Heart medications, such as angiotensin-converting enzyme (ACE) inhibitors or beta blockers, if muscular dystrophy damages the heart. [C]

Then there are the several types of therapy to choose from and available assistive devices which can improve quality of life. Muscular dystrophy can restrict the flexibility and mobility of joints. Limbs often draw inward and become fixed in that position. Range-of-motion exercises can help to keep joints as flexible as possible.[C]

Low-impact aerobic exercise, such as walking and swimming, can help maintain strength, mobility and general health. Some types of strengthening exercises also might be helpful. But it's important to talk to your doctor first because some types of exercise might be harmful. Braces can help keep muscles and tendons stretched and flexible, slowing the progression of contractual. Braces can also aid mobility and function by providing support for weakened muscles.[C] 

Mobility aids such as canes, walkers and wheelchairs can help maintain mobility and independence. As respiratory muscles weaken, a sleep apnea device may help improve oxygen delivery during the night. Some people with severe muscular dystrophy may need to use a machine that forces air in and out of their lungs (ventilator). Surgery may be needed to correct a spinal curvature that could eventually make breathing more difficult.[C]

RESEARCH: 

A recent landmark study has successfully treated muscle wasting in large mammals. These results have given both doctors and patients hope in a new treatment for muscular dystrophy (most common genetic condition in children that is ultimately fatal). Researchers from this particular study were able to mend mutations which is also cause the very same disease in dogs. Before the procedure is secured as safe and effective for human patients much more work is needed in future animal studies. They believe that a clinical trial involving patients with Duchenne muscular dystrophy could be launched within a few years.[D] 

Researchers led by Eric Olson at the University of Texas Southwestern Medical Center used a powerful but experimental gene-editing procedure known as Crispr-Cas9 to correct mutations in the dystrophin gene in four one-month-old dogs. The therapy uses harmless viruses to smuggle the gene-editing molecules into cells. Once inside, they home in on the mutated gene and cut it, causing the cell’s natural repair system to swing into action.[D]

CONCLUSION:

The scientists went on to assess how well the procedure worked if it was delivered by an infusion into the bloodstream instead of directly into muscles. This time, two beagles were infused with either a high or low dose of the Crispr gene editing molecules. Their muscle tissue was examined eight weeks later.[D]

Researchers describe how the infusions had a variable effect on the dogs’ muscles. In skeletal muscles, dystrophin was boosted by as little as 3% to as much as 90% of normal levels. In crucial diaphragm and heart muscles, dystrophin levels rose to 58% and 92% of normal levels respectively. Discovering that intravenous delivery of the virus resulted in significant restoration of dystrophin in the heart and diaphragm muscles, which are important in this disease.[D]

The scientists now plan extensive studies to assess the impact of the treatment on dogs. Those will reveal whether correcting the faulty genes actually improves the animals’ muscles and whether any benefits last. Because the study was small and run over a short time, it is impossible to know how effective the approach might be at alleviating the disease in humans.

This specific procedure is extremely promising based on our preliminary findings, but more work is needed to ensure safety and to determine long term durability of dystrophin expression. How soon it can be tested in humans depends on the results of forthcoming long term studies in dogs that will carefully assess the efficacy and safety of the procedure.

If everything were to continue smoothly, we might be able to anticipate moving into a human trial in a few years, but caution is paramount. Observing these advances in gene editing for Duchenne Muscular Dystrophy is very exciting, but limits to this study are real too.

The sample size was small and the study duration too short to know whether the gene editing was safe and effective. Although it seems to have largely boosted dystrophin production, which is key to tackling this condition, the team weren’t looking to record improvements in function. The next step will be to conduct larger, longer-term studies to see if the gene-editing approach does help to slow the progression of the condition and improve muscle strength. This won’t be a cure, but that shouldn’t obscure that this is a key step forward in proving the Crispr-Cas9 technology could work for Duchenne.[D]

LINKS:
[A] https://www.mayoclinic.org/diseases-conditions/muscular-dystrophy/symptoms-causes/syc-20375388
[B] https://medlineplus.gov/musculardystrophy.html
[C] https://www.mda.org/disease/duchenne-muscular-dystrophy
[D] https://www.theguardian.com/science/2018/aug/30/doctors-hail-breakthrough-in-muscular-dystrophy-treatment
[E]  https://screenmusings.org/movie/blu-ray/Slumdog-Millionaire/index_4.htm

*Please note! These images are not mine. They were found on various tumblr, pinterest, google image sites! If any are yours’ please let me know so that I can give you credit for them! Also the people in the images have no relation to the diseases, illnesses, or cancers I write about. Thanks so much & enjoy~