RELATED APPLICATIONS

This application claims the benefit under 35 U.S.C. § 119(e) of U.S. Provisional Patent Application filed June 29, 2015, entitled "TREATMENT FOR MYOPATHY", Serial No. 62/185,760, the contents of which are incorporated by reference herein in their entirety.

GOVERNMENT SUPPORT

This invention was made with government support under grants R01AR044345, F31NS081928, and K01AR062601 awarded by the National Institutes of Health. The government has certain rights in the invention.

BACKGROUND OF INVENTION

Myopathies are a heterogeneous group of disorders that manifest as skeletal muscle weakness and are defined by the presence of morphological features on muscle biopsy. Treatment for myopathies has traditionally been limited to supportive and palliative care. There remains a need for effective and specific treatments for myopathies.

SUMMARY OF THE INVENTION

The disclosure is based, in part, on a throughput chemical screen on the relatively relaxed (ryrlb) zebrafish that identified inhibitors of Janus kinase - Signal Transducer and Activator of Transcription (JAK-STAT) pathway. JAK-STAT cytokine signaling was identified as a druggable molecular pathway to treat the manifestations of myopathies.

In some aspects, the disclosure provides a method of treating a myopathy, the method comprising administering to a subject having a myopathy an effective amount of an inhibitor of Janus kinase - Signal Transducer and Activator of Transcription (JAK- STAT) pathway.

In some embodiments, the inhibitor of JAK-STAT is a small molecule, an antisense oligonucleotide, a small interfering RNA (siRNA), or an antibody. In some embodiments, the inhibitor of JAK-STAT is selected from the group consisting of: nifuroxazide, ketoprofen, sulfasalazine, 5,15-diphenylporphyrin, and AG490.

In some embodiments, the inhibitor of JAK-STAT is an inhibitor of JAK. In some embodiments, the inhibitor of JAK-STAT is an inhibitor of STAT. In some embodiments, the inhibitor of JAK-STAT is an inhibitor of STAT3.

Other aspects of the disclosure relate to a method of treating a myopathy, the method comprising administering to a subject having a myopathy an effective amount of an agent selected from the group consisting of: nifuroxazide, ketoprofen, sulfasalazine, 5,15-diphenylporphyrin, pargyline hydrochloride, metolazone, zimelidine

dihydrochloride monohydrate, miconazole, ticlopidine hydrochloride, iohexol, benoxinate hydrochloride, nimodipine, tranylcypromine hydrochloride, and AG490.

In some embodiments, the myopathy is congenital, myofibrillar, endocrine or metabolic, toxic, or caused by a systemic illness. In some embodiments, the congenital myopathy is a ryanodine receptor 1 (RYR1) -related myopathy. In some embodiments, the congenital myopathy is selected from the group consisting of: central core disease (CCD), multiminicore disease (MmD), centronuclear myopathy (CNM), nemaline myopathy (NM), core-rod myopathy, and congenital fiber- type disproportion (CFTD). In some embodiments, RYRl-related myopathy is selected from the group consisting of: central core disease (CCD), multiminicore disease (MmD), centronuclear myopathy (CNM), nemaline myopathy (NM), core-rod myopathy, and congenital fiber-type disproportion (CFTD).

Other aspects of the disclosure relate to an inhibitor of Janus kinase - Signal Transducer and Activator of Transcription (JAK-STAT) pathway for use in the treatment of a myopathy.

In some embodiments, the inhibitor of JAK-STAT is a small molecule, an antisense oligonucleotide, a small interfering RNA (siRNA), or an antibody.

In some embodiments, the inhibitor of JAK-STAT is selected from the group consisting of: nifuroxazide, ketoprofen, sulfasalazine, 5,15-diphenylporphyrin, and AG490.

In some embodiments, the inhibitor of JAK-STAT is an inhibitor of JAK. In some embodiments, the inhibitor of JAK-STAT is an inhibitor of STAT. In some

embodiments, the inhibitor of JAK-STAT is an inhibitor of STAT3.

Other aspects of the disclosure relate to an agent for use in the treatment of a myopathy, wherein the agent is selected from the group consisting of: nifuroxazide, ketoprofen, sulfasalazine, 5,15-diphenylporphyrin, pargyline hydrochloride, metolazone, zimelidine dihydrochloride monohydrate, miconazole, ticlopidine hydrochloride, iohexol, benoxinate hydrochloride, nimodipine, tranylcypromine hydrochloride, and AG490.

In some embodiments the myopathy is congenital, myofibrillar, endocrine or metabolic, toxic, or caused by a systemic illness. In some embodiments, the congenital myopathy is a ryanodine receptor 1 (RYR1) -related myopathy.

In some embodiments, the congenital myopathy is selected from the group consisting of: central core disease (CCD), multiminicore disease (MmD), centronuclear myopathy (CNM), nemaline myopathy (NM), core -rod myopathy, and congenital fiber- type disproportion (CFTD).

In some embodiments, RYRl-related myopathy is selected from the group consisting of: central core disease (CCD), multiminicore disease (MmD), centronuclear myopathy (CNM), nemaline myopathy (NM), core -rod myopathy, and congenital fiber- type disproportion (CFTD).

Yet other aspects of the disclosure relate to the use of an inhibitor of Janus kinase

- Signal Transducer and Activator of Transcription (JAK-STAT) in the manufacture of a medicament for the treatment of a myopathy.

In some embodiments, the inhibitor of JAK-STAT is a small molecule, an antisense oligonucleotide, a small interfering RNA (siRNA), or an antibody. In some embodiments, the inhibitor of JAK-STAT is selected from the group consisting of:

nifuroxazide, ketoprofen, sulfasalazine, 5,15-diphenylporphyrin, and AG490.

In some embodiments, the inhibitor of JAK-STAT is an inhibitor of JAK. In some embodiments, the inhibitor of JAK-STAT is an inhibitor of STAT. In some

embodiments, the inhibitor of JAK-STAT is an inhibitor of STAT3.

Still other aspects of the disclosure relate to the use of an agent in the

manufacture of a medicament for the treatment of a myopathy, wherein the agent is selected from the group consisting of: nifuroxazide, ketoprofen, sulfasalazine, 5,15- diphenylporphyrin, pargyline hydrochloride, metolazone, zimelidine dihydrochloride monohydrate, miconazole, ticlopidine hydrochloride, iohexol, benoxinate hydrochloride, nimodipine, tranylcypromine hydrochloride, and AG490.

In some embodiments the myopathy is congenital, myofibrillar, endocrine or metabolic, toxic, or caused by a systemic illness. In some embodiments, the congenital myopathy is a ryanodine receptor 1 (RYR1) -related myopathy. In some embodiments, the congenital myopathy is selected from the group consisting of: central core disease (CCD), multiminicore disease (MmD), centronuclear myopathy (CNM), nemaline myopathy (NM), core -rod myopathy, and congenital fiber- type disproportion (CFTD).

In some embodiments, RYRl-related myopathy is selected from the group consisting of: central core disease (CCD), multiminicore disease (MmD), centronuclear myopathy (CNM), nemaline myopathy (NM), core -rod myopathy, and congenital fiber- type disproportion (CFTD).

These and other aspects of the disclosure, as well as various advantages and utilities will be apparent with reference to the Detailed Description of the Invention. Each aspect of the disclosure can encompass various embodiments as will be understood.

All documents identified in this application are incorporated in their entirety herein by reference.

BRIEF DESCRIPTION OF THE DRAWINGS

The following drawings form part of the present specification and are included to further demonstrate certain aspects of the present disclosure, which can be better understood by reference to one or more of these drawings in combination with the detailed description of specific embodiments presented herein. The patent or application file contains at least one drawing executed in color. Copies of this patent or patent application publication with color drawing(s) will be provided by the Office upon request and payment of the necessary fee,

FIG. 1 is a representative diagram of a 48-well plate used in the ryrlb primary screen showing the chemical screening plate set-up. No two rows of the plate were filled with embryos from the same clutch, and each row contained a negative control well treated with vehicle only (0.4% DMSO). Experimental replicates were placed vertically from one another. An example treatment of the first two rows is illustrated, with negative controls in the first column shown in gray and replicate wells treated with the same chemical pool shown using different colors.

FIGs. 2A-2B show the numerical scoring of touch-evoked escape behaviors. In FIG. 2A, four days following treatment with DMSO or drug, all larvae present in each screened well were counted and evaluated in terms of mobility using a touch-evoked escape behavior assay. Behaviors were scored using the following numeric scoring system: 3 = 4-6 cm, fast (wild-type); 2 = 2-4 cm (moderate); 1 = < 2 cm, slow (ryrlb); 0 = no movement (dead). A representative response of each score is shown. FIG. 2B shows the average swimming distance of 5 days post-fertilization (dpf) larvae in

5 response to touch (WT/HT: 6.2 + 0.8 cm/0.1 s; ryrlb: 0.5 + 0.3 cm/0.1 s). Motor

functions were quantified using 15 embryos per group from three independent clutches.

Significance was determined by a Student's t-test, P = 1.2 x 10 - ^" 25.

FIGs. 3A-3B show the genotyping of ryrlb larvae. In FIG. 3A, the ryrlb mutant allele carries a 4046 bp DNA insertion in the intron between exons 48 and 49 that o includes an additional 32 bp sequence found in mutant cDNA. Schematic image adapted from Hirata et al. (2007) Development, 134: 2771-81. Genotypes of individual embryos were examined using three-primer genomic PCR. Primer binding sites are indicated. FIG. 3B is a representative agarose gel used for PCR-based genotyping of individual wild-type, heterozygous, and ryrlb mutant larvae.

5 FIG. 4 is a schematic outline of a two-tiered ryrlb chemical screen. Primary and secondary ryrlb chemical screening procedures were performed on compounds from the Prestwick2 chemical library. Images of homozygous ryrlb mutants at 5 dpf under brightfield (top) and polarized light (bottom) are also included, illustrating that mutants exhibit wild-type birefringence levels and must therefore be assayed for a skeletal muscle o phenotype using an alternative assay, touch-evoked escape behavior (TEEB).

FIG. 5 shows screened wells containing an expected 3: 1 ratio of unaffected (WT) to affected (ryrlb) larvae. Genotypes and phenotypes compared in three independent DMSO-treated controls verify approximate 3: 1 ratio of wild-type/heterozygous larvae to ryrlb mutant larvae. Each group represents the contents of two wells, considered

5 experimental replicates (n = 40). Note: Genotyping of one larva in "Control 1" was not conclusive (*).

FIG. 6 shows mobility and survival measurements of the primary screen "hit" pools. All treatments were performed in duplicate, with each replicate consisting of 20 larvae from heterozygous ryrlb matings (n = 40). Larvae obtained from wild-type

0 zebrafish (strain AB) matings served as positive controls. Significance was determined by pairwise comparisons between experimental and control pools using a Student's t- test. "LS" and "VG" designates the person who performed each trial, as two individuals conducted the ryrlb primary screen over the course of two years (Green = Wild type; Yellow = Moderate; Orange = ryrlb; Red = Dead).

FIG. 7 shows the vitality scores of individual "hit" compounds on secondary screens. Each scored compound represents an average of two replicates, consisting of 20 larvae from heterozygous ryrlb matings (n = 40). Larvae obtained from wild-type AB matings served as positive controls. Experimental treatments that significantly improved ryrlb mutant survival and mobility (combined as "vitality") compared to DMSO-treated controls were considered candidate "hit" compounds warranting further study.

Significance was determined by pairwise comparisons between control and experimental pools using a Student's t-test. Vitality score = (# Dead * 0) + (# ryrlb * 1) + (#

Moderate * 2) + (# Wild-type * 3). Standard deviations shown for positive and negative controls were calculated based on results from 5 and 21 independent experiments, respectively.

FIGs. 8A-8D demonstrate that nifuroxazide acts on the ryrlb phenotype in a dose-dependent manner. FIG. 8 A shows the dose-response for nifuroxazide (NIF). In two independent experiments, two pools of 20 larvae from heterozygous ryrlb matings were treated with DMSO or with one of three different concentrations of NIF (1.0-100.0 μg/mL) at 1 dpf and evaluated in terms of touch-evoked escape behaviors at 5 dpf (n = 40). Following phenotypic scoring, all living embryos were genotyped using three- primer genomic PCR. Swimming scores for larvae genotype-confirmed as ryrlb homozygous mutants are shown as a percentage of the total number of living larvae in each dose category: 1 = poor swimming; 2 or 3 = moderate or wild-type swimming. NIF improved mobility of ryrlb mutants at a dose of 10 μg/mL. FIG. 8B shows the dose- response for 5,15-DPP, a known inhibitor of STAT3. 5,15-DPP improved mobility of select ryrlb mutants at a dose of 100 μg/mL, but also showed evidence of toxicity since treated pools consistently contained less than 25% genotyped ryrlb larvae. FIG. 8C shows that zebrafish stat3 expression is significantly increased in ryrlb mutants compared to unaffected larvae from the same clutch at 5 dpf (P < 0.005). FIG. 8D is a Western blot at 5 dpf showing levels of phosphorylated Stat3 in zebrafish suggesting that ryrlb mutations may increase Stat3 sensitivity to pharmacological inhibition. Phospho-

Stat.3 band intensities were normalized to β-Actin control bands and quantified in Image J (NIH). FIGs. 9A-9B show that nifuroxazide increases the contractile strength of ryrlb skeletal muscles. In FIG. 9A, DMSO-treated ryrlb mutants exhibit reduced tetanic force per cross-sectional area (CSA) compared to DMSO-treated wild-type larvae at 5 dpf. Tetanic forces in mutants treated with NIF, however, are restored to wild-type levels at 5 dpf. Tetanic forces were measured following stimulation with 9 biphasic, 200 μ8 square- wave pulses at 300 Hz (WT-DMSO: 45.6 + 4.2 kPa, n = 5; WT-NIF: 52.8 + 4.1 kPa, n = 5; r rib-DMSO: 11.4 + 1.3 kPa, n = 7; r rib-NIF: 25.4 + 4.0 kPa, n = 7). Significance was determined by a one-way ANOVA (F = 29.61, P < 0.0001), followed by pairwise Tukey's HSD post hoc tests. FIG. 9B shows the dose response relationship between caffeine concentration and depolarization-induced calcium release in wild-type mouse myotubes. Prior to testing, myotubes were differentiated in either DMSO or NIF (20 μΜ) for 5 consecutive days (DMSO EC ₅₀ : 8.6 mM; NIF EC ₅₀ : 7.9 mM). Non-linear regression data of curves were not statistically different, as determined by an extra sum- of-squares F test (P = 1.0).

FIGs. 10A-10D show that nifuroxazide corrects ryrlb morphological features and swimming behaviors. In FIG. 10A, body angles of ryrlb mutants after 20 days of NIF treatment (10.0 μg/mL) are corrected and statistically indistinguishable from wild-type controls. FIG. 10B shows the quantification of body angle measurements. Angles were measured by first drawing/extending straight lines between the eyes of the larva as well as along the midline of the trunk (shown by dotted red lines). The angle of intersection was determined using Adobe Photoshop CS3 software (WT-DMSO: 179.1 + 0.9°, n = 6; WT-NIF: 176.8 + 1.1°, n = 6; ryrlb-OMSO: 142.6 + 6.2°, n = 11; ryrib-NIF: 174.4 + 2.0°, n = 4). Significance was determined by a one-way ANOVA (F = 13.60, P < 0.0001), followed by pairwise Tukey's HSD post hoc tests. FIG. IOC shows the swimming behaviors of 20 dpf larvae quantified in terms of distance traveled during a

2.0-hour period using the Noldus Daniovision, a high-resolution system that allows for automated analysis of larval locations and orientations. Three independent trials were performed with larvae from three different clutches, examining a total of 14-20 wild-type and ryrlb larvae from both DMSO- and NIF-treated groups. Genotypes of individual embryos were confirmed by genomic PCR following the study. Significance was determined by a one-way ANOVA (F = 10.03, P = 0.0009), followed by pairwise Tukey's HSD post hoc tests. FIG. 10D shows monitored activities of DMSO- and NIF- treated wild-type and ryrlb zebrafish at 20 dpf using the Noldus Daniovision' s infrared light source. One representative 20-minute time interval within the recording period is shown.

FIG. 11 shows the effect of nifuroxazide on life span of ryrlb mutants. Kaplan- Meier survival curves of ryrlb mutants treated with either DMSO or NIF (10 μg/mL) 5 from 1 to 50 dpf. Mutants were sorted from unaffected controls at 5 dpf using a touch- evoked escape behavior assay. Untreated fish all died by 35 days of life. Median survival of DMSO- versus NIF-treated mutants was 15.0 and 13.0 days, respectively. No statistically significant differences were detected according to a log-rank test (P = 0.5), however, two affected fish treated with NIF survived until termination of the study at 50 o days of age.

FIGs. 12A-12C show a ketoprofen dose-response and proposed mechanistic link. FIG. 12A depicts the chemical structures of ketoprofen and nifuroxazide. FIG. 12B is a dose-response graph for ketoprofen (KETO). Two pools of 20 larvae from heterozygous ryrlb matings were treated with DMSO or four different concentrations of KETO (1.0-5 100.0 μg/mL) at 1 dpf and evaluated in terms of touch-evoked escape behaviors at 5 dpf (n = 40). Following phenotypic scoring, all living embryos were genotyped using three- primer genomic PCR. Swimming scores for larvae genotype-confirmed as ryrlb homozygous mutants are shown as a percentage of the total number of living larvae in each dose category: 1 = poor swimming, 2 or 3 = moderate or wild-type swimming. o FIG. 12C shows a potential mechanistic link between candidate compounds via the IL-

6/JAK2/STAT3 signaling pathway. Phosphorylated STATs form dimers, translocate to nuclei, and from there are associated with various transcriptional activities. Dubowitz, V. and Sewry, C. (2006) Muscle Biopsy: A Practical Approach. Elsevier - Health Sciences Division.

5

DETAILED DESCRIPTION OF THE INVENTION

Aspects of the disclosure relate to methods for treating a myopathy. In some aspects, the disclosure is based, in part, on a two-tiered chemical screen aimed at identifying lead FDA-approved compounds that can rescue the function of skeletal

0 muscle in the relatively relaxed zebrafish model of ryrlb mutation. In the primary

screen, pools of four chemicals from the Prestwick2 chemical library (280 pools, 1120 chemicals) were scored for their ability to improve survival and postnatal motility of ryrlb homozygous mutant fry. Individual chemicals from hit pools were further evaluated in a secondary screen, and 12 candidate compounds were identified that could ameliorate the relatively relaxed muscle phenotype. One chemical, nifuroxazide, which is known to inhibit JAK-STAT cytokine signaling, restores the locomotive activities and corrects mild morphological abnormalities observed in ryrlb mutants.

Methods of treatment

Aspects of the disclosure relate to a method of treating a myopathy. In some embodiments, the method comprises administering to a subject (e.g., a subject having a myopathy) an effective amount of an inhibitor of JAK-STAT pathway. Examples of an inhibitor of JAK-STAT pathway include but are not limited to: nifuroxazide, ketoprofen, sulfasalazine, 5,15-diphenylporphyrin, and AG490. Other examples of inhibitors of JAK-STAT pathway include: S31-201, fludarabine, stattic, niclosamide, SG-4-54, HO- 3867, cryptotanshinone, cucurbitacin I, OPB-31121, resveratrol, pimozide, MS 1020, LLL12, ruxolitinib, tofacitinib, baricitinib, CYT387, filgotinib, GSK2586184, lestaurtinib, pacritinib, SB 1518, SAR302503, XL019, AZD1480, INCB028050, INCB 16562, tasocitinib, NVP-BSK805, TG101348, galiellactone, and CP-690550.

In some embodiments, the inhibitor of JAK-STAT pathway is an inhibitor of JAK. The inhibitor of JAK may be any inhibitor of JAK known in the art or as described herein. Examples of inhibitors of JAK include, but are not limited to: ruxolitinib, tofacitinib, baricitinib, CYT387, filgotinib, GSK2586184, lestaurtinib, pacritinib,

SB 1518, SAR302503, XL019, AZD1480, INCB028050, INCB 16562, tasocitinib, NVP- BSK805, and TG101348

In some embodiments, the inhibitor of JAK-STAT pathway is an inhibitor of STAT. The inhibitor of STAT may be any inhibitor of STAT known in the art or as described herein. Examples of inhibitors of STAT include, but are not limited to: S31-

201, fludarabine, stattic, niclosamide, nifuroxazide, SG-4-54, HO-3867,

cryptotanshinone, cucurbitacin I, OPB-31121, resveratrol, pimozide, MS 1020, LLL12, and galiellactone.

In some embodiments, the inhibitor of JAK-STAT pathway is an inhibitor of STAT3. The inhibitor of STAT3 may be any inhibitor of STAT3 known in the art or as described herein. Examples of inhibitors STAT3 include, but are not limited to:

cryptotanshinone, cucurbitacin I, niclosamide, NSC 74859, RSVA 405, SD 1008, stattic, BP-1-102, S31-201 , STA-21, and SPI. The JAK/STAT pathway is a major signaling mechanism for a diverse group of cytokines and growth factors (reviewed in Rawlings et al., 2004, J. Cell Sci., 117: 1281). Binding of these ligands to their receptors induces multimerization of receptor subunits that are associated with Janus tyrosine kinases (JAKs), allowing transphosphorylation of the JAKs. Activated JAKs phosphorylate signal transducers and activators of transcription proteins (STATs), transcription factors that are present in the cytoplasm in latent form until activated. Phosphorylated STATs dimerize and are translocated into the nucleus, where they activate or repress transcription of target genes. In addition to these main components of the JAK/STAT pathway, other proteins that contribute to

JAK/STAT signaling include signal-trans adapter molecules (STAMs), STAT- interacting protein (StIP), and the SH2B/Lnk/APS family. There are three main classes of negative regulators of JAK/STAT signaling: suppressor of cytokine signaling (SOCS) proteins, protein inhibitors of activated STATs (PIAS) proteins, and protein tyrosine phosphatases (PTPs).

Janus kinase (JAK) represents a family of intracellular, nonreceptor tyrosine kinases. They transduce cytokine-mediated signals via the JAK-STAT pathway. The family consists of four members: JAK1, JAK2, JAK3, and tyrosine kinase 2 (TYK2). They range from 120-140 kDa in size, and include seven regions of homology (Janus homology domains 1 to 7, JH1-7). JH1 is the kinase domain and includes the conserved tyrosines necessary for JAK activation. Phosphorylation of the dual tyrosines causes a conformation change in the JAK protein, allowing the substrate to bind. The amino terminal of the JAK (JH4-JH7) is involved in the association of JAKs with cytosine receptors and other kinases.

JAKs phosphorylate and activate downstream proteins of type I and type II cytokine receptor families. JAKs bind to the proline-rich domains of paired intracellular receptors. When the appropriate ligand binds the receptors, the receptors undergo a conformational change, bringing the two JAKs close enough so they can phosphorylate one another. This autophosphorylation causes a conformational change with allows the JAK to transduce the intracellular signal through the phosphorylation and activation of Signal Transducer and Activator of Transcription (STAT) transcription factors. An exemplary human JAK protein sequence is provided below:

MGMACLTMTEMEGTSTSSIYQNGDISGNANSMKQIDPVLQVYLYHSLGKSEAD YLTFPS GE Y V AEEIC IA AS KAC GITP V YHNMFALMS ETERIW YPPNH VFHIDES TR HN VLYRIRF YFPRW YC S GS NRA YRHGIS RG AE APLLDDF VMS YLF AQWRHDF V

HGWIKVPVTHETQEECLGMAVLDMMRIAKENDQTPLAIYNSISYKTFLPKCIRA

KIQDYHILTRKRIRYRFRRFIQQFSQCKATARNLKLKYLINLETLQSAFYTEKFEV

KEPGSGPSGEEIFATIIITGNGGIQWSRGKHKESETLTEQDLQLYCDFPNIIDVSIK Q

ANQEGSNESRVVTIHKQDGKNLEIELSSLREALSFVSLIDGYYRLTADAHHYLCK

EVAPPAVLENIQSNCHGPISMDFAISKLKKAGNQTGLYVLRCSPKDFNKYFLTFA

VERENVIEYKHCLITKNENEEYNLSGTKKNFSSLKDLLNCYQMETVRSDNIIFQF

TKCCPPKPKDKSNLLVFRTNGVSDVPTSPTLQRPTHMNQMVFHKIRNEDLIFNES

LGQGTFTKIFKGVRREVGDYGQLHETEVLLKVLDKAHRNYSESFFEAASMMSK

LSHKHLVLNYGVCVCGDENILVQEFVKFGSLDTYLKKNKNCINILWKLEVAKQL

AWAMHFLEENTLIHGNVCAKNILLIREEDRKTGNPPFIKLSDPGISITVLPKDILQE

RIPWVPPECIENPKNLNLATDKWSFGTTLWEICSGGDKPLSALDSQRKLQFYEDR

HQLPAPKWAELANLINNCMDYEPDFRPSFRAIIRDLNSLFTPDYELLTENDMLPN

MRIGALGFSGAFEDRDPTQFEERHLKFLQQLGKGNFGSVEMCRYDPLQDNTGE

V V A VKKLQHS TEEHLRDFEREIEILKS LQHDNIVKYKG VC YS AGRRNLKLIME Y

LPYGSLRDYLQKHKERIDHIKLLQYTSQICKGMEYLGTKRYIHRDLATRNILVEN

ENRVKIGDFGLTKVLPQDKEYYKVKEPGESPIFWYAPESLTESKFSVASDVWSFG

VVLYELFTYIEKSKSPPAEFMRMIGNDKQGQMIVFHLIELLKNNGRLPRPDGCPD

EIYMIMTECWNNNVNQRPSFRDLALRVDQIRDNMAG (SEQ ID NO: 1) (JAK2 -

NP_004963.1).

The Signal Transducer and Activator of Transcription (STAT) protein regulates aspects of cellular growth, survival, and differentiation. The STAT family includes STATl, STAT2, STAT3, STAT4, STAT5 (STAT5A and STAT5B), and STAT6. STAT proteins exists in the cytosol and nucleus in an unphosphorylated state. On

phosphorylation by JAK, STAT monomers dimerize via their SH2 domain and are then actively transported in the nucleus by the importin a/b and RanGDP complex. In the nucleus, the dimerized STAT binds to cytokine-inducible promoter regions of genes containing gamma-activated site (GAS) motifs, leading to the transcription of the gene. STATs are dephosphorylated and inactivated by nuclear phosphatases. An exemplary human STAT protein sequence is provided below:

MAQWEMLQNLDSPFQDQLHQLYSHSLLPVDIRQYLAVWIEDQNWQEAALGSD DS KATMLFFHFLDQLNYECGRCS QDPESLLLQHNLRKFCRDIQPFS QDPTQLAE MIFNLLLEEKRILIQAQRAQLEQGEPVLETPVESQQHEIESRILDLRAMMEKLVKS IS QLKDQQD VFCFRYKIQAKGKTPS LDPHQTKEQKILQETLNELDKRRKE VLD AS

KALLGRLTTLIELLLPKLEEWKAQQQKACIRAPIDHGLEQLETWFTAGAKLLFHL

RQLLKELKGLSCLVSYQDDPLTKGVDLRNAQVTELLQRLLHRAFVVETQPCMP

QTPHRPLILKTGSKFTVRTRLLVRLQEGNESLTVEVSIDRNPPQLQGFRKFNILTS

NQKTLTPEKGQSQGLIWDFGYLTLVEQRSGGSGKGSNKGPLGVTEELHIISFTVK

YT YQGLKQELKTDTLP V VIIS NMNQLS IA W AS VLWFNLLS PNLQNQQFFS NPPK

APWSLLGPALSWQFSSYVGRGLNSDQLSMLRNKLFGQNCRTEDPLLSWADFTK

RESPPGKLPFWTWLDKILELVHDHLKDLWNDGRIMGFVSRSQERRLLKKTMSG

TFLLRFSESSEGGITCSWVEHQDDDKVLIYSVQPYTKEVLQSLPLTEIIRHYQLLT

EENIPENPLRFLYPRIPRDEAFGCYYQEKVNLQERRKYLKHRLIVVSNRQVDELQ

QPLELKPEPELESLELELGLVPEPELSLDLEPLLKAGLDLGPELESVLESTLEPVIE P

TLCMVS QT VPEPDQGPVS QPVPEPDLPCDLRHLNTEPMEIFRNC VKIEEIMPNGD

PLLAGQNT VDE V Y VS RPS HF YTDGPLMPS DF (SEQ ID NO: 2) (STAT2 -

NP _. 005410.1).

Signal Transducer and Activator of Transcription 3 (STAT3) is a transcription factor that mediates the expression of a variety of genes in response to cell stimuli, playing a key role in many cellular processes, including cell growth and apoptosis.

STAT3 is activated by the phosphorylation of tyrosine 705 in response to certain cytokines and growth factors. Some activators of STAT3 include the following:

interferons, epidermal growth factor, interleukin - (IL) 5, IL-6, hepatocyte growth factor, leukemia inhibitory factor, bone morphogenetic protein 2, IL-10, and leptin. STAT3 may promote oncogenesis when it is constitutively active. It also may play a role in tumor suppression; in glioblastoma tumors, STAT3 was shown to suppress a tumor with a specific mutational background. An exemplary STAT3 human protein sequence is provided below:

MAQWNQLQQLDTRYLEQLHQLYSDSFPMELRQFLAPWIESQDWAYAASKESH

ATLVFHNLLGEIDQQYSRFLQESNVLYQHNLRRIKQFLQSRYLEKPMEIARIVAR

CLWEESRLLQTAATAAQQGGQANHPTAAVVTEKQQMLEQHLQDVRKRVQDLE

QKMKVVENLQDDFDFNYKTLKSQGDMQDLNGNNQSVTRQKMQQLEQMLTAL

DQMRRSrVSELAGLLSAMEYVQKTLTDEELADWKRRQQIACIGGPPNICLDRLE

NWrrSLAESQLQTRQQIKKLEELQQKVSYKGDPIVQHRPMLEERIVELFRNLMKS

AFVVERQPCMPMHPDRPLVIKTGVQFTTKVRLLVKFPELNYQLKIKVCIDKDSG

DVAALRGSRKFNILGTNTKVMNMEESNNGSLSAEFKHLTLREQRCGNGGRANC DAS LIVTEELHLITFETE V YHQGLKIDLETHS LP V V VIS NICQMPN A W AS ILW YN MLTNNPKNVNFFTKPPIGTWDQVAEVLSWQFSSTTKRGLSIEQLTTLAEKLLGPG VNYSGCQITWAKFCKENMAGKGFSFWVWLDNIIDLVKKYILALWNEGYIMGFI S KERERAILSTKPPGTFLLRFSES S KEGGVTFTWVEKDIS GKTQIQS VEPYTKQQL

5 NNMSFAEIIMGYKIMDATNILVSPLVYLYPDIPKEEAFGKYCRPESQEHPEADPGS AAPYLKTKFICVTPTTCSNTIDLPMSPRTLDSLMQFGNNGEGAEPSAGGQFESLT FDMELTSECATSPM (SEQ ID NO: 3) (STAT3 - NP_644805.1).

As used herein, "treat" or "treatment" of a myopathy includes, but is not limited to, preventing, reducing, or halting the development of a myopathy, reducing or

o eliminating the sign(s) and/or symptom(s) of a myopathy or results in a desired clinical effect. The primary symptom in myopathy is muscle weakness. Other symptoms of myopathy can include, for example, muscle cramps, stiffness, and spasm. Other manifestations of myopathy can also include, but are not limited to, hypotonia, delayed motor milestones, impaired ambulation, joint contractures, scoliosis, eye movement5 paralysis, respiratory insufficiency or failure, and malignant hyperthermia susceptibility.

In some embodiments, treatment of a myopathy involves increasing or restoring muscle strength and/or restoration of muscle function and/or phenotype. Signs and symptoms of myopathy are known to those of ordinary skill in the art who know how to test for them and monitor their progression/regression.

o The subject may be any subject, such as a human subject having a myopathy

(e.g., a skeletal muscle myopathy). A myopathy is a disorder where the muscle fibers (e.g., skeletal muscle fibers) do not function properly, for any one of many reasons, leading to muscle weakness. Any type of myopathy is contemplated herein, including, but not limited to congenital myopathy, myofibrillar myopathy, endocrine or metabolic 5 myopathy, toxic myopathy, or a myopathy caused by a systemic illness.

The congenital myopathies (CMs) are a heterogeneous group of inherited neuromuscular disorders that manifest as skeletal muscle weakness at birth or early in life, and are defined by the presence of specific morphological features on biopsy 1- ^" 3. The most common forms of CM can be roughly subdivided into four categories based on the 0 predominant pathologic features observed under light and electron microscopy: (i)

centronuclear myopathies; (ii) core myopathies; (iii) nemaline (or rod) myopathies; and (iv) myopathies with congenital fiber type disproportion. However, accurate diagnoses are often confounded due to broad variations in the clinical severity of each phenotype, and to substantial histological overlap between the different forms of these disorders ⁴ ' ⁵ . CMs can also result from mutations in more than one gene, with causative genes associated with multiple pathologies. Clinical features, such as the presentation of hypotonia during the newborn period, may be similar to features found in patients with congenital myasthenic syndromes, metabolic myopathies, spinal muscular atrophy, as well as muscular dystrophies. Thus, CMs are typically a diagnosis of exclusion and require detailed clinical data combined with electromyographic and histopathological findings to prioritize gene testing and establish a genetic basis ³ ' ⁶ .

Mutations of more than twenty known genes are capable of causing CM and their biological functions are widely studied in vitro and in vivo. Major pathophysiologic pathways responsible for weakness in CMs are hypothesized to result from either malformed contractile filaments, in the case of nemaline and other rod myopathies, or from disruptions in calcium homeostasis at the skeletal muscle triad, in the case of many centronuclear and core myopathies 1 ' 7.

Centronuclear myopathies (CNMs) are classically defined by the abnormal centralization of nuclei in >25% of muscle fibers, although there can be considerable variability both in the number of myofibers with central nuclei and in the number of central nuclei within a single myofiber . Several genetically distinct forms of CNM have been described based on age of onset, severity of symptoms, and mode of inheritance ⁹ ' ¹⁰ . Clinically, these can be categorized as the severe X-linked recessive form with prenatal or neonatal onset, the autosomal recessive form with onset in infancy or childhood, and the autosomal dominant form, typically mild with late onset. Despite copious variability in the clinical features among these groups, emerging evidence suggests that defective excitation-contraction coupling at the level of the triad may be a unifying pathophysiological feature in CNM ¹¹ .

X-linked centronuclear myopathy, also referred to as myotubular myopathy or X- linked myotubular myopathy (XLMTM), is caused by mutations in the myotubularin

(MTMl) gene 12. Of the more than 500 known MTMl mutations, most are believed to result in loss of protein expression, although there are a few recurring missense mutations that can cause either the classic severe phenotype or a milder presentation 13- ^" 15.

XLMTM may present prenatally with polyhydramnios and reduced fetal movements in utero, and in affected newborn boys as severe hypotonia, generalized weakness, and muscle wasting. Additional features include thin ribs, ophthalmoplegia, ptosis, pyloric stenosis, and contractures of the hips and knees. XLMTM carries a poor long-term prognosis, with death due to respiratory failure occurring within the first year of life in 20-25% of cases ¹⁶ ' ¹¹ . Although a small proportion of boys may be less affected in the neonatal period and survive into childhood or even adulthood, most remain severely impaired and require permanent ventilation.

Mutations in the large GTPase dynamin 2 (DNM2) are the second most common cause of CNM and display dominant inheritance ¹⁸ ' ¹⁹ . Autosomal dominant CNM showing late adult onset with slowly progressive weakness, together with de novo forms of CNM with earlier onset, has a broader range of clinical presentation than the X-linked form ^19-21 . Generally, limb girdle, trunk, and neck muscles are involved, with degrees of ptosis and limitation of eye movements paralleling the age of onset. While most patients are ventilator independent, phases of respiratory decline may require non-invasive ventilation but rarely necessitate invasive support ^22~26 .

Autosomal recessive centronuclear myopathy is the rarest form of CNM, with causative mutations identified in the skeletal muscle ryanodine receptor (RYR1), titin

27-29

(777V), and bridging integrator 1 (BIN1) genes ^" . The recessive forms of the disease generally present in infancy or early childhood with diffuse muscle weakness and respiratory distress. Facial diplegia, ptosis, and varying degrees of ophthalmoplegia are also common features. The clinical course of the disease is marked by slowly progressive weakness, development of scoliosis or kyphosis, as well as delays in motor milestones such as walking, running, and stair climbing.

Core myopathies are characterized by areas in the muscle fiber lacking oxidative and glycolytic enzymatic activity. Central cores run along the length of the myofiber, whereas minicores are short zones of myofibrillar disorganization that are wider than they are long on longitudinal section. Based on the presence of these abnormal features, patients with core myopathies are traditionally sub-classified as having either central

30

core disease (CCD) or multiminicore disease (MmD) . The vast majority of CCD patients (>90%) have autosomal dominant or de novo dominant mutations in the RYR1

31-34

gene ^" , while MmD core myopathy is most commonly caused by recessive mutations

35

in the selenoprotein N gene (SEPN1) gene .

CCD was the first CM defined on the basis of specific morphological changes in skeletal muscle. In 1956, Magee and Shy described the first patient with single, well- circumscribed circular regions in the center of type I (slow twitch) fibers ³⁶ . The term "central core disease" was introduced soon afterwards to reflect the absence of oxidative enzymes, phosphorylase, and glycogen in the core area due to mitochondrial depletion 37. Whereas cores are best observed on sections stained for oxidative enzyme activity (e.g., succinate dehydrogenase [SDH], cytochrome-c -oxidase [COX], or nicotinamide adenine 5 dinucleotide [NADH] dehydrogenase reacted sections), cores examined using electron microscopy contain densely packed and disorganized myofibrils, and have been divided into two types based on whether myofibrillar organization is maintained. Structured cores preserve basic sarcomeric architecture, although sarcomeres may be out of register with adjacent fibrils as well as with each other, whereas unstructured cores contain large of Z-line streaming 38

o areas . Clinically, CCD typically presents in infancy with hypotonia or in early childhood with delays in motor development. Although weakness

preferentially affects proximal musculature, such as hip girdle and axial muscles, almost all CCD patients achieve the ability to walk independently. The primary exceptions are cases with debilitating hip dislocations or severe cases presenting with neonatal

5 weakness, arthrogryposis, and respiratory failure ³⁴ · ^39-42 .

Fifteen years after the initial description of CCD, Engel and colleagues reported a family with two affected siblings exhibiting multiple small cores within muscle fibers ⁴³ . Patients with the classic form of MmD generally present in infancy or childhood with pronounced hypotonia and proximal weakness, although select cases of prenatal or adult o onset have been recognized ^44~47 . Axial muscle weakness, particularly affecting the neck and trunk flexors, is a prominent feature of MmD, and failure to acquire head control is an early clinical sign. Spinal rigidity and scoliosis are also common. The clinical course of MmD is static for the majority of patients. However, some experience cardiac involvement secondary to marked decline in respiratory function during adolescence or 5 young adulthood ⁴⁴ .

MmD is diagnosed on muscle biopsy by the presence of multifocal, well- circumscribed areas in the muscle fiber with reduced oxidative staining and low myofibrillar ATPase activity ⁴³ . In contrast to central cores, "minicores" are typically unstructured, extend for only a short distance along the longitudinal axis of the myofiber, and may affect both type I (slow twitch) and type II (fast twitch) fibers 48

0 . Minicores appear as regions of myofibrillar disruption lacking mitochondria in electron

micrographs, with sarcomere degeneration and structural abnormalities of the triad. Core-rod myopathy is a congenital myopathy characterized by the presence of "cores" and "rods" in distinct locations within the same or different muscle fibers, and has been reported in a small number of sporadic or familial cases. Familial cases have been associated with mutations in the skeletal muscle RYR1 , nebulin (NEB), and alpha- actin (A CTA 1 ) gene s .

Clinically, nemaline myopathy (NM) phenotypes vary and are sub-classified into different groups according to age of onset as well as severity of motor and respiratory involvement: (i) severe congenital NM, (ii) intermediate congenital NM, (iii) typical congenital NM, (iv) childhood/juvenile-onset NM, (v) adult-onset NM, and (vi) other forms with atypical clinical features such as cardiomyopathy and ophthalmoplegia ⁴⁹ .

Although these classifications have been well established and can be used to accurately predict prognosis, certain morphological and clinical features are common and shared between two or more groups. Nemaline rods, for example, are the pathological and diagnostic hallmark of NM, and by definition are shared among all genetic forms of this disorder.

Rods appear as red or purple structures against a blue-green myofibrillar background upon modified Gomori trichrome staining, and show a tendency to cluster under the sarcolemma and around nuclei. Rods are considered to derive from the lateral expansion of the Z-line, based on their structural continuity with Z-lines, electron density, and criss-cross pattern in electron micrographs. Rods also stain positively for antibodies to alpha- actinin isoforms 2 and 3, the two major components of the skeletal muscle Z-line ⁵⁰ · ⁵¹ . With few exceptions (e.g., patients with TPM3 mutations), rods are present in both type I and type II muscle fibers, although type I fiber predominance is a common feature of NM and fiber type disproportions tend to become more prominent

52 53

with age ' . The proportion of myofibers containing rods varies considerably between cases, however, and the sizes and numbers of rods within a muscle specimen do not appear to correlate with disease severity ⁵⁴ . Nemaline rods are usually cytoplasmic. Intranuclear rods are occasionally a prominent feature, particularly in severe cases ⁵⁵ .

NMs are considered diseases in which mutations disrupt the ability of the myofiber to generate adequate force during contraction. To date, mutations in ten different genes have been identified in a subset of NM patients: alpha- skeletal muscle actin (ACTA1) ⁵⁶ ; slow alpha-tropomyosin (TPM3) ^57~59 ; nebulin (NEB) ⁶⁰ ; slow troponin T (TNNT1) ⁶¹ ' ⁶² ; beta-tropomyosin (TPM2) ⁵⁹ ' ⁶³ ; muscle- specific cofilin (CFL2) ^M~66 leiomodin 3 (LMOD3) ^ϋ/ ; kelch-like family members 40 (KLHL40) ⁰⁸ and 41 (KLHL41) ⁶⁹ ; and kelch repeat and BTB domain containing 13 (KBTBD13) ⁷⁰ . Seven of these ten genes encode protein components of the muscle fiber thin filament, while the other three likely participate as regulators of the thin filament degradation/turnover apparatus.

Congenital fiber type disproportion (CFTD) is a histological diagnosis with multiple etiologies 71. Brooke and Engel first used the term in 1973 in a large morphology study of children's biopsies to describe a group of 14 patients who all had clinical features of a CM and whose prevalent abnormality on muscle biopsy was a discrepancy in muscle fiber size 72. It is now the consensus that the diagnosis of CFTD can be made when a mutation in a CM gene has been identified and type I fibers are consistently smaller than type II fibers by at least 35-40% 73. However, type I fiber hypotrophy is also observed in a variety of metabolic myopathies, in central nervous system malformations, and in the severe neonatal form of myotonic muscular dystrophy

. Some experts therefore include additional histologic features in the definition of CFTD, such as type I fiber predominance (>55% type I fibers) or a paucity (<5%) of type

IIB fibers 73. While CFTD generally mimics the clinical course of other forms of CM that share the same genetic cause, early respiratory failure is frequent among CFTD patients and nocturnal hypoventilation should be monitored even in ambulant individuals

2 Most cases of CFTD are associated with mutations in the TPM3 gene, encoding the type I fiber- specific protein slow alpha-tropomyosin 79- ^" 81. TPM3 mutations are

7Q

hypothesized to alter the interaction between tropomyosin and actin , and some data suggest that clinical weakness may arise from misregulated actin-myosin interactions 82.

RYRl mutations are less commonly seen 83 and only rarely have mutations in ACTA1 84 , MYH7 ⁸⁵ ' ⁸⁶ , SEPN1 ⁸⁷ , TPM2 ⁸⁸ , or an X-linked form ⁸⁹ been reported. Most recently, mutations of the LMNA gene, coding for lamin A/C, were identified in several Japanese patients with CFTD ⁹⁰ . Since LMNA defects are known to cause a variety of different muscular dystrophies and related cardiomyopathies ⁹¹ , these patients may represent a subset of CFTD cases at risk for cardiac disease.

The CM may be a ryanodine receptor 1 (RYRl)-related myopathy . RYR1- related myopathies are defined as a group of inherited disorders associated with causative mutations in the skeletal muscle RYRl gene (RYRl). Although age of clinical onset is variable, patients with RYRl mutations typically present with skeletal muscle weakness in infancy or early childhood. Other manifestations can also include, but are not limited to, delayed motor milestones, impaired ambulation, joint contractures, scoliosis, eye movement paralysis, respiratory failure, and malignant hyperthermia susceptibility.

Examples of RYRl -related myopathies include, for example, CCD, CFTD, CNM, MmD, NM, and core-rod myopathy.

The myofibrillar myopathies are a clinically and genetically heterogeneous group of disorders defined by the presence of focal myofibrillar disarray and desmin-positive myofibrillar aggregates on muscle biopsy. Myofibrillar myopathies are primarily a disorder of adulthood, but their age of onset ranges from early childhood to middle age, and does include a severe, progressive childhood presentation. Weakness is most commonly distal, or may be more diffuse, and bulbar or respiratory involvement occurs in some families. Cardiac symptoms may dominate the clinical picture, particularly hypertrophic cardiomyopathy or atrioventricular conduction block. Lens opacities and neuropathic features have also been reported in some families.

Endocrine and metabolic myopathies result in muscle fatigue and weakness, frequently shown as muscle atrophy. Endocrine myopathies include myopathies caused but are not limited to, thyroid disorders, including hypothyroidism and hyperthyroidism, parathyroid disorders, including hyperparathyroidism and hypoparathyroidism, adrenal disorders, and pituitary disorders. Metabolic myopathies, include, myopathies caused but are not limited to, diabetes mellitus, and a vitamin deficiency.

Myopathies resulting from systemic illnesses often result in fatigue, muscle wasting, and weakness. Exemplary systemic illnesses causing myopathies include chronic respiratory, cardiac, and hepatic failure. Chronic renal failure may also result in myopathy, independent of uremic polyneuropathy. The resulting calcium and

phosphorus homeostasis abnormalities, as well as bone metabolism irregularities may lead to the development of hypocalcemia augmented by hyperphosphatemia, causing secondary hyperparathyroidism. The compensatory hyperparathyroidism then yields renal osteodystrophy, osteomalacia, and osteitis fibrosa. Chronic renal failure can also lead to gangrenous calcification; extensive arterial calcification results in ischemia, myopathy, and skin necrosis.

Toxic myopathies occur when drugs and chemicals produce damage to skeletal muscle. Focal damage is typically caused by the injection of narcotic analgesics, for example, pentazocine, meperidine, or heroin. Injections may cause severe fibrotic reactions in the muscle, the formation of local abscesses, and cutaneous ulcerations and depressions. Other drugs can lead to generalized muscle weakness, specifically in the proximal muscles. Examples include propranolol, cyclosporine, iodines, clofibrate, chloroquine, gemfibrozil, HMG-CoA reductase inhibitors (e.g., statins such as

5 atorvastatin (Lipitor®), fluvastatin (Lescol®), lovastatin (Mevacor®, Altocor®),

pitavastatin (Livalo®), pravastatin (Pravachol®), rosuvastatin (Crestor®), and simvastatin (Zocor®)), niacin, colchicine, cyclosporine, emetine, ε-amino-caproic acid, glucocorticoids, labetalol, perhexilline, propranolol, vincristine, zidovudine, alcohol, amphetamine, barbiturates, cocaine, heroin, and phencyclidine.

o Subjects having a myopathy may be identified using any method known in the art

(including, but not limited to, physical examination, strength testing, skeletal muscle biopsy with histology, immunohistochemistry, and/or electron microscopy,

electromyogram, blood test(s), CT scan, X-ray, MRI, physical exam, cytogenetic analysis, urinalysis, or genetic testing). A subject suspected of having a myopathy might5 show one or more sign(s) or symptom(s) of the disease. Signs and symptoms of

myopathies are well known to those of ordinary skill in the art.

The inhibitor of JAK-STAT pathway, JAK, STAT, or STAT3 may be any inhibitor of JAK-STAT pathway, JAK, STAT, or STAT3 known in the art or described herein. The inhibitor may reduce the level and/or activity of JAK-STAT pathway, JAK, o STAT, or STAT3. A reduced level of one or more of JAK-STAT pathway, JAK, STAT, or STAT3 includes a level that is, for example, 1%, 5%, 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, 150%, 200%, 300%, 400%, 500% or more below a control level. In some embodiments, the level is reduced to a level that is undetectable. Levels of JAK, STAT, or STAT3 (e.g., mRNA level or protein level) can be measured using a 5 method known in the art or described herein, such as by Northern blot analysis, q.RT-

PCR, sequencing technology, RNA in situ hybridization, in situ RT-PCR,

oligonucleotide microarray, immunoassays (e.g., Western blot, immunohistochemistry and ELISA assays), Mass spectrometry, or multiplex bead-based assays.

In some embodiments, the inhibitor is a small molecule, an antisense 0 oligonucleotide, a small interfering RNA (siRNA), a microRNA (miRNA), or an

antibody. Methods of making such inhibitors are known in the art. The antibody may be a full-length antibody or an antigen-binding fragment thereof, such as a Fab, F(ab)2, Fv, single chain antibody, Fab or sFab fragment, F(ab')2, Fd fragments, scFv, or dAb fragments. Methods for producing antibodies and antigen -binding fragments thereof are well known in the art (see, e.g., Sambrook et al, "Molecular Cloning: A Laboratory Manual" (2nd Ed.), Cold Spring Harbor Laboratory Press (1989); Lewin, "Genes IV", Oxford University Press, New York, (1990), and Roitt et al., "Immunology" (2nd Ed.), 5 Gower Medical Publishing, London, New York (1989), WO2006/040153,

WO2006/122786, and WO2003/002609). The small molecule may be, in some embodiments, an organic compound having a molecular weight of below 900, below 800, below 700, below 600, or below 500 daltons. Methods of making such small molecules are known in the art. Antisense oligonucleotides may be modified or

o unmodified single-stranded DNA molecules of less than 50 nucleotides in length (e.g.,

13-25 nucleotides in length). siRNAs may be double-stranded RNA molecules of about 19-25 base pairs in length with optional 3' dinucleotide overhangs on each strand.

Antisense oligonucleotides and siRNAs are generally made by chemical synthesis methods that are known in the art. MicroRNAs (miRNAs) are small non-coding RNA5 molecules. They may be transcribed and then processed from a primary-microRNA (pri- miRNA) to a progenitor- microRNA (pro-miRNA) to a pre-microRNA (pre-miRNA), and finally to a mature miRNA, which can act as an inhibitor. miRNAs may be produced in a subject by delivering a gene that encodes the pri-miRNA, which is then processed in the subject to a mature miRNA.

o An effective amount of an agent or inhibitor as described herein is an amount that is sufficient to provide a medically desirable result, such as treatment of a myopathy (e.g., manifestation(s), or sign(s) and/or symptom(s) of a myopathy). The effective amount will vary with the particular myopathy being treated, the age and physical condition of the subject being treated, the severity of the condition, the duration of the 5 treatment, the nature of any concurrent therapy, the specific route of administration and the like factors within the knowledge and expertise of the health practitioner. For administration to a subject such as a human, a dosage of from about 0.001, 0.01, 0.1, or 1 mg/kg up to 50, 100, 150, or 500 mg/kg or more can typically be employed.

An agent or inhibitor as described herein and compositions thereof can be

0 formulated for a variety of modes of administration, including systemic, topical or

localized administration. A variety of administration routes are available. The particular mode selected will depend upon the type of myopathy or other disease being treated and the dosage required for therapeutic efficacy. The methods of the disclosure, generally speaking, may be practiced using any mode of administration that is medically acceptable, meaning any mode that produces effective levels of the active compounds without causing clinically unacceptable adverse effects. Such modes of administration include, but are not limited to, oral, rectal, topical, nasal, intradermal, or parenteral routes. The term "parenteral" includes subcutaneous, intravenous, intramuscular, or infusion.

Techniques and formulations generally can be found in Remington: The Science and Practice of Pharmacy, Pharmaceutical Press; 22nd edition and other similar references. When administered, an agent or inhibitor as described herein may be applied in pharmaceutically-acceptable amounts and in pharmaceutically-acceptable

compositions. Pharmaceutical compositions and pharmaceutically-acceptable carriers are also described herein. Such preparations may routinely contain salt, buffering agents, preservatives, compatible carriers, and optionally other therapeutic agents. When used in medicine, the salts should be pharmaceutically acceptable, but non-pharmaceutically acceptable salts may conveniently be used to prepare pharmaceutically-acceptable salts thereof and are not excluded from the scope of the disclosure. Such pharmacologically and pharmaceutically-acceptable salts include, but are not limited to, those prepared from the following acids: hydrochloric, hydrobromic, sulfuric, nitric, phosphoric, maleic, acetic, salicylic, citric, formic, malonic, succinic, and the like. Also, pharmaceutically- acceptable salts can be prepared as alkaline metal or alkaline earth salts, such as sodium, potassium or calcium salts.

Compositions and Pharmaceutically-acceptable carriers

Other aspects of the disclosure relate to compositions comprising an agent or inhibitor as described herein, e.g., for use in treatment of a myopathy. In some embodiments, the composition is a pharmaceutical composition. In some embodiments, the composition comprises an agent or inhibitor as described herein and a

pharmaceutically-acceptable carrier. In some embodiments, the composition is for use in treating a myopathy.

The term "pharmaceutically-acceptable carrier" as used herein means one or more compatible solid or liquid filler, diluents or encapsulating substances which are suitable for administration into a subject, e.g., a human. A pharmaceutically acceptable carrier is "acceptable" in the sense of being compatible with the other ingredients of the formulation and not injurious to the tissue of the patient (e.g., physiologically

compatible, sterile, physiologic pH, etc.). The term "carrier" denotes an organic or inorganic ingredient, natural or synthetic, with which the active ingredient is combined to facilitate the application. The components of the pharmaceutical compositions also are capable of being co-mingled with the molecules of the present disclosure, and with each other, in a manner such that there is no interaction which would substantially impair the desired pharmaceutical efficacy. Some examples of materials which can serve as pharmaceutically-acceptable carriers include: (1) sugars, such as lactose, glucose and sucrose; (2) starches, such as corn starch and potato starch; (3) cellulose, and its derivatives, such as sodium carboxymethyl cellulose, methylcellulose, ethyl cellulose, microcrystalline cellulose and cellulose acetate; (4) powdered tragacanth; (5) malt; (6) gelatin; (7) lubricating agents, such as magnesium stearate, sodium lauryl sulfate and talc; (8) excipients, such as cocoa butter and suppository waxes; (9) oils, such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil and soybean oil; (10) glycols, such as propylene glycol; (11) polyols, such as glycerin, sorbitol, mannitol and polyethylene glycol (PEG); (12) esters, such as ethyl oleate and ethyl laurate; (13) agar; (14) buffering agents, such as magnesium hydroxide and aluminum hydroxide; (15) alginic acid; (16) pyrogen-free water; (17) isotonic saline; (18) Ringer's solution; (19) ethyl alcohol; (20) pH buffered solutions; (21) polyesters, polycarbonates and/or polyanhydrides; (22) bulking agents, such as polypeptides and amino acids (23) serum component, such as serum albumin, HDL and LDL; (22) C2-C12 alcohols, such as ethanol; and (23) other non-toxic compatible substances employed in pharmaceutical formulations. Wetting agents, coloring agents, release agents, coating agents, sweetening agents, flavoring agents, perfuming agents, preservative and antioxidants can also be present in the composition.

The pharmaceutical compositions may conveniently be presented in unit dosage form and may be prepared by any of the methods well-known in the art of pharmacy. The term "unit dose" when used in reference to a pharmaceutical composition of the present disclosure refers to physically discrete units suitable as unitary dosage for the subject, each unit containing a predetermined quantity of active material calculated to produce the desired therapeutic effect in association with the required diluent; i.e., carrier, or vehicle. The formulation of the pharmaceutical composition may depend upon the route of administration. Injectable preparations suitable for parenteral administration or intratumoral, peritumoral, intralesional or perilesional administration include, for example, sterile injectable aqueous or oleaginous suspensions and may be formulated 5 according to the known art using suitable dispersing or wetting agents and suspending agents. The sterile injectable preparation may also be a sterile injectable solution, suspension or emulsion in a nontoxic parenterally acceptable diluent or solvent, for example, as a solution in 1,3 propanediol or 1,3 butanediol. Among the acceptable vehicles and solvents that may be employed are water, Ringer's solution, U.S. P. and o isotonic sodium chloride solution. In addition, sterile, fixed oils are conventionally employed as a solvent or suspending medium. For this purpose any bland fixed oil may be employed including synthetic mono- or di-glycerides. In addition, fatty acids such as oleic acid find use in the preparation of injectables. The injectable formulations can be sterilized, for example, by filtration through a bacterial-retaining filter, or by

5 incorporating sterilizing agents in the form of sterile solid compositions which can be dissolved or dispersed in sterile water or other sterile injectable medium prior to use.

For topical administration, the pharmaceutical composition can be formulated into ointments, salves, gels, or creams, as is generally known in the art. Topical administration can utilize transdermal delivery systems well known in the art. An o example is a dermal patch.

Compositions suitable for oral administration may be presented as discrete units, such as capsules, tablets, lozenges, each containing a predetermined amount of the antiinflammatory agent. Other compositions include suspensions in aqueous liquids or nonaqueous liquids such as a syrup, elixir or an emulsion.

5 Other delivery systems can include time-release, delayed release or sustained release delivery systems. Such systems can avoid repeated administrations of the agent or inhibitor, increasing convenience to the subject and the physician. Many types of release delivery systems are available and known to those of ordinary skill in the art. They include polymer base systems such as poly(lactide-glycolide), copolyoxalates, 0 polycaprolactones, polyesteramides, polyorthoesters, polyhydroxybutyric acid, and polyanhydrides. Microcapsules of the foregoing polymers containing drugs are described in, for example, U.S. Patent 5,075,109. Delivery systems also include non- polymer systems that are: lipids including sterols such as cholesterol, cholesterol esters and fatty acids or neutral fats such as mono- di- and tri-glycerides; hydrogel release systems; sylastic systems; peptide based systems; wax coatings; compressed tablets using conventional binders and excipients; partially fused implants; and the like.

Specific examples include, but are not limited to: (a) erosional systems in which the anti- 5 inflammatory agent is contained in a form within a matrix such as those described in U.S. Patent Nos. 4,452,775, 4,667,014, 4,748,034 and 5,239,660 and (b) diffusional systems in which an active component permeates at a controlled rate from a polymer such as described in U.S. Patent Nos. 3,832,253, and 3,854,480. In addition, pump- based hardware delivery systems can be used, some of which are adapted for

o implantation.

Use of a long-term sustained release implant may be particularly suitable for treatment of chronic conditions. Long-term release, are used herein, means that the implant is constructed and arranged to delivery therapeutic levels of the active ingredient for at least 30 days, and preferably 60 days. Long-term sustained release implants are5 well-known to those of ordinary skill in the art and include some of the release systems described above.

In some embodiments, the pharmaceutical compositions used for therapeutic administration must be sterile. Sterility is readily accomplished by filtration through sterile filtration membranes (e.g., 0.2 micron membranes). Alternatively, preservatives o can be used to prevent the growth or action of microorganisms. Various preservatives are well known and include, for example, phenol and ascorbic acid. The agent or inhibitor described herein and/or the pharmaceutical composition ordinarily will be stored in lyophilized form or as an aqueous solution if it is highly stable to thermal and oxidative denaturation. The pH of the preparations typically will be about from 6 to 8, although 5 higher or lower pH values can also be appropriate in certain instances.

Without further elaboration, it is believed that one skilled in the art can, based on the above description, utilize the present disclosure to its fullest extent. The following specific embodiments are, therefore, to be construed as merely illustrative, and not limitative of the remainder of the disclosure in any way whatsoever. All publications 0 cited herein are incorporated by reference for the purposes or subject matter referenced herein.

References for Detailed Description of the Invention 1. Nance, J.R., Dowling, J.J., Gibbs, E.M. and Bonnemann, C.G. (2012) Congenital myopathies: an update. Curr Neurol Neurosci Rep, 12, 165-174.

2. Romero, N.B. and Clarke, N.F. (2013) Congenital myopathies. Handb Clin Neurol, 113, 1321-1336.

3. North, K.N., Wang, C.H., Clarke, N., Jungbluth, H., Vainzof, M., Dowling, J.J., Amburgey, K., Quijano-Roy, S., Beggs, A.H., Sewry, C. et al. (2014) Approach to the diagnosis of congenital myopathies. Neuromuscul Disord, 24, 97-116.

4. Ryan, M.M., Schnell, C, Strickland, CD., Shield, L.K., Morgan, G., Iannaccone,

5. T., Laing, N.G., Beggs, A.H. and North, K.N. (2001) Nemaline myopathy: a clinical study of 143 cases. Ann Neurol, 50, 312-320.

5. Romero, N.B., Monnier, N., Viollet, L., Cortey, A., Chevallay, M., Leroy, J. P., Lunardi, J. and Fardeau, M. (2003) Dominant and recessive central core disease associated with RYR1 mutations and fetal akinesia. Brain, 126, 2341-2349.

6. North, K.N. (2011) Clinical approach to the diagnosis of congenital myopathies. Semin Pediatr Neurol, 18, 216-220.

7. Al-Qusairi, L. and Laporte, J. (2011) T-tubule biogenesis and triad formation in skeletal muscle and implication in human diseases. Skelet Muscle, 1, 26.

8. Pierson, C.R., Tomczak, K., Agrawal, P., Moghadaszadeh, B. and Beggs, A.H. (2005) X-linked myotubular and centronuclear myopathies. J Neuropathol Exp Neurol, 64, 555-564.

9. Romero, N.B. and Bitoun, M. (2011) Centronuclear myopathies. Semin Pediatr Neurol, 18, 250-256.

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Small Molecule Screening in Ryanodine Receptor Mutant Zebrafish for Therapeutic

Development in Core Myopathy

Introduction:

Human cells express three distinct isoforms of the ryanodine receptor, each encoded by a different gene: RyRl, RyR2, and RyR3 ^{1 2} . RyRl and RyR2 are predominantly expressed in skeletal and cardiac muscles, respectively, whereas RyR3 has widespread expression during development but is present at relatively low levels. The skeletal muscle RYR1 gene encodes a large, homotetrameric transmembrane ion channel that serves as one of the major intracellular calcium channels in this tissue . First identified in the 1980s and named for its ability to bind the plant alkaloid ryanodine, RyRl resides on the terminal sarcoplasmic reticulum (SR) and exists in close proximity with the T-tubule ⁴ . Its functional role is to mediate excitation-contraction coupling, by releasing calcium from the SR into the cytosol in response to motor neuron stimulation at the neuromuscular junction.

Causative mutations in RYR1 are associated with a wide range of pathologies.

Inherited as a dominant trait, RYR1 mutations often give rise to malignant hyperthermia (MH) and/or central core disease (CCD). MH is a pharmacogenetic condition

manifesting as muscle rigidity and a dramatic rise in body temperature upon exposure to certain anesthetics or environmental conditions ³ ' ⁵ ' ⁶ , whereas CCD is characterized by infantile hypotonia and weakness affecting proximal muscles. Pathologically, the cardinal diagnostic feature of patients with CCD is the presence of "central cores" running along the long axis of myofibers that are devoid of mitochondria and deficient in oxidative enzymes, phosphorylase activity, and glycogen. Only occasionally will autosomal recessive RYR1 mutations yield CCD pathology. More frequently, recessive mutations will lead to alternative findings on muscle biopsy, including characteristic features of multiminicore disease (MmD) 7 , centronuclear and core-rod myopathies 8 ' 9 , congenital fiber type disproportion ¹⁰ ' ^u , and muscular dystrophy ¹² .

5 The molecular mechanisms underlying R YR1 -related disorders are not yet

precisely defined, although trends regarding some genotype-phenotype correlations are emerging. Vis-a-vis the functional effects of dominant RYR1 mutations, MH is believed to arise from "hyperactive" RyRl channels that show increased sensitivity to RyRl agonists in vitro. Caffeine and halothane both activate RyRl channels carrying MH o mutations at lower concentrations than those required to stimulate Ca ²⁺ release in normal channels 13- ^" 15. RyRl dysfunction in CCD is debated between two models: increased cytosolic calcium levels and depletion of SR calcium stores ("leaky channel" hypothesis) and disruptions in excitation-contraction coupling ("uncoupling" hypothesis) 15- ^" 17. In vitro studies have demonstrated reduced levels of stimulated calcium release consistent with both hypotheses 14 ' 17- ^" 21

5 . The functional consequences of recessive RYR1 mutations, however, have only begun to be elucidated, though poorly functioning and reduced numbers of RyRl channels are a common finding 22. Protein levels of RyRl and the physically coupled dihydropyridine receptor (DHPR) are both reduced in autosomal recessive RYR1 patient muscles 23. Localization of the DHPR alpha subunit is also perturbed in cultured myotubes treated with RYR1 -targeting siRNAs 23

o . These two

alterations result in impaired excitation-contraction coupling 23. Recessive RYR1 mutations have also been tied to changes in cellular secretion of interleukin 6 17 ' 24. This cytokine's involvement in a variety of biological events across many tissues and cell types highlights the importance of identifying new molecular pathways that might be 5 involved in RYR1 disease pathogenesis.

Several vertebrate models have been created to help define the histopathological course of various R YR1 -related disorders. Heterozygous mice carrying the p.R163C and p.Y522S mutations undergo full MH episodes when exposed to volatile anesthetics or heat ²⁵ ' ²⁶ . Their skeletal muscles display caffeine- and heat-induced contractures in vitro, 0 as well as increased calcium release from leaky RyRl channels under conditions of oxidative stress ²⁶ · ²⁷ . Another established murine model is the heterozygous line carrying the p.I4895T uncoupling mutation at the C-terminus of RYRL These mice exhibit a slowly progressive myopathy and age-dependent formation of cores and nemaline rods in skeletal muscles . There are currently no working mouse models of recessive RYR1- related myopathies, since homozygous Ryrl ^1' mice die perinatally with skeletal muscles unresponsive to electrical stimulation . Fortuitously, a spontaneous zebrafish mutant that closely mimics human MmD has opened new doors for the study of these diseases in vivo.

The relatively relaxed {ryrlb) zebrafish mutant is homozygous for a recessive nonsense mutation in the ryrlb gene, which results in reduced levels of Ryrl protein 30. Whereas wild-type zebrafish larvae swim away in response to tactile stimulation, ryrlb mutants swim slowly due to weak muscle contractions despite normal output from the central nervous system. Ryrlb mutants exhibit small amorphous cores in myofibers, similar to both human MmD patients and our sepnl zebrafish model described in the previous chapter. Furthermore, Ca2+ transients in ryrlb mutants are also drastically reduced, consistent with the prevailing hypothesis that RYR1 -related disorders are chiefly due to impairments in excitation-contraction coupling.

Following initial characterization of the ryrlb zebrafish, comparative microarray expression analysis was performed on RNA isolated from mutants and wild-type clutchmates in order to identify novel pathogenic pathways associated with the loss of Ryrl function. Several of the mis-expressed transcripts were involved in redox and cellular homeostasis 31. This finding was particularly noteworthy since the redox regulation of RyRl ' s cytosolic thiol groups is known to affect the channel' s gating properties, its opening in response to ions and caffeine, as well as its ability to bind calstabin and calmodulin (two proteins that help dictate RyRl-mediated Ca2+ release in skeletal muscle) 32- ^" 34. A candidate compound approach confirmed a role for oxidative stress in these disorders when the antioxidant N-acetylcysteine was shown to ameliorate select aspects of the ryrlb phenotype, including major histopathological abnormalities 31. In an attempt to better understand RYRl-related pathophysiology and elucidate new molecular pathways that might contribute to disease phenotypes, a chemical screen aimed at identifying lead compounds that can rescue the function of skeletal muscle in the relatively relaxed zebrafish was performed.

Materials and Methods:

Zebrafish lines and husbandry

Zebrafish (Danio rerio) were bred and maintained under standard conditions Zebrafish (Danio rerio) from the wild-type Oregon AB line were bred and maintained according to standard procedures in the Boston Children's Hospital Aquatic Research

Program facility 35. Embryos were collected by natural spawning, staged by hours (hpf) or days (dpf) post fertilization ³⁶ , and raised at 28.5°C in egg water. The relatively 5 relaxed (abbreviated ryrlb) line was acquired after its full characterization as a zebrafish model of MmD 30. The skeletal muscle phenotype in homozygous ryrlb mutants is transmitted in a recessive manner such that 25% of the offspring from mating heterozygous ryrlb ^+/~ adults show diminished touch-evoked swimming by 5 dpf.

Embryos were staged by hours (hpf) or days (dpf) post fertilization at 28.5°C ³⁶ . All l o animal work was performed with approval from the Boston Children's Hospital Animal Care and Use Committee (14-05-2717R).

Chemical library

The Prestwick2 chemical library was supplied by the Institute of Chemistry and 15 Cell Biology Screening Facility at Harvard Medical School and used as the source of small molecules for chemical screening experiments. This library contains 1,120 small molecule composed of 90% marketed drugs and 10% bioactive alkaloids or related substances. Compounds in the Prestwick2 collection were selected for their high chemical and pharmacological diversity, as well as their established bioavailability and afety in humans 37

2 o s .

Chemical screening

Primary screen. For the primary screen, twenty embryos (1 dpf) resulting from a mating of heterozygous ryrlb zebrafish were manually sorted into 48-well plates 25 containing 250 embryo IX E3 medium (5.0 mM NaCl, 0.17 mM KC1, 0.33 mM

CaCi ₂ *2H ₂ 0, 0.33 mM MgS0 ₄ *7H ₂ 0) and four pooled chemicals from the Prestwick2 chemical library. Each chemical pool was assayed in duplicate using embryos from two independent clutches, for a total of 24 distinct pools tested per plate (Fig. 1). The chemicals were dissolved to a final concentration of 2.0 μg/mL and 0.4% DMSO, which o concentrations other groups have used in zebrafish studies 37 ' 38

30 is similar t . As a

negative control, twenty embryos from each clutch were cultured without chemicals in vehicle only (0.4% DMSO) (Fig. 1). Larvae obtained from wild-type (Oregon AB) matings served as positive controls in separate plates. All plates containing embryos were incubated at 28.5°C and maintained as initially treated for 5 days. Dead embryos were removed from wells when observed during the first 4 days of the study. On day 5, dead or "motion-dead" larvae were scored alongside living larvae.

At 5 dpf, pools were scored for their ability to improve the survival and touch- evoked escape behaviors of ryrlb homozygous mutants using the following numeric scoring system: 3 = 4-6 cm, fast (wild-type); 2 = 2-4 cm (moderate); 1 = < 2 cm, slow (ryrlb); 0 = no movement (dead) (Fig. 2A). Survival, swimming, and combined endpoints of the primary screen were then examined for their ability to distinguish positive from negative controls. Since the survival component of the primary screen proved to be most statistically robust (Z'-f actor _sur vivai = 1 - [(3 * (σ _ρ + σ _η )) / Ιμ _ρ -μ _η Ι] = 0.60), chemical pools with significantly higher ryrlb survival rates than DMSO-treated controls were considered hits (P < 0.005). Taking into account both experimental replicates (n = 40), hit pools contained at least 37 alive larvae on day 5 (i.e., 70-100% of the larvae assumed to be ryrlb mutants survived the duration of the study), and were selected for analysis in a secondary screen.

Secondary screen. In the secondary screen, hit pools were separated and tested as 68 individual chemicals. Screening was performed precisely as described for the primary screen with few modifications. Embryos were raised in wells containing 750 μΐ _^ IX E3 medium, as opposed to 250 μί, although the final concentration of each compound was maintained at 2.0 μg/mL. Additionally, because full establishment of our heterozygous ryrlb line resulted in improved robustness of a combined survival and mobility assay, ryrlb larvae in this tier of the screen were evaluated in terms of an overall "vitality" score (Z' -factor = 0.37). Vitality scores, weighting survival and swimming ratios appropriately, were calculated as (# Dead * 0) + (# ryrlb * 1) + (# Moderate * 2) + (# Wild-type * 3). Theoretical maximum and minimum scores were 60 and 0, respectively, with an expected score of 50 in DMSO-treated controls. Secondary screen hits (P < 0.05), considered "candidate" compounds, are currently being examined in dose- response and long-term studies.

Genotyping of ryrlb mutants

The relatively relaxed zebrafish was initially identified due to a spontaneous autosomal recessive mutation within the ryrlb gene 30. Specifically, ryrlb mutants carry a 4046 base pair (bp) DNA insertion in the intron between exons 48 and 49 that includes an additional 32 bp sequence found in mutant cDNA (Fig. 3) . Genotypes of individual embryos were examined using three-primer genomic PCR, with an expected wild-type band of 1,668 bp and a mutant band of 653 bp. Primer sequences were as follows: ryrlb #1 (forward): 5 '-GTGGGTTTCTTGCCCGATATGAGAGCTTCA-3 ' (SEQ ID NO: 4); 5 ryrlb #2 (reverse): 5 '- AAC AGTGGGGC AC ATTT AGTGAGC AGAGG -3 ' (SEQ ID

NO: 5); and ryrlb #3 (reverse): 5'-CTTTAAATAAGCTCTGTGGCATTGGTTGACTC- 3' (SEQ ID NO: 6).

Western blotting

o Western blotting was performed on groups of 50-100 wild-type or mutant

zebrafish larvae at 5 dpf. Mouse monoclonal anti-phospho-STAT3 (1: 1000, D128-3, MBL International, Woburn, MA, USA) and mouse monoclonal anti-P-actin (1: 1000, A5441, Sigma) were used as primary antibodies, and were visualized with HRP- conjugated anti-rabbit (1:2500, 170-6515) and anti-mouse (1:5000, 170-6516) IgG

5 (BioRad). Of three candidates, a reliable antibody for the detection of total Stat3 in

zebrafish was not found. Phospho-Stat3 band intensities were normalized to control bands and quantified in Image J (NIH).

Real-time PCR (RT-PCR)

o Total RNA was prepared from zebrafish embryos using RNeasy fibrous tissue mini kits (Qiagen). cDNAs were synthesized from 1-2 μg of total RNA using Superscript III reverse transcriptase (Invitrogen) and random hexamers. To assess relative stat3 expression levels in 5 dpf embryos, quantitative real-time RT-PCR amplification of cDNAs was performed with a Taqman assay for stat3 exonl5-exonl6 (Applied

5 Biosystems) on a 7300 Real Time PCR System (Applied Biosystems). Gapdh served as the control to normalize stat3 expression using the 2 ^{~ O} method.

Activity monitoring

Zebrafish behavioral parameters were defined using the Noldus Daniovision 0 activity monitoring system. In 12-well plates, wild-type and mutant larvae (5 or 20 dpf) were placed into the machine with the light box off. After a 10 min acclimation to the dark, larvae were stimulated by light exposure for 50 min. This cycle was repeated two times during the course of a single trial. Swimming behaviors were recorded over the entire 2.0-hour period with an infrared light source. Three independent trials were performed with larvae from three different clutches, examining a total of 14-20 wild-type and ryrlb larvae from both DMSO- and nifuroxazide-treated groups. Behavioral parameters recorded include frequency, mean velocity, total distance, and cumulative duration of movement, and reflect the average of all larvae in an experimental group.

Calcium imaging in murine cell culture

Primary myoblasts from C57BL/6N mice were isolated and differentiated as described previously . Calcium imaging was performed 5 days after differentiation in myotubes loaded with 3 μΜ Fluo-4-AM (Life Technologies). Myotubes were imaged in imaging buffer (125 mM NaCl, 5 mM KC1, 2 mM CaCl ₂ , 1.2 mM MgS0 ₄ , 6 mM glucose, 2 mM Ca ²⁺ , 25 mM Hepes/Tris, pH 7.4) at 490-500 nm with a Stanford

Photonics 10 bit digital intensified CCD using a DG4 multi-wavelength light source. Fluorescent emission at 510 was acquired and analyzed using QED Imaging software (QED Software, Pittsburgh, PA, USA) from regions of interest within each myotube at 30 frames per second. Sensitivity to K ⁺ -depolarization and caffeine-activation were determined by a 5 second perfusion with 5-6 volumes of KC1 (10 mM to 60 mM) or caffeine (3 mM to 40 mM). Statistical analysis

GraphPad Prism 7 software (GraphPad Software Inc.) was used to graph all quantitative data and perform statistical analyses. P values for pairwise comparisons were determined using a two-tailed Student's t-test. P values for Kaplan-Meier survival curves were calculated using a log-rank test, and for dose response curves in murine myotubes using an extra sum-of- squares F test. Multiple comparison tests were calculated using one-way ANOVAs, followed by Tukey's honestly significant difference (HSD) post hoc tests (alpha = 0.05). Studies were considered significant when P < 0.05 (*), P < 0.01 (**), and P < 0.001 (***). All quantitative data are shown as the mean ± standard deviation.

Example 1. Primary screening of ryrlb zebrafish

Homozygous ryrlb mutants do not have morphological or birefringence abnormalities during the first week of development, and are typically only distinguishable from wild-type and heterozygous clutchmates by touch-evoked swimming behaviors (Fig. 2B). However, mutants obtained from newly established ryrlb ^+l~ lines also exhibit increased mortality and die before 5 dpf, prioritizing survival as the most robust endpoint for chemical screening. Therefore, for the primary screen (schematically outlined in Fig. 4), 280 chemical pools from a total of 1,120 chemicals in the Prestwick2 chemical library were tested for their ability to improve the survival rate of homozygous ryrlb mutants. Of these chemical pools, 41 (14.6%) resulted in the death of all embryos, whereas the remaining 239 yielded surviving larvae after four full days of treatment (Table 1). Surviving wells were expected, and subsequently confirmed, to contain approximately 25% homozygous ryrlb mutants (Fig. 5). Assuming this ratio, the 17 chemical pools found to significantly improve ryrlb mutant survival compared to DMSO-treated controls were considered hits (P < 0.005) and selected for analysis in a secondary screen (Fig. 6). Table 1. Embryonic zebrafish survival in Prestwick2 library chemical screen.

Survival in Primary Screen Total Viable Lethal

Chemical Pools 280 239 41

Chemicals 1 ,120 956 164

Percentage 100.0 85.4 14.6

Survival in Secondary Screen Total Viable Lethal

Chemicals 68 58 10

Percentage 100.0 85.3 14.7

Example 2. Secondary screening of ryrlb zebrafish

The second tier of the chemical screen was performed two years following the primary screen, with a fully established ryrlb ^+l~ line. Healthier clutches tended to result in better survival of homozygous ryrlb mutants. Median mutant life spans more accurately adhered to the 7-15 day estimate previously published 30. Therefore, in the secondary screen, hit chemical pools were separated into individual compounds and each of 68 total compounds was examined for its ability to positively influence both ryrlb survival and motor function (referred to in combination as "vitality"). Weighing survival and swimming appropriately, twelve compounds were found to improve ryrlb mutant vitality compared to DMSO-treated controls (Table 2; Fig. 7). While these twelve compounds varied with regard to annotated function, several showed considerable overlap. These included two anti-inflammatory agents (sulfasalazine and ketoprofen), two monoamine oxidase inhibitors (pargyline hydrochloride and tranylcypromine hydrochloride), and two ion channel modulators (metolazone and nimodipine).

Table 2. Candidate compounds identified by two-tiered ryrlb chemical screen.

Vitality

Chemical Name Formula MW Mechanism of Action Score

58.0 Pargyline hydrochloride * Cnh^CIN 195.69 Irreversible monoamine oxidase (MAO) inhibitor

57.0 Sulfasalazine C ₁₈ H ₁₄ N ₄ 0 ₅ S 398.39 NF-KB inhibitor; anti-inflammatory

55.5 Metolazone ** C _{1 6} H ₁₆ CIN ₃ 0 ₃ S 365.83 Sodium-chloride channel inhibitor

55.0 Zimelidine dihydrochloride monohydrate ** C ₁₆ H ₂ BrCl2N ₂ 0 408.16 Selective serotonin reuptake inhibitor

54.0 Miconazole *** C ₁₈ H ₁₄ Cl4N ₂ 0 416.13 Anti-fungal agent

54.0 Ticlopidine hydrochloride *** C ₁₄ H ₁₅ CI ₂ NS 300.25 Inhibitor of platelet aggregation

53.5 lohexol ^C 19 ^H 26'3 ^N 3°9 821.14 Low-osmolality contrast agent

52.5 Benoxinate hydrochloride *** C ₁₇ H ₂₉ CIN ₂ 0 ₃ 344.88 Surface anaesthetic

52.0 Ketoprofen ^C 16 ^H 14°3 254.28 Cyclooxygenase inhibitor; anti-inflammatory

52.0 Nifuroxazide C ₁₂ H ₉ N ₃ 0 ₅ 275.22 JAK STAT signaling inhibitor

52.0 Nimodipine ^c 21 ^H 26 ^N 2°7 418.44 Dihydropyridine calcium channel blocker

52.0 Tranylcypromine hydrochloride * CgH ₁₂ CIN 169.65 Irreversible MAO inhibitor

Asterisks indicate compounds originating from the same chemical pool. MW, molecular weight.

Example 3. Dose-response identifies nifuroxazide as a modulator of the ryrlb phenotype

The primary and secondary screens only tested chemical pools and individual compounds at a single concentration (2.0 μg/mL). Although beneficial in a high- throughput context, this approach can result in false positives and false negatives. All twelve candidate compounds are now being investigated to identify those that exhibit a dose-dependent, positive effect on the ryrlb mutant phenotype. Nifuroxazide (NIF), a potent inhibitor of the JAK-STAT signaling pathway, was one of the first candidates found to improve ryrlb mobility in a dose-dependent manner (Fig. 8A). For analysis, pools of 20 larvae obtained from heterozygous ryrlb matings were treated in duplicate with DMSO or with one of three different concentrations of NIF (1.0-100.0 μg/mL) at 1 dpf and scored for touch-evoked escape behaviors at 5 dpf. All scored larvae were then genotyped using three-primer genomic PCR. An intermediate dose of 10 μg/mL resulted 5 in confirmed ryrlb larvae that swam similar to wild-type controls. Next, hit expansion was used to verify JAK-STAT as a potential molecular pathway involved in ryrlb mutant pathology. Whereas NIF acts by reducing tyrosine phosphorylation of JAK2 kinase and blocking downstream phosphorylation of the transcription factor STAT3, 5,15-diphenylporphyrin (5,15-DPP) is a cell permeable porphyrin that specifically l o inhibits interleukin 6-induced STAT3 activation by preventing its dimerization. As anticipated, 5,15-DPP also showed a dose-response relationship with ryrlb mutants and exhibited optimal activity at 100.0 μg/mL (Fig. 8B). A higher effective dose for 5,15- DPP was consistent with the IC ₅₀ measurements reported for each compound ⁴⁰ · ⁴¹ .

In skeletal muscle, activation of the JAK-STAT pathway is correlated with

15 myogenic differentiation, and inhibition of JAK-STAT signaling in dystrophic mice has been shown to rescue defects in muscle regeneration ^42~44 . To determine whether zebrafish stat3 is differentially expressed in the wild-type and Ryrl -deficient background, quantitative real-time RT-PCR was performed using fluorescently tagged Taqman probes. Interestingly, stat3 expression is significantly increased in ryrlb

20 mutants in comparison with unaffected controls at 5 dpf (Fig. 8C). Western blots

subsequently showed that zebrafish with homozygous ryrlb mutations are also more sensitive to pharmacological inhibition of Stat3. Levels of phosphorylated Stat3 protein experienced a larger decrease in ryrlb mutants than in unaffected controls following NIF treatment (10 μg/mL) (Fig. 8D).

25

Example 4, Nifuroxazide Improves contractile forces in Ryrl -deficient larvae

Ryrlb mutants display weaker muscle contractions than wild-type clutchmates as early as 2 dpf ⁰ . To investigate whether NIF affects contractile strength in zebrafish, ryrlb mutants and unaffected controls were treated with the compound for several days. 30 At 5 dpf, electrophysiological studies were performed with the help of Dr. Jeffrey

Widrick. Whereas ryrlb mutants exhibited reduced tetanic force per cross-sectional area compared to unaffected controls, tetanic forces in NIF-treated mutants were restored to wild-type levels (Fig. 9A). These data, together with published observations that Ca ²⁺ transients are smaller in Ryrl -deficient zebrafish and mouse muscles relative to wild- type, prompted the hypothesis that nifuroxazide may act, either directly or indirectly, on defective excitation-contraction coupling in ryrlb mutants.

Depolarization of the muscle membrane causes a transient increase in

cytoplasmic Ca ²⁺ , a result of excitation-contraction coupling that leads to actin-myosin sliding and skeletal muscle contraction ⁴⁵ . To examine the effect of NIF on Ca ²⁺ transients in vertebrate muscle, wild-type murine myotubes were cultured in the presence or absence of compound for 5 days. Depolarization-induced calcium release was then studied in response to increasing doses of caffeine. As expected, only very modest increases in calcium release were observed in the wild-type background (Fig. 9B). While these data are supportive of an effect of the compound on RyRl -mediated calcium release, more experiments are necessary and must be designed to look at other aspects of calcium homeostasis in RyRl deficiency, such as SR calcium load, resting free calcium concentration, and/or passive calcium entry. This particular experiment was not possible in RYRl null muscle cells since these do not respond to any direct agonist of this channel (e.g., caffeine, potassium).

Example 5. Long-term Stat3 inhibition as a potential treatment for homozygous ryrlb zebrafish

Wild-type zebrafish larvae display straight bodies throughout the first 20 days of life, with angles that do not deviate significantly from 180 degrees. Although

homozygous ryrlb mutants do not exhibit early morphological defects, ryrlb trunks are frequently bent by 20 dpf with angles reduced to 140 degrees. This bending is likely a consequence of skeletal muscle weakness, and may be analogous to neck and trunk flexor weakness observed in human patients with MmD (Fig. 10A). To determine if NIF could correct this abnormality, larvae were treated with the compound from 1 to 20 dpf. After 20 days, body angles were measured as the angle of intersection between two lines, one drawn between the eyes of each larva and one drawn along the trunk midline. Body angles of NIF-treated ryrlb mutants were significantly increased and statistically indistinguishable from unaffected controls (Fig. 10B). These improvements in morphology reflect long-term strengthening of ryrlb skeletal muscles as a result of exposure to NIF.

Next, to determine if long-term NIF treatment affects ryrlb motor functions, spontaneous swimming behaviors of 20 dpf larvae were quantified using the Noldus Daniovision. As expected, untreated ryrlb mutants moved significantly less than control clutchmates. In contrast, NIF treatment resulted in a large and robust increase on the distance travelled by ryrlb zebrafish, restoring their movements to the levels of NIF- 5 treated controls (Figs. 10C-10D). Together with the dose-response data, these findings indicate that NIF improves the motor phenotype and endurance of ryrlb mutants.

In addition to their muscular defects, ryrlb mutants die prematurely 30. To examine whether long-term treatment with NIF positively impacts the life span of ryrlb mutants, affected larvae (selected at 5 dpf by touch-evoked escape behavior assay) were o treated with compound from 1 to 50 dpf. Despite drug-mediated improvements in

anatomy and swimming, Kaplan-Meier survival curves and median survival did not significantly differ between NIF- and DMSO-treated ryrlb larvae, although select ryrlb mutants treated with NIF did survive the complete duration of the study (Fig. 11). 5 Example 6. Ketoprofen candidate further supports a role for JAK-STAT signaling in Ryrl deficiency

A second candidate compound, ketoprofen, is a nonsteroidal anti-inflammatory drug that reversibly inhibits cyclooxygenase- 1 and -2 and reduces the production of proinflammatory prostaglandin precursors (Fig. 12A, top). A literature -based search o revealed interleukin 6 (IL-6) to be one of the most prominently down-regulated

precursors ⁴⁶ , and one that acts in the same molecular pathway as nifuroxazide (Fig. 12, bottom). Preliminary dose-response experiments have confirmed a relationship between ketoprofen and improvements in ryrlb mobility (Fig. 12B). It is believed that increased IL-6 production in Ryrl deficiency leads to increases in JAK-STAT signaling

5 downstream, and to changes in skeletal muscle gene expression that are not altered in healthy muscle (Fig. 12C) ¹¹ .

Discussion

Chemical screening in the ryrlb zebrafish

0 Current research on congenital myopathies and muscular dystrophies is focused on using traditional methods to develop gene- and protein-based treatments ^48~53 . These methods, while having great potential, are fraught with methodological and logistical problems that are general to the approach (i.e., delivery, immune rejection, carcinogenic potential, cost, etc.). The present ryrlb chemical screen represents a paradigm shift by taking a more pragmatic approach to drug development, by testing bioactive compounds in a validated vertebrate model and then using the identity of positive "hits" to learn more about the molecular pathways associated with core myopathies. The use of zebrafish to screen small molecule libraries was developed in collaboration with Boston Children's Hospital Division of Genetics and Genomics, and is innovative in its application to the ryrlb phenotype 37.

In contrast to target-based strategies, chemical screens in zebrafish are guided by a desired phenotype and allow for drug discovery without knowledge of specific molecular targets and mechanisms 38 ' 54- ^" 57. Embryonic and larval zebrafish are also permeable to small molecules and can be assayed in large numbers. Since zebrafish with homozygous recessive mutations in the ryrlb gene have been characterized as excellent models of core myopathy, the Prestwick2 library was screened for chemicals that could correct the severely impaired swimming behaviors of ryrlb mutants 30. The two-tiered screening strategy of first pooling chemicals and then screening individual compounds resulted in the identification of twelve candidate compounds that decreased the number of phenotypically affected ryrlb larvae. Dose-response experiments are now in progress to identify those candidates that clearly demonstrate a causal relationship with improvements in the ryrlb phenotype.

JAK-STAT signaling and ROS in RyRl deficiency

Genetic- and pharmacological-based approaches have recently shown that increases in JAK-STAT signaling impair muscle regeneration by suppressing myogenic activities and satellite cell functions ^42_44 . Follow-up studies conducted in vitro and in mice demonstrated that inhibition of either JAK kinase (using inhibitor AG490) or

STAT3 (using inhibitor 5,15-DPP) promotes satellite cell expansion and rescues defects in muscle generation in both aging and dystrophic mouse models ⁴³ ' ⁴⁴ . Intriguingly, nifuroxazide, a nitrofuran inhibitor of STAT3 transcription factor signaling, was one candidate compound found to rescue the muscle weakness of ryrlb larvae in a dose- dependent manner. Geno typing of the ryrlb gene in 5 dpf larvae treated with nifuroxazide (10 or 100 μg/mL) or with 5,15-DPP (100 μg/mL) beginning at 1 dpf revealed that ryrlb mutants were among larvae that exhibited wild-type touch-evoked escape behaviors. These data suggesting that STAT3 inhibition might prevent the onset of muscular abnormalities in zebrafish with ryrlb mutation, together with reports linking JAK-STAT signaling to myogenesis, prompted further studies of nifuroxazide in the model system.

Stat3 transcripts were significantly increased in ryrlb mutants relative to

5 unaffected controls, while levels of Stat3 protein were similar between groups. However, phosphorylated Stat3 protein levels in ryrlb mutants treated with nifuroxazide at the lowest effective dose were largely reduced compared to ryrlb mutants treated with vehicle only. Such a decrease was not observed in between DMSO- and drug-treated unaffected control larvae. These observations indicate an increased sensitivity of Ryrl- o deficient zebrafish to the inhibitor, and strongly suggest that JAK-STAT signaling is relevant to induction of the ryrlb phenotype. Although nifuroxazide did not dramatically impact ryrlb survival, chemical treatment definitively improved contractile strength, body morphology, and locomotive activities of mutants.

NADPH oxidase-generated reactive oxygen species (ROS) have been implicated AT3 activation 58

5 in ST . Since Ryrl -deficient zebrafish demonstrate excessive production of ROS 31 as well as increased stat3 expression, it is quite plausible that there is a causal relationship between the two. Independent experiments showing that ryrlb swimming abnormalities can be treated with either N-acetylcysteine antioxidant 31 or JAK-STAT inhibitors serve as further support of this model. It is important to note that other o candidates identified in our screen may also act within the same signaling pathway.

Ketoprofen, a nonsteroidal anti-inflammatory drug that reversibly inhibits

cyclooxygenase-1 and -2, inhibits the production of IL-6 in vitro and shows a dose- response relationship with ryrlb mutants ⁴⁶ . Similarly, sulfasalazine is another antiinflammatory candidate shown to inhibit IL-6 release in skeletal muscle ⁵⁹ . IL-6 is a 5 pleiotropic cytokine that exerts both pro-inflammatory and anti-inflammatory effects depending on the cellular context ^60~62 , and has been implicated in the pathogenesis of several neurodegenerative disorders, including Alzheimer's disease ⁶³ · ⁶⁴ ₅ Parkinson's disease ⁶⁵ , and multiple sclerosis ⁶⁶ . IL-6 preferentially activates STAT3 ⁶¹ . Activation of STAT3 also induces IL-6 mRNA production and increases secretion of IL-6 through the 0 direct activation of IL-6 promoters ⁶² . Based on these reports, it is believed that

ketoprofen (and potentially sulfasalazine) might act by decreasing JAK-STAT signaling in Ryrl -deficient zebrafish and restoring a feedback loop that becomes dysregulated under oxidizing conditions within their muscle cells. Apart from candidates modulating JAK-STAT signaling, a fourth compound identified in the chemical screen has previously been reported to have beneficial effects on vertebrate models of muscle disease. Notably, the monoamine oxidase inhibitor pargyline hydrochloride significantly decreases myofiber apoptosis and increases muscle 5 strength in mouse models of Duchenne and Ullrich congenital muscular dystrophies ^6S .

This study also found that ROS produced in mitochondria oxidize myofibrillar proteins important for contractile function in dystrophic muscle, such as tropomyosin, and pargyline hydrochloride corrects this defect at the molecular level.

The four candidates discussed herein validate the present screening strategy as a o means to find pathways that might influence abnormalities within skeletal muscle, and also open up promising avenues for future studies with the ryrlb and sepnl zebrafish.

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5

OTHER EMBODIMENTS

All of the features disclosed in this specification may be combined in any combination. Each feature disclosed in this specification may be replaced by an alternative feature serving the same, equivalent, or similar purpose. Thus, unless o expressly stated otherwise, each feature disclosed is only an example of a generic series of equivalent or similar features.

From the above description, one skilled in the art can easily ascertain the essential characteristics of the present disclosure, and without departing from the spirit and scope thereof, can make various changes and modifications of the disclosure to adapt5 it to various usages and conditions. Thus, other embodiments are also within the claims.

EQUIVALENTS

While several inventive embodiments have been described and illustrated herein, those of ordinary skill in the art will readily envision a variety of other means and/or o structures for performing the function and/or obtaining the results and/or one or more of the advantages described herein, and each of such variations and/or modifications is deemed to be within the scope of the inventive embodiments described herein. More generally, those skilled in the art will readily appreciate that all parameters, dimensions, materials, and configurations described herein are meant to be exemplary and that the 5 actual parameters, dimensions, materials, and/or configurations will depend upon the specific application or applications for which the inventive teachings is/are used. Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific inventive embodiments described herein. It is, therefore, to be understood that the foregoing embodiments are presented 0 by way of example only and that, within the scope of the appended claims and

equivalents thereto, inventive embodiments may be practiced otherwise than as specifically described and claimed. Inventive embodiments of the present disclosure are directed to each individual feature, system, article, material, kit, and/or method described herein. In addition, any combination of two or more such features, systems, articles, materials, kits, and/or methods, if such features, systems, articles, materials, kits, and/or methods are not mutually inconsistent, is included within the inventive scope of the present disclosure.

All definitions, as defined and used herein, should be understood to control over dictionary definitions, definitions in documents incorporated by reference, and/or ordinary meanings of the defined terms.

All references, patents and patent applications disclosed herein are incorporated by reference with respect to the subject matter for which each is cited, which in some cases may encompass the entirety of the document.

The indefinite articles "a" and "an," as used herein in the specification and in the claims, unless clearly indicated to the contrary, should be understood to mean "at least one."

The phrase "and/or," as used herein in the specification and in the claims, should be understood to mean "either or both" of the elements so conjoined, i.e., elements that are conjunctively present in some cases and disjunctively present in other cases.

Multiple elements listed with "and/or" should be construed in the same fashion, i.e., "one or more" of the elements so conjoined. Other elements may optionally be present other than the elements specifically identified by the "and/or" clause, whether related or unrelated to those elements specifically identified. Thus, as a non-limiting example, a reference to "A and/or B", when used in conjunction with open-ended language such as "comprising" can refer, in one embodiment, to A only (optionally including elements other than B); in another embodiment, to B only (optionally including elements other than A); in yet another embodiment, to both A and B (optionally including other elements); etc.

As used herein in the specification and in the claims, "or" should be understood to have the same meaning as "and/or" as defined above. For example, when separating items in a list, "or" or "and/or" shall be interpreted as being inclusive, i.e., the inclusion of at least one, but also including more than one, of a number or list of elements, and, optionally, additional unlisted items. Only terms clearly indicated to the contrary, such as "only one of or "exactly one of," or, when used in the claims, "consisting of," will refer to the inclusion of exactly one element of a number or list of elements. In general, the term "or" as used herein shall only be interpreted as indicating exclusive alternatives (i.e. "one or the other but not both") when preceded by terms of exclusivity, such as "either," "one of," "only one of," or "exactly one of." "Consisting essentially of," when used in the claims, shall have its ordinary meaning as used in the field of patent law.

As used herein in the specification and in the claims, the phrase "at least one," in reference to a list of one or more elements, should be understood to mean at least one element selected from any one or more of the elements in the list of elements, but not necessarily including at least one of each and every element specifically listed within the list of elements and not excluding any combinations of elements in the list of elements. This definition also allows that elements may optionally be present other than the elements specifically identified within the list of elements to which the phrase "at least one" refers, whether related or unrelated to those elements specifically identified. Thus, as a non-limiting example, "at least one of A and B" (or, equivalently, "at least one of A or B," or, equivalently "at least one of A and/or B") can refer, in one embodiment, to at least one, optionally including more than one, A, with no B present (and optionally including elements other than B); in another embodiment, to at least one, optionally including more than one, B, with no A present (and optionally including elements other than A); in yet another embodiment, to at least one, optionally including more than one, A, and at least one, optionally including more than one, B (and optionally including other elements); etc.

It should also be understood that, unless clearly indicated to the contrary, in any methods claimed herein that include more than one step or act, the order of the steps or acts of the method is not necessarily limited to the order in which the steps or acts of the method are recited.

In the claims, as well as in the specification above, all transitional phrases such as "comprising," "including," "carrying," "having," "containing," "involving," "holding," "composed of," and the like are to be understood to be open-ended, i.e., to mean including but not limited to. Only the transitional phrases "consisting of and

"consisting essentially of shall be closed or semi-closed transitional phrases, respectively, as set forth in the United States Patent Office Manual of Patent Examining Procedures, Section 2111.03.