Methodology of clinical research in rare diseases: development of a research program in juvenile neuronal ceroid lipofuscinosis (JNCL) via creation of a patient registry and collaboration with patient advocates

INTRODUCTION

Juvenile neuronal ceroid lipofuscinosis (JNCL; Batten disease) is a rare, inherited, fatal lysosomal storage childhood disorder. True for many rare diseases, there are no treatments that impact the course of JNCL. The University of Rochester Batten Center's (URBC) mission is to find treatments to slow, halt, or prevent JNCL.

OBJECTIVES

Our initial objective was to develop clinical research infrastructure preparatory to clinical trials, establish a JNCL research cohort, construct a disease-specific clinical outcome measure, and validate a non-invasive diagnostic sampling method. The long-term objective is to design and implement JNCL clinical trials.

METHODS

The Unified Batten Disease Rating Scale (UBDRS) was developed. The Batten Disease Support and Research Association (BDSRA) referred participants; annual BDSRA meetings provided a mobile research setting for registry enrollment and UBDRS piloting. Neuropsychological examinations were performed, enabling external validation of the UBDRS. Buccal epithelial cell collection for genotyping was introduced. Telemedicine for remote UBDRS assessment was piloted.

RESULTS

The registry enrolled 198 families representing 237 children with NCL. The UBDRS was piloted, was validated and has been used to collect natural history data from 120 subjects. Funding and regulatory approval were obtained for a recently launched phase II clinical trial. Several additional lines of inquiry were reported.

CONCLUSION

The registry and BDSRA collaboration have enabled development of a clinical rating scale, natural history and neuropsychological studies, and genetic studies for disease confirmation. This work highlights an approach for preparatory natural history research and infrastructure development needed to facilitate efficient implementation of clinical trials in rare diseases.

Laser-beam zooming to mitigate crossed-beam energy losses in direct-drive implosions

Spherically symmetric direct-drive-ignition designs driven by laser beams with a focal-spot size nearly equal to the target diameter suffer from energy losses due to crossed-beam energy transfer (CBET). Significant reduction of CBET and improvements in implosion hydrodynamic efficiency can be achieved by reducing the beam diameter. Narrow beams increase low-mode perturbations of the targets because of decreased illumination uniformity that degrades implosion performance. Initiating an implosion with nominal beams (equal in size to the target diameter) and reducing the beam diameter by ∼ 30%-40% after developing a sufficiently thick target corona, which smooths the perturbations, mitigate CBET while maintaining low-mode target uniformity in ignition designs with a fusion gain ≫ 1.

Compact Kirkpatrick-Baez microscope mirrors for imaging laser-plasma x-ray emission

Compact Kirkpatrick-Baez microscope mirror components for use in imaging laser-plasma x-ray emission have been manufactured, coated, and tested. A single mirror pair has dimensions of 14 × 7 × 9 mm and a best resolution of ~5 μm. The mirrors are coated with Ir providing a useful energy range of 2-8 keV when operated at a grazing angle of 0.7°. The mirrors can be circularly arranged to provide 16 images of the target emission a configuration best suited for use in combination with a custom framing camera [F. J. Marshall, J. A. Oertel, and P. J. Walsh, Rev. Sci. Instrum. 75, 4045 (2004)]. An alternative arrangement of the mirrors would allow alignment of the images with a four-strip framing camera such as described in D. K. Bradley et al. [Rev. Sci. Instrum. 66, 716 (1995)].

A new compact, high sensitivity neutron imaging system

We have developed a new small neutron imaging system (SNIS) diagnostic for the OMEGA laser facility. The SNIS uses a penumbral coded aperture and has been designed to record images from low yield (10(9)-10(10) neutrons) implosions such as those using deuterium as the fuel. This camera was tested at OMEGA in 2009 on a rugby hohlraum energetics experiment where it recorded an image at a yield of 1.4 × 10(10). The resolution of this image was 54 μm and the camera was located only 4 meters from target chamber centre. We recently improved the instrument by adding a cooled CCD camera. The sensitivity of the new camera has been fully characterized using a linear accelerator and a (60)Co γ-ray source. The calibration showed that the signal-to-noise ratio could be improved by using raw binning detection.

Note: spatial resolution of Fuji BAS-TR and BAS-SR imaging plates

The spatial resolution of two types of imaging plates, Fuji BAS-TR and Fuji BAS-SR, has been measured using a knife-edge x-ray source of 8-keV Cu K(α) radiation. The values for the spatial resolution, defined as the distance between 10% and 90% levels of the edge spread function, are 94 μm and 109 μm, respectively. The resolution values are important for quantitative analysis of x-ray and particle imaging and spectroscopic diagnostics.

Approach to the elderly patient with gait disturbance

The prevalence of gait disturbances and falls increases dramatically with age, but these problems are not universal in the elderly. They should trigger a systematic search for underlying disease states, many of which can be treated medically or surgically, or significantly ameliorated through provision of physical therapy focused on gait training and aids to ambulation, removal of safety hazards in the environment, and the elimination of polypharmacy. While cardiovascular, orthopedic, and rheumatologic diseases account for the majority of gait disturbances in the elderly, the aim here is to outline an approach to the diagnosis and treatment of a broad array of neurologic conditions causing gait disturbance in the elderly.

Females experience a more severe disease course in Batten disease

Juvenile neuronal ceroid lipofuscinosis (JNCL; CLN3 disease; Batten disease) is an autosomal recessive neurodegenerative disease of childhood. Symptoms typically present at school age with vision loss followed by progressive cognitive decline, motor dysfunction, seizures, and behavior problems. Studies on sex differences in JNCL have yielded mixed results, but parent anecdotes suggest that females experience a more precipitous disease course. Therefore, we sought to determine if sex-based differences exist in JNCL. We used data from the Unified Batten Disease Rating Scale (UBDRS), the Batten Disease Support and Research Association (BDSRA) database, and the PedsQL quality of life (QoL) survey to evaluate sex-based differences in functional independence and time from symptom onset to death. On average, females had JNCL symptom onset one year later and death one year earlier than did males. Despite a later age at onset, females had lower functional capability, earlier loss of independent function, and lower physical QoL. Future research in sex differences in JNCL may help to further understand the biological mechanisms underpinning the disease course and may point to targeted therapies.

Increasing hydrodynamic efficiency by reducing cross-beam energy transfer in direct-drive-implosion experiments

A series of experiments to determine the optimum laser-beam radius by balancing the reduction of cross-beam energy transfer (CBET) with increased illumination nonuniformities shows that the hydrodynamic efficiency is increased by ∼35%, which leads to a factor of 2.6 increase in the neutron yield when the laser-spot size is reduced by 20%. Over this range, the absorption is measured to increase by 15%, resulting in a 17% increase in the implosion velocity and a 10% earlier bang time. When reducing the ratio of laser-spot size to a target radius below 0.8, the rms amplitudes of the nonuniformities imposed by the smaller laser spots are measured at a convergence ratio of 2.5 to exceed 8  μm and the neutron yield saturates despite increasing absorbed energy, implosion velocity, and decreasing bang time. The results agree well with hydrodynamic simulations that include both nonlocal and CBET models.

Development of the large neutron imaging system for inertial confinement fusion experiments

Inertial confinement fusion (ICF) requires a high resolution (~10 μm) neutron imaging system to observe deuterium and tritium (DT) core implosion asymmetries. A new large (150 mm entrance diameter: scaled for Laser MégaJoule [P. A. Holstein, F. Chaland, C. Charpin, J. M. Dufour, H. Dumont, J. Giorla, L. Hallo, S. Laffite, G. Malinie, Y. Saillard, G. Schurtz, M. Vandenboomgaerde, and F. Wagon, Laser and Particle Beams 17, 403 (1999)]) neutron imaging detector has been developed for such ICF experiments. The detector has been fully characterized using a linear accelerator and a (60)Co γ-ray source. A penumbral aperture was used to observe DT-gas-filled target implosions performed on the OMEGA laser facility. [T. R. Boehly, D. L. Brown, R. S. Craxton, R. L. Keck, J. P. Knauer, J. H. Kelly, T. J. Kessler, S. A. Kumpan, S. J. Loucks, S. A. Letzring, F. J. Marshall, R. L. McCrory, S. F. B. Morse, W. Seka, J. M. Soures, and C. P. Verdon, Opt. Commun. 133, 495 (1997)] Neutron core images of 14 MeV with a resolution of 15 μm were obtained and are compared to x-ray images of comparable resolution.

Quantifying physical decline in juvenile neuronal ceroid lipofuscinosis (Batten disease)

OBJECTIVE

To use the Unified Batten Disease Rating Scale (UBDRS) to measure the rate of decline in physical and functional capability domains in patients with juvenile neuronal ceroid lipofuscinosis (JNCL) or Batten disease, a neurodegenerative lysosomal storage disorder. We have evaluated the UBDRS in subjects with JNCL since 2002; during that time, the scale has been refined to improve reliability and validity. Now that therapies are being proposed to prevent, slow, or reverse the course of JNCL, the UBDRS will play an important role in quantitatively assessing clinical outcomes in research trials.

METHODS

We administered the UBDRS to 82 subjects with JNCL genetically confirmed by CLN3 mutational analysis. Forty-four subjects were seen for more than one annual visit. From these data, the rate of physical impairment over time was quantified using multivariate linear regression and repeated-measures analysis.

RESULTS

The UBDRS Physical Impairment subscale shows worsening over time that proceeds at a quantifiable linear rate in the years following initial onset of clinical symptoms. This deterioration correlates with functional capability and is not influenced by CLN3 genotype.

CONCLUSION

The UBDRS is a reliable and valid instrument that measures clinical progression in JNCL. Our data support the use of the UBDRS to quantify the rate of progression of physical impairment in subjects with JNCL in clinical trials.

Quantitative telemedicine ratings in Batten disease: implications for rare disease research

OBJECTIVE

To determine if remote administration of the Unified Batten Disease Rating Scale (UBDRS) Physical Impairment subscale by telemedicine is reliable and feasible across a broad range of disease severity.

METHODS

For the majority (n = 10) of subjects, the examination was performed by a nonphysician who had been trained to perform the examination but not to score the subjects. A trained rater scored the subjects via live video; a second trained rater performed a separate examination in person and scored that examination. For 3 telemedicine evaluations, examinations were performed and scored by a trained rater while a second trained rater simultaneously scored the subjects via live video. Reliability was determined by intraclass correlation coefficient (ICC).

RESULTS

Subjects (n = 13) represented a wide range of disease severity. Remote administration of the UBDRS Physical Impairment subscale had high interrater reliability across all subjects (ICC = 0.94). When only the subjects (n = 10) who had been examined by the nonphysician and scored remotely were included in the analysis, the reliability was unchanged (ICC = 0.95).

CONCLUSIONS

The UBDRS Physical Impairment subscale is reliable and feasible for remote administration. Telemedicine has the potential to be a useful tool in rare neurologic disease research and clinical assessment.

Parent-reported benefits of flupirtine in juvenile neuronal ceroid lipofuscinosis (Batten disease; CLN3) are not supported by quantitative data

Juvenile neuronal ceroid lipofuscinosis (JNCL; CLN3 disease; Batten disease) is an autosomal recessive neurodegenerative disease of childhood that typically presents at school age with vision loss followed by progressive cognitive decline, motor dysfunction, seizures, and behavior problems. No therapy has been shown to slow the progression of disease in JNCL patients, and all current treatments are symptomatic. Flupirtine has been shown in vitro to reduce apoptosis in CLN3 lymphocytes. Based on that preclinical study, several children with JNCL were given flupirtine by their parents. The purpose of this study was to determine if there was evidence of attenuated disease progression in any JNCL symptom domain. We administered a survey to parents of JNCL children to qualitatively assess flupirtine efficacy. We used the Unified Batten Disease Rating Scale (UBDRS) to determine specific aspects of disease progression and investigated three age-related factors: loss of independent ambulation, loss of intelligible speech, and loss of ability to perform independent activities of daily living. The median scores for the UBDRS physical, behavior, and capability subscales were determined in flupirtine-exposed subjects and compared to age-, sex-, and genotype-matched subjects who had never taken flupirtine. Twenty-one percent of survey responders reported administering flupirtine to their JNCL child, and 56% of these families perceived beneficial changes that they attributed to flupirtine. However, our quantitative, prospectively obtained data did not show any change in JNCL disease progression that could be attributed to flupirtine. This study highlights the need for prospective experimental therapeutic research.

Fusion yield enhancement in magnetized laser-driven implosions

Enhancement of the ion temperature and fusion yield has been observed in magnetized laser-driven inertial confinement fusion implosions on the OMEGA Laser Facility. A spherical CH target with a 10 atm D2 gas fill was imploded in a polar-drive configuration. A magnetic field of 80 kG was embedded in the target and was subsequently trapped and compressed by the imploding conductive plasma. As a result of the hot-spot magnetization, the electron radial heat losses were suppressed and the observed ion temperature and neutron yield were enhanced by 15% and 30%, respectively.

Group patient visits for Parkinson disease: a randomized feasibility trial

BACKGROUND

Group patient visits are medical appointments shared among patients with a common medical condition. This care delivery method has demonstrated benefits for individuals with chronic conditions but has not been evaluated for Parkinson disease (PD).

METHODS

We conducted a 12-month, randomized trial of group patient visits vs usual (one-on-one) care for patients with PD. Visits were led by one of 3 study physicians, included patients and caregivers, and lasted approximately 90 minutes. Those receiving group visits had 4 sessions over 12 months. The primary outcome measure was feasibility as measured by the ability to recruit participants and by the proportion of participants who completed the study. The primary efficacy outcome was quality of life as measured by the PD Questionnaire-39.

RESULTS

Thirty patients and 27 caregivers enrolled in the study. Thirteen of the 15 patients randomized to group patient visits and 14 of the 15 randomized to usual care completed the study. Quality of life measured 12 months after baseline between the 2 groups was not different (25.9 points for group patient visits vs 26.0 points for usual care; p = 0.99).

CONCLUSIONS

Group patient visits may be a feasible means of providing care to individuals with PD and may offer an alternative or complementary method of care delivery for some patients and physicians.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that group patient visits did not improve quality of life for individuals with PD over a 1-year period.

A U.S. survey of patients with Parkinson's disease: satisfaction with medical care and support groups

Relatively little is known about patient satisfaction with Parkinson's disease (PD) care and the use of support groups in the United States. We surveyed members of the Muhammad Ali Parkinson's Disease Registry to assess satisfaction with medical care and to evaluate support group use. Satisfaction was measured on a 5-point Likert scale, with high satisfaction defined as a four or five. We used multiple logistic regression to identify factors associated with high satisfaction and support group use. The response rate was 38% (726 of 1923). Most (57%) expressed high satisfaction with PD care. Individuals were most satisfied with the time their provider spent with them (61%) and PD education (56%) but least satisfied with prognostic information (35%) and information about non-drug interventions (28%). Patients seeing a PD specialist were three times more satisfied with their care than those seeing a general neurologist (OR = 3.00, 95% CI: 1.92-4.71; P < 0.0001). Support group use is common, and 61% of survey respondents had attended one at any point. Caucasian race (OR = 2.85, 95% CI: 1.45-5.61), PD duration (OR = 1.05 per year, CI: 1.01-1.10), and PD specialist care (OR = 1.80, CI: 1.16-2.77) were associated with greater support group attendance. Overall, 49% reported high satisfaction with their support group. The greatest concerns were specific needs not being addressed (15%) and insufficient expertise within the group (14%). Most individuals with Parkinson's disease expressed high levels of satisfaction, especially with specialist care. Specialty care and improved education, in the clinic or through support groups, may enhance satisfaction and health care quality.

Charge-injection-device performance in the high-energy-neutron environment of laser-fusion experiments

Charge-injection devices (CIDs) are being used to image x rays in laser-fusion experiments on the University of Rochester's OMEGA Laser System. The CID cameras are routinely used up to the maximum neutron yields generated (∼10(14) DT). The detectors are deployed in x-ray pinhole cameras and Kirkpatrick-Baez microscopes. The neutron fluences ranged from ∼10(7) to ∼10(9) neutrons/cm(2) and useful x-ray images were obtained even at the highest fluences. It is intended to use CID cameras at the National Ignition Facility (NIF) as a supporting means of recording x-ray images. The results of this work predict that x-ray images should be obtainable on the NIF at yields up to ∼10(15), depending on distance and shielding.

Demonstration of the highest deuterium-tritium areal density using multiple-picket cryogenic designs on OMEGA

The performance of triple-picket deuterium-tritium cryogenic target designs on the OMEGA Laser System [T. R. Boehly, Opt. Commun. 133, 495 (1997)] is reported. These designs facilitate control of shock heating in low-adiabat inertial confinement fusion targets. Areal densities up to 300 mg/cm2 (the highest ever measured in cryogenic deuterium-tritium implosions) are inferred in the experiments with an implosion velocity approximately 3x10(7) cm/s driven at peak laser intensities of 8x10(14) W/cm2. Extension of these designs to ignition on the National Ignition Facility [J. A. Paisner, Laser Focus World 30, 75 (1994)] is presented.

Plasma-density determination from x-ray radiography of laser-driven spherical implosions

The fuel layer density of an imploding laser-driven spherical shell is inferred from framed x-ray radiographs. The density distribution is determined by using Abel inversion to compute the radial distribution of the opacity kappa from the observed optical depth tau. With the additional assumption of the mass of the remaining fuel, the absolute density distribution is determined. This is demonstrated on the OMEGA laser system with two x-ray backlighters of different mean energies that lead to the same inferred density distribution independent of backlighter energy.

Diagnostics hardening for harsh environment in Laser Megajoule (invited)

The diagnostic designs for the Laser Megajoule (LMJ) will require components to operate in environments far more severe than those encountered in present facilities. This harsh environment will be induced by fluxes of neutrons, gamma rays, energetic ions, electromagnetic radiations, and, in some cases, debris and shrapnel, at levels several orders of magnitude higher than those experienced today on existing facilities. The lessons learned about the vulnerabilities of present diagnostic parts fielded mainly on OMEGA for many years, have been very useful guide for the design of future LMJ diagnostics. The present and future LMJ diagnostic designs including this vulnerability approach and their main mitigation techniques will be presented together with the main characteristics of the LMJ facility that provide for diagnostic protection.

A versatile high-resolution x-ray imager (HRXI) for laser-plasma experiments on OMEGA

A high-resolution x-ray imager (HRXI) devoted to laser-plasma experiments combines two state-of-the-art technologies developed in France: a high-resolution x-ray microscope and a high-speed x-ray streak camera. The resulting streaked imager achieves spatial and temporal resolutions of approximately 5 microm and approximately 10 ps, respectively. The HXRI has recorded enhanced spatial and temporal resolution radiographs of indirectly driven targets on OMEGA. This paper describes the main features of the instrument and details the activation process on OMEGA (particularly the alignment). Recent results obtained on joint CEA/LLE radiographic OMEGA experiments will also be presented.

High-areal-density fuel assembly in direct-drive cryogenic implosions

The first observation of ignition-relevant areal-density deuterium from implosions of capsules with cryogenic fuel layers at ignition-relevant adiabats is reported. The experiments were performed on the 60-beam, 30-kJUV OMEGA Laser System [T. R. Boehly, Opt. Commun. 133, 495 (1997)10.1016/S0030-4018(96)00325-2]. Neutron-averaged areal densities of 202+/-7 mg/cm2 and 182+/-7 mg/cm2 (corresponding to estimated peak fuel densities in excess of 100 g/cm3) were inferred using an 18-kJ direct-drive pulse designed to put the converging fuel on an adiabat of 2.5. These areal densities are in good agreement with the predictions of hydrodynamic simulations indicating that the fuel adiabat can be accurately controlled under ignition-relevant conditions.

Proton radiography of inertial fusion implosions

A distinctive way of quantitatively imaging inertial fusion implosions has resulted in the characterization of two different types of electromagnetic configurations and in the measurement of the temporal evolution of capsule size and areal density. Radiography with a pulsed, monoenergetic, isotropic proton source reveals field structures through deflection of proton trajectories, and areal densities are quantified through the energy lost by protons while traversing the plasma. The two field structures consist of (i) many radial filaments with complex striations and bifurcations, permeating the entire field of view, of magnetic field magnitude 60 tesla and (ii) a coherent, centrally directed electric field of order 10(9) volts per meter, seen in proximity to the capsule surface. Although the mechanism for generating these fields is unclear, their effect on implosion dynamics is potentially consequential.

Potential outcome measures and trial design issues for multiple system atrophy

Multiple system atrophy (MSA) is a neurodegenerative disorder exhibiting a combination of parkinsonism, cerebellar ataxia, and autonomic failure. A disease-specific scale, the Unified Multiple System Atrophy Rating Scale (UMSARS), has been developed and validated to measure progression of MSA, but its use as an outcome measure for therapeutic trials has not been evaluated. On the basis of twelve months of follow-up from an observational study of 67 patients with probable MSA, we evaluated three disease-specific scores: Activities of Daily Living, Motor Examination, and a combined score from the UMSARS and two general health scores, the Physical Health and Mental Health scores of the SF-36 health survey, for their use as outcome measures in a therapeutic trial. We discuss related design issues and provide sample size estimates. Scores based on the disease-specific UMSARS seemed to be equal or superior to scores based on the SF-36 health survey. They appeared to capture disease progression, were well correlated and required the smallest sample size. The UMSARS Motor Examination score exhibited the most favorable characteristics as an outcome measure for a therapeutic trial in MSA with 1 year of follow-up.

Spectroscopic determination of temperature and density spatial profiles and mix in indirect-drive implosion cores

In the field of inertial confinement fusion (ICF), work has been consistently progressing in the past decade toward a more fundamental understanding of the plasma conditions in ICF implosion cores. The research presented here represents a substantial evolution in the ability to diagnose plasma temperatures and densities, along with characteristics of mixing between fuel and shell materials. Mixing is a vital property to study and quantify, since it can significantly affect implosion quality. We employ a number of new spectroscopic techniques that allow us to probe these important quantities. The first technique developed is an emissivity analysis, which uses the emissivity ratio of the optically thin Lybeta and Hebeta lines to spectroscopically extract temperature profiles, followed by the solution of emissivity equations to infer density profiles. The second technique, an intensity analysis, models the radiation transport through the implosion core. The nature of the intensity analysis allows us to use an optically thick line, the Lyalpha, to extract information on mixing near the core edge. With this work, it is now possible to extract directly from experimental data not only detailed temperature and density maps of the core, but also spatial mixing profiles.

G2019S mutation in the leucine-rich repeat kinase 2 gene is not associated with multiple system atrophy

Multiple system atrophy (MSA) is characterized clinically by Parkinsonism, cerebellar dysfunction, and autonomic impairment. Multiple mutations in the LRRK2 gene are associated with parkinsonian disorders, and the most common one, the G2019S mutation, has been found in approximately 1% of sporadic cases of Parkinsonism. In a well-characterized cohort of 136 subjects with probable MSA and 110 neurologically evaluated control subjects, none carried the G2019S mutation. We conclude that the G2019S mutation in the LRRK2 gene is unlikely to be associated with MSA.