Identification of LAMA1 mutations ends diagnostic odyssey and has prognostic implications for patients with presumed Joubert syndrome

Paediatric neurology syndromes are a broad and complex group of conditions with a large spectrum of clinical phenotypes. Joubert syndrome is a genetically heterogeneous neurological ciliopathy syndrome with molar tooth sign as the neuroimaging hallmark. We reviewed the clinical, radiological and genetic data for several families with a clinical diagnosis of Joubert syndrome but negative genetic analysis. We detected biallelic pathogenic variants in LAMA1, including novel alleles, in each of the four cases we report, thereby establishing a firm diagnosis of Poretti-Boltshauser syndrome. Analysis of brain MRI revealed cerebellar dysplasia and cerebellar cysts, associated with Poretti-Boltshauser syndrome and the absence of typical molar tooth signs. Using large UK patient cohorts, the relative prevalence of Joubert syndrome as a cause of intellectual disability was 0.2% and of Poretti-Boltshauser syndrome was 0.02%. We conclude that children with congenital brain disorders that mimic Joubert syndrome may have a delayed diagnosis due to poor recognition of key features on brain imaging and the lack of inclusion of LAMA1 on molecular genetic gene panels. We advocate the inclusion of LAMA1 genetic analysis on all intellectual disability and Joubert syndrome gene panels and promote a wider awareness of the clinical and radiological features of these syndromes.

OP0058-PARE MY SJÖGREN’S DIARY: AN ONLINE PATIENT PORTAL FOR PATIENT LED SJÖGREN’S SYNDROME RESEARCH

Background:

Sjögren’s Syndrome is a chronic autoimmune disease affecting the exocrine glands accompanied by variable extra-glandular manifestations. Symptom flares, including dry eyes, dry mouth, dry skin, fatigue, myalgia and arthralgia, are frequent. Many of these symptoms have a considerable impact on quality of life, but are variable, sensitive to external factors, and difficult to measure objectively.

Clinical research on Sjögren’s Syndrome is advancing with the help of patient registries: an array of clinical data is collected and available for approved studies. However, many of these registries focus on collecting clinical information and often fail to capture the diverse patient experience adequately. Thus, there is an unmet need for an online ‘patient portal’, secure and encrypted with the capability of interacting with existing registries, while also patient-facing to encourage active involvement in research and personal healthcare. Patient demand for this resource was highlighted in 2017 when the Cambridgeshire regional support group of the British Sjögren’s Syndrome Association (BSSA) contacted the Patient Led Research Hub (PLRH). The PLRH provides research expertise to co-produce research ideas with patient organisations1; the PLRH and Cambridgeshire group have since secured funding and initiated work on this project with the Cambridge Clinical Trials Unit.

Objectives:

Develop ‘My Sjögren’s Diary’ a cross-platform patient portal to:

1.Act as an interactive tool to help patients manage their healthcare needs and aid communication with healthcare providers.

2.Function as a research platform, enabling patients to consent to contact, as well as support home-based data entry, allowing real-time capture of symptom scores and ensuring ease of participation for patients. Link with the UK Primary Sjögren’s Syndrome Registry and NHS Digital to provide complementary clinical datasets.

Methods:

The PLRH has coordinated a team of rheumatologists, database programmers, patients and family members to develop My Sjögren’s Diary. Regular meetings, national surveys and correspondence with patients ensures the project remains relevant to patient needs, while collaborating with rheumatologists ensures the database is reliable, valid and of benefit to clinical care. Workshops hosted at key stages of database development have allowed both patients and rheumatologists to direct and refine My Sjögren’s Diary. A prototype was presented at the 2019 BSSA Annual Conference before further improvements and beta release.

Results:

A beta version of My Sjögren’s Diary enabling BSSA members to track their medication and symptoms is now active. Feedback will be incorporated into the final version before it is publicly available to Sjögren’s Syndrome patients. Further funding is required to develop the research platform.

Conclusion:

My Sjögren’s Diary encourages equal partnership between patients, clinicians and researchers. It presents a unique opportunity for comprehensive analysis of Sjögren’s Syndrome and associated health utilities. Research participation is not mandatory, encouraging all patients to have an active role in personal healthcare management.

References:

[1]Mader LB, Harris T, Kläger S, Wilkinson IB, Hiemstra TF. Inverting the patient involvement paradigm: defining patient led research.Research Involvement and Engagement4, 21 (2018).

Acknowledgments:

Thank you to Cambridgeshire and North Eastern BSSA regional support groups for ongoing review of the portal’s usability, function and design. Thank you to BSSA for project funding, and to the Cambridge Clinical Trials Unit and University of Cambridge Medical Library for providing workshop facilities.

Disclosure of Interests:

None declared

Better governance, better access: practising responsible data sharing in the METADAC governance infrastructure

BACKGROUND

Genomic and biosocial research data about individuals is rapidly proliferating, bringing the potential for novel opportunities for data integration and use. The scale, pace and novelty of these applications raise a number of urgent sociotechnical, ethical and legal questions, including optimal methods of data storage, management and access. Although the open science movement advocates unfettered access to research data, many of the UK's longitudinal cohort studies operate systems of managed data access, in which access is governed by legal and ethical agreements between stewards of research datasets and researchers wishing to make use of them. Amongst other things, these agreements aim to respect the reasonable expectations of the research participants who provided data and samples, as expressed in the consent process. Arguably, responsible data management and governance of data and sample use are foundational to the consent process in longitudinal studies and are an important source of trustworthiness in the eyes of those who contribute data to genomic and biosocial research.

METHODS

This paper presents an ethnographic case study exploring the foundational principles of a governance infrastructure for Managing Ethico-social, Technical and Administrative issues in Data ACcess (METADAC), which are operationalised through a committee known as the METADAC Access Committee. METADAC governs access to phenotype, genotype and 'omic' data and samples from five UK longitudinal studies.

FINDINGS

Using the example of METADAC, we argue that three key structural features are foundational for practising responsible data sharing: independence and transparency; interdisciplinarity; and participant-centric decision-making. We observe that the international research community is proactively working towards optimising the use of research data, integrating/linking these data with routine data generated by health and social care services and other administrative data services to improve the analysis, interpretation and utility of these data. The governance of these new complex data assemblages will require a range of expertise from across a number of domains and disciplines, including that of study participants. Human-mediated decision-making bodies will be central to ensuring achievable, reasoned and responsible decisions about the use of these data; the METADAC model described in this paper provides an example of how this could be realised.

Establishing the feasibility of a community and primary health care intervention to raise awareness of symptoms of Type 1 Diabetes-The Early Detection of Type 1 Diabetes in Youth (EDDY) study

AIMS

To design, develop, and evaluate the feasibility of delivering a multi-component community based intervention to parents and primary health care professionals to raise awareness of the symptoms of Type 1 diabetes (T1D) in childhood in 3 adjoining borough counties of South Wales.

MATERIALS AND METHODS

Parent and primary health care advisory groups were established to design the intervention. Qualitative interviews with stakeholders and parents assessed the acceptability, feasibility and any potential impact of the intervention.

RESULTS

The parent component of the intervention developed was a re-useable shopping bag with the 4 main symptoms of T1D illustrated on the side, based on the road traffic system of red warning triangles and an octagon "stop" sign stating "Seek Medical Help". Accompanying the bag was an A5 leaflet giving further information. Both were overwrapped with clear plastic and delivered to 98% (323/329) schools, equating to 101 371 children. The primary health care professional component was a dual glucose/ketone meter, single use lancets, stickers, the A5 parent leaflet displayed as a poster and an educational visit from a Community Diabetes Liaison Nurse. 87% (73/84) of GP practices received the intervention, 100% received the materials. The intervention was delivered within Cardiff, the Vale of Glamorgan and Bridgend. Qualitative analyses suggest that the intervention raised awareness and had some impact.

CONCLUSION

This study showed that it is feasible and acceptable to design, develop and deliver a community based intervention to raise awareness of T1D. There is some suggestion of impact but a definitive evaluation of effectiveness is still required.

What can we Learn from Patients' Ethical Thinking about the right 'not to know' in Genomics? Lessons from Cancer Genetic Testing for Genetic Counselling

This article is based on a qualitative empirical project about a distinct kinship group who were among the first identified internationally as having a genetic susceptibility to cancer (Lynch Syndrome). 50 were invited to participate (42 were tested; eight declined genetic testing). 15, who had all accepted testing, were interviewed. They form a unique case study. This study aimed to explore interviewees' experiences of genetic testing and how these influenced their family relationships. A key finding was that participants framed the decision to be tested as 'common sense'; the idea of choice around the decision was negated and replaced by a moral imperative to be tested. Those who did not follow 'common sense' were judged to be imprudent. Family members who declined testing were discussed negatively by participants. The article addresses what is ethically problematic about how test decliners were discussed and whether these ethical concerns extend to others who are offered genetic testing. Discussions showed that genetic testing was viewed as both an autonomous choice and a responsibility. Yet the apparent conflict between the right to autonomy and the moral imperative of responsibility allowed participants to defend test decliners' decisions by expressing a preference for or defending choice over responsibility. The 'right not to know' seemed an important moral construct to help ethically manage unpopular decisions made by close family who declined testing. In light of this research, the erosion of the 'right not to know' in the genomic age could have subtle yet profound consequences for family relationships.

Report from the UK and Eire Association of Genetic Nurses and Counsellors (AGNC) supervision working group on genetic counselling supervision

The Association of Genetic Nurses and Counsellors (AGNC) is the professional organisation which represents genetic counsellors and genetic nurses in the United Kingdom (UK) and Eire. The AGNC recognises that genetic counselling supervision is instrumental to the practice, training and registration of genetic counsellors in the UK. The AGNC formed a Supervision Working Group, whose terms of reference were to collate information on supervision and create a list of 'best practice' recommendations for its genetic counsellor members. This report delivers the findings from the Supervision Working Group and has been peer reviewed by the AGNC membership in the UK and Eire and ratified by the AGNC Committee. It offers a working definition of genetic counselling supervision, gives an overview of some of the literature on supervision and concludes with practice recommendations.

Editorial on supervision

This Editorial provides background information to inform the report from the United Kingdom (UK) and Eire Association of Genetic Nurses and Counsellors (AGNC) Supervision Working Group on Genetic Counselling Supervision. We begin by introducing the context of practice as a genetic counselor in the UK and then follow with an overview of events that have happened in our profession that led to the need and creation of the report. Genetic counseling supervision has become instrumental to our practice, training and registration as genetic counselors in the UK.

How women receiving adjuvant chemotherapy for breast cancer cope with their treatment: a risk management perspective

Retrospective interviews were undertaken with 12 women who had received an 18-week course of adjuvant chemotherapy for positive node breast cancer 1 year previously, and who had not experienced cancer recurrence. The nonstandardized interviews covered women's preconceptions about adjuvant chemotherapy, their information needs, and the impact of treatment. The qualitative data analysis drew upon the theoretical ideas of patient career, trajectory projection and qualitative risk analysis. Some women regarded adjuvant chemotherapy as no more than an 'insurance policy'. This perception may have arisen because doctors, attempting to minimize patient anxiety, did not discuss the high risk of disease recurrence which they faced. Other women equated adjuvant with curative chemotherapy, and anticipated hair loss or almost certain death. The women tried to cope with the physical and mental suffering associated with adjuvant chemotherapy through normalizing strategies, such as keeping a brave face, maintaining previous patterns of life, looking for humour and restructuring time. However, the rapid alterations in physical and mental state resulting from cycles of adjuvant chemotherapy resulted in a 'rollercoaster' experience for women which made normalization more difficult. Health professionals caring for women who must cope with uncertain future trajectories need to manage a risk communication dilemma. A strategy of fully informing women about the risks they face may cause anxiety or depression, and even impede recovery, given the evidence for psychological influences on health outcomes. But, if women do not understand the medical thinking on which their treatment is based, their misconceptions may be equally damaging.

Hephaestin, a ceruloplasmin homologue implicated in intestinal iron transport, is defective in the sla mouse

Iron is essential for many cellular functions; consequently, disturbances of iron homeostasis, leading to either iron deficiency or iron overload, can have significant clinical consequences. Despite the clinical prevalence of these disorders, the mechanism by which dietary iron is absorbed into the body is poorly understood. We have identified a key component in intestinal iron transport by study of the sex-linked anaemia (sla) mouse, which has a block in intestinal iron transport. Mice carrying the sla mutation develop moderate to severe microcytic hypochromic anaemia. Although these mice take up iron from the intestinal lumen into mature epithelial cells normally, the subsequent exit of iron into the circulation is diminished. As a result, iron accumulates in enterocytes and is lost during turnover of the intestinal epithelium. Biochemical studies have failed to identify the underlying difference between sla and normal mice, therefore, we used a genetic approach to identify the gene mutant in sla mice. We describe here a novel gene, Heph, encoding a transmembrane-bound ceruloplasmin homologue that is mutant in the sla mouse and highly expressed in intestine. We suggest that the hephaestin protein is a multicopper ferroxidase necessary for iron egress from intestinal enterocytes into the circulation and that it is an important link between copper and iron metabolism in mammals.

Mapping the gene for sex-linked anemia: an inherited defect of intestinal iron absorption in the mouse

The sex-linked anemic (sla) mouse carries an anemia that results from an inherited defect of intestinal iron absorption and provides an ideal model with which to investigate this poorly understood yet clinically important process. We have precisely mapped the sla locus within the central region of the X chromosome in relation to a panel of microsatellite markers. Analysis of over 500 progeny from an intraspecific intercross and a smaller intraspecific backcross segregating sla established the following locus order in the sla region: DXMit45-sla- (DXMit16, DXMit96)-DXMit41-DXMit169-DXMit170- DXMit148-(DXMit18, DXMit171)-DXMit84-DXMit64. The two microsatellites DXMit16 and DXMit96 are located 0.60 +/- 0.35cM from sla and form the telomeric limit of the sla region. The mapping of the sla locus is an important first step to identifying the gene itself.

Activation of lysosomal acid phosphatase of eosinophil leukocytes

Acid phosphatase (AP) within the specific granules of eosinophils is held in a latent, inactive form prior to degranulation. Eosinophils responded to membrane stimuli with activation of AP throughout the granules of the cell, prior to degranulation. Activation occurred within the time required for fixation of the cells by glutaraldehyde. Whereas resting normal eosinophils demonstrated AP activity in 7.8 +/- 1.2 per cent of the granules, cells stimulated with opsonized staphylococci demonstrated activity in 78.9 +/- 5.0 per cent of the granules, and the amount of lead phosphate reactant deposited per active granule was considerably more intense in the stimulated than in the unstimulated cells. A similar stimulation of AP activity in eosinophils occurred with exposure to the surface-active agent phorbol myristate acetate or the calcium ionophore A23187. Activation was not altered by 5 microgram. per ml. of cytochalasin B or 4 x 10(-6) M colchicine. These aspects of the response closely parallel the stimulation of oxidative metabolism of eosinophils; however, the two were separable. Eosinophils obtained from a patient with chronic granulomatous disease, although unable to activate the normal oxidative metabolic burst, demonstrated a normal activation of AP.