EURO-NMD registry: federated FAIR infrastructure, innovative technologies and concepts of a patient-centred registry for rare neuromuscular disorders

BACKGROUND

The EURO-NMD Registry collects data from all neuromuscular patients seen at EURO-NMD's expert centres. In-kind contributions from three patient organisations have ensured that the registry is patient-centred, meaningful, and impactful. The consenting process covers other uses, such as research, cohort finding and trial readiness.

RESULTS

The registry has three-layered datasets, with European Commission-mandated data elements (EU-CDEs), a set of cross-neuromuscular data elements (NMD-CDEs) and a dataset of disease-specific data elements that function modularly (DS-DEs). The registry captures clinical, neuromuscular imaging, neuromuscular histopathology, biological and genetic data and patient-reported outcomes in a computer-interpretable format using selected ontologies and classifications. The EURO-NMD registry is connected to the EURO-NMD Registry Hub through an interoperability layer. The Hub provides an entry point to other neuromuscular registries that follow the FAIR data stewardship principles and enable GDPR-compliant information exchange. Four national or disease-specific patient registries are interoperable with the EURO-NMD Registry, allowing for federated analysis across these different resources.

CONCLUSIONS

Collectively, the Registry Hub brings together data that are currently siloed and fragmented to improve healthcare and advance research for neuromuscular diseases.

Sediment recontamination potential and biological impacts of hydrophobic organics from stormwater in a mixed-use watershed

This study focused on understanding the influence of stormwater on sediment recontamination and biota bioaccumulation. Stormwater and sediment sampling was conducted at Paleta Creek San Diego, CA, a mixed-use urban watershed. Stormwater samples were size fractioned into clay, silt, sand, and filtered fractions to better understand the association of PAHs and PCBs with different particle sizes. Settling traps were deployed during storm seasons to capture solid particles deposited by stormwater. Bioaccumulation studies of the receiving water sediments were conducted on bent-nosed clams (Macoma nasuta) both in-situ and ex-situ. The results indicated that the majority of PAHs and PCBs were discharged during the early stages of the storm and were primarily associated with coarser particles (>20 μm). Sediment near the discharge exhibited higher levels of contaminants, consistent with the findings from the settling traps and stormwater discharges. Ex-situ bioaccumulation studies demonstrated that sediment contamination did not correlate with bioaccumulation in Macoma nasuta, whereas porewater accurately reflected bioaccumulation trends. This study highlights the importance of considering stormwater discharge patterns and particle sizes when assessing sediment recontamination but also that the resulting bulk sediment contamination may not reflect bioavailability as measured by organism bioaccumulation. These insights contribute to a better understanding of the impacts of stormwater runoff on sediment and biota in southern California coastal watersheds, aiding in the development of effective management strategies.

Eupatilin improves cilia defects in human CEP290 ciliopathy models

The photoreceptor outer segment is a highly specialized primary cilium essential for phototransduction and vision. Biallelic pathogenic variants in the cilia-associated gene CEP290 cause non-syndromic Leber congenital amaurosis 10 (LCA10) and syndromic diseases, where the retina is also affected. While RNA antisense oligonucleotides and gene editing are potential treatment options for the common deep intronic variant c.2991+1655A>G in CEP290 , there is a need for variant-independent approaches that could be applied to a broader spectrum of ciliopathies. Here, we generated several distinct human models of CEP290 -related retinal disease and investigated the effects of the flavonoid eupatilin as a potential treatment. Eupatilin improved cilium formation and length in CEP290 LCA10 patient-derived fibroblasts, in gene-edited CEP290 knockout (CEP290 KO) RPE1 cells, and in both CEP290 LCA10 and CEP290 KO iPSCs-derived retinal organoids. Furthermore, eupatilin reduced rhodopsin retention in the outer nuclear layer of CEP290 LCA10 retinal organoids. Eupatilin altered gene transcription in retinal organoids, by modulating the expression of rhodopsin, and by targeting cilia and synaptic plasticity pathways. This work sheds light into the mechanism of action of eupatilin, and supports its potential as a variant-independent approach for CEP290 -associated ciliopathies.

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Environmental Impacts of Hurricane Harvey on the Neches-Brakes Bayou River System in Beaumont, Texas

Hurricane Harvey caused unprecedented floods across large regions of Southeast Texas resulting in several infrastructural issues. One of the notable failures was of a drinking water source pump in Beaumont, Texas, that necessitated the emergency use of a temporary pump intake station in the Neches River system. This study examines the environmental consequences of Harvey-induced flooding in the Neches River system by focusing on sensitive locations, including a Superfund site (International Creosoting, IC) and adjacent to the temporary pump intake. Post-Harvey water samples showed greater than two orders of magnitude increase in polycyclic aromatic hydrocarbons (PAH) about 3 weeks after Harvey (350-420 µg L^-1 on September 22) at locations adjacent to IC and the temporary water pump intake, which by that time was no longer in use. The organic carbon normalized PAH measurements in the heavily contaminated water samples from both locations (~3% w/w) agreed well with surficial soil/sediment samples collected at the east bank adjacent to the IC site (0.7-5.2% w/w). Furthermore, molecular diagnostic ratios of select PAHs supported the contribution of PAHs from the IC site into the surface waters. PAH measurements were consistent with sediment resuspension by floodwaters that were initially diluted by large flows but became more significant as the flood subsided. Overall, our data showed that flooding can cause high levels of contamination weeks after the initial flooding event, with potential for cascading risks through mobilization of pollutants from source areas and impacts to critical water infrastructure systems.

Recommendations by the European Network of Paediatric Research at the European Medicines Agency (Enpr-EMA) Working Group on preparedness of clinical trials about paediatric medicines process

Conduct of clinical trials in babies, children and young people is often hindered by issues that could have been foreseen before the trial opened; that is, some clinical trials are often underprepared. In order to identify a good approach to trial preparedness, the European Network of Paediatric Research at the European Medicines Agency formed a working group. The Working Group included representation from regulators, industry, academics, paediatric clinical research networks and parents.The Working Group consulted widely about how to prepare for paediatric clinical trials. The Group's detailed recommendations have been published (https://www.ema.europa.eu/en/documents/other/preparedness-medicines-clinical-trials-paediatrics-recommendations-enpr-ema-working-group-trial_en.pdf).This paper is a summary of the key recommendations including the following: start early, preferably in parallel to designing the medicine's development plan and individual protocols; identify the rationale and clinical need; listen to the perspectives of children and families, and of patient advocacy groups; identify how many people will be eligible for the trial; identify the resources needed, such as clinical facilities (including play therapy) and out-of-pocket expenditure by participants and their families; use all available data to estimate what is possible; present information about preparedness in a structured way; deploy proportionate resources to support the preparation of trials.A well-prepared, well-designed trial is likely to require fewer changes during its course, be run in a shorter time frame and achieve expected objectives.

Global Collaborative Social Network (Share4Rare) to Promote Citizen Science in Rare Disease Research: Platform Development Study

BACKGROUND

Rare disease communities are spread around the globe and segmented by their condition. Little research has been performed on the majority of rare diseases. Most patients who are affected by a rare disease have no research on their condition because of a lack of knowledge due to absence of common groups in the research community.

OBJECTIVE

We aimed to develop a safe and secure community of rare disease patients, without geographic or language barriers, to promote research.

METHODS

Cocreation design methodology was applied to build Share4Rare, with consultation and input through workshops from a variety of stakeholders (patients, caregivers, clinicians, and researchers).

RESULTS

The workshops allowed us to develop a layered version of the platform based on educating patients and caregivers with publicly accessible information, a secure community for the patients and caregivers, and a research section with the purpose of collecting patient information for analysis, which was the core and final value of the platform.

CONCLUSIONS

Rare disease research requires global collaboration in which patients and caregivers have key roles. Collective intelligence methods implemented in digital platforms reduce geographic and language boundaries and involve patients in a unique and universal project. Their contributions are essential to increase the amount of scientific knowledge that experts have on rare diseases. Share4Rare has been designed as a global platform to facilitate the donation of clinical information to foster research that matters to patients with rare conditions. The codesign methods with patients have been essential to create a patient-centric design.

Propelling Healthcare with Advanced Therapy Medicinal Products: A Policy Discussion

Recent advances in biomedicine are opening the door to new approaches, and treatment and prevention are being transformed by novel medicines based on genetic engineering, innovative cell-based therapies and tissue-engineered products, and combinations of a medical device with embedded cell or tissue components. These advanced therapy medicinal products (ATMPs) hold one of the keys to making a reality of genuinely personalised medicine. There are an estimated 450 companies across the globe working on the development of gene therapies and more than 1,000 clinical trials underway worldwide, and some 20-30 new ATMPs filings are expected in Europe annually over the next 5 years. But challenges confront the sector, complicating the translation from research into patient access. Scientific, clinical development and regulatory issues are compounded by limited experience with clinical and commercial use, limited manufacturing know-how, high costs, and difficulties in accessing development funding and investment. Pricing and reimbursement and market access issues are an additional challenge, particularly in Europe, where unfamiliarity with the technology and uncertainty over the use of real-world evidence induce caution among clinicians, health technology assessment bodies and payers. There is a need for a review of the suitability of the regulatory and market access framework for these products, focused development of data, public/private partnerships, and fuller collaboration governments, doctors, insurers, patients, and pharmaceutical companies. This paper makes specific recommendations for all stakeholders, ranging from early dialogue on potential products, linking of clinical data and patient registries or standardisation of control frameworks, to a comprehensive approach to evidence generation, assessment, pricing, and payment for ATMPs.

Seasonal Toxicity Observed with Amphipods (Eohaustorius estuarius) at Paleta Creek, San Diego Bay, USA

To assess potential impacts on receiving systems, associated with storm water contaminants, laboratory 10-d amphipod (Eohaustorius estuarius) survival toxicity tests were performed using intact sediment cores collected from Paleta Creek (San Diego Bay, CA, USA) on 5 occasions between 2015 and 2017. The approach included deposition-associated sediment particles collected from sediment traps placed at each of 4 locations during the 2015 to 2016 wet seasons. The bioassays demonstrated wet season toxicity, especially closest to the creek mouth, and greater mortality associated with particles deposited in the wet season compared with dry season samples. Grain size analysis of sediment trap material indicated coarser sediment at the mouth of the creek and finer sediment in the outer depositional areas. Contaminant concentrations of metals (Cd, Cu, Hg, Ni, Pb, and Zn) and organic compounds (polycyclic aromatic hydrocarbons [PAHs], polychlorinated biphenyls [PCBs], and pesticides) were quantified to assess possible causes of toxicity. Contaminant concentrations were determined in the top 5 cm of sediment and porewater (using passive samplers). Whereas metals, PAHs, and PCBs were rarely detected at sufficient concentrations to elicit a response, pyrethroid pesticides were highly correlated with amphipod toxicity. Summing individual pyrethroid constituents using a toxic unit approach suggested that toxicity to E. estuarius could be associated with pyrethroids. This unique test design allowed delineation of spatial and temporal differences in toxicity, suggesting that storm water discharge from Paleta Creek may be the source of seasonal toxicity. Environ Toxicol Chem 2019;39:229-239. © 2019 SETAC.

Unmet Medical Need: An Introduction to Definitions and Stakeholder Perceptions

BACKGROUND

Despite increasing informal and formal use of unmet medical need (UMN) in drug development, regulation, and assessment, there is no insight into its definitions in use. This study aims to provide insight into the current definitions in use and to provide a starting point for a multi-stakeholder discussion on alignment.

METHODS

A scoping and a gray literature review were performed to locate definitions of UMN in literature and on stakeholder websites. These definitions were categorized and then discussed among the multi-stakeholder author group via semistructured group discussions and open session workshops with a broader stakeholder audience. Issues with the formation of a common definition and mechanisms for use were discussed.

RESULTS

The reviews yielded 16 definitions. Differences were evident, but all included 1 or more of the following elements: (adequacy of) available treatments (16 of 16: 100%), disease severity or burden (6 of 16: 38%), and patient population size (1 of 16: 6%). The stakeholder discussions led to a suggestion for a definition including the first 2 items and, depending on context, population size. The discussions also showed that quantification of UMN is highly dependent on the scope and the value framework in which it is used based on different stakeholder preferences and responsibilities.

CONCLUSION

We encourage stakeholders that want to promote alignment on the concept of UMN to prospectively discuss the scope in which they want to apply the concept, what elements they find important for consideration in each case, and how they would measure UMN within the broader regulatory or value framework applicable.

4099High intensity endurance and strength training in water polo Olympic team players: impact on arterial wall properties

Background

Regular physical activity is recommended for health improvement. However the upper intensity threshold associated with best health outcome is difficult to determine. Water polo (WP) Olympic athletes present unique characteristics with very high intensity work, long training sessions and a combination of endurance and strength training.

Purpose

To examine how long term, intense mixed endurance and strength training affect peripheral and central hemodynamics and biomarkers of cardiovascular health.

Methods

The study population consisted of 20 WP Olympic team player's, 20 matched recreational active subjects (RA) and 20 sedentary control subjects (Cl). Reflected waves were assessed with the Augmentation index (AIx), central aortic stiffness with pulse wave velocity (PWV) and endothelial function with flow mediated dilation (FMD).

Results

From Cl subjects to RA active subjects and to WP players there was a stepwise decrease in aortic systolic pressure (116±16 mmHg vs. 107±14 mmHg vs. 106±6 mmHg, p=0.03) while there was no difference in branchial systolic pressure (p=0.52). There was also a stepwise improvement in AIx (−4.22±9.97% vs. −6.97±11.28% vs. −12.14±6.62%, p=0.03) and FMD (6.61±1.78% vs. 7.78±1.98% vs. 8.3±2.05%, p=0.04) according to the intensity of exercise and WP players had lower AIx and higher FMD compared to RA subjects and to Cl subjects.

Conclusions

In young WP Olympic team players intense mixed endurance and strength training has no adverse impact on arterial wall properties and endothelial function with a parallel improvement in central hemodynamics. These findings highlight that there are no definitive data to support on any adverse vascular related impact of ultra-endurance training while mixed endurance and strength training may be associated with a favorable vascular profile.

European regulators' views on a wearable-derived performance measurement of ambulation for Duchenne muscular dystrophy regulatory trials

Development of novel therapies for Duchenne muscular dystrophy (DMD) are driving the need for more efficient ways of detecting changes in disease- progression in DMD [1]. However, medicines' approval must be based on outcome measures that are acceptable from a regulatory perspective. In this article, European regulators provide an update on the recent regulatory consideration of a new endpoint (Stride Velocity 95th Centile (SV95C)) that could be used in therapeutic DMD trials. This new endpoint aims to quantify a patient's ambulation directly, reliably and continuously in a home environment with a wearable device.

A multimodal dataset for authoring and editing multimedia content: The MAMEM project

We present a dataset that combines multimodal biosignals and eye tracking information gathered under a human-computer interaction framework. The dataset was developed in the vein of the MAMEM project that aims to endow people with motor disabilities with the ability to edit and author multimedia content through mental commands and gaze activity. The dataset includes EEG, eye-tracking, and physiological (GSR and Heart rate) signals collected from 34 individuals (18 able-bodied and 16 motor-impaired). Data were collected during the interaction with specifically designed interface for web browsing and multimedia content manipulation and during imaginary movement tasks. The presented dataset will contribute towards the development and evaluation of modern human-computer interaction systems that would foster the integration of people with severe motor impairments back into society.

The passive biomechanics of human pelvic collecting lymphatic vessels

The lymphatic system has a major significance in the metastatic pathways in women's cancers. Lymphatic pumping depends on both extrinsic and intrinsic mechanisms, and the mechanical behavior of lymphatic vessels regulates the function of the system. However, data on the mechanical properties and function of human lymphatics are lacking. Our aim is to characterize, for the first time, the passive biomechanical behavior of human collecting lymphatic vessels removed at pelvic lymph node dissection during primary debulking surgeries for epithelial ovarian cancer. Isolated vessels were cannulated and then pressurized at varying levels of applied axial stretch in a calcium-free Krebs buffer. Pressurized vessels were then imaged using multi-photon microscopy for collagen-elastin structural composition and fiber orientation. Both pressure-diameter and force-elongation responses were highly nonlinear, and axial stretching of the vessel served to decrease diameter at constant pressure. Pressure-diameter behavior for the human vessels is very similar to data from rat mesenteric vessels, though the human vessels were approximately 10× larger than those from rats. Multiphoton microscopy revealed the vessels to be composed of an inner layer of elastin with an outer layer of aligned collagen fibers. This is the first study that successfully described the passive biomechanical response and composition of human lymphatic vessels in patients with ovarian cancer. Future work should expand on this knowledge base with investigations of vessels from other anatomical locations, contractile behavior, and the implications on metastatic cell transport.

The Acute Impact of Different Types of Aerobic Exercise on Arterial Wave Reflections and Inflammation

Objectives: Whilst physical activity is linked to cardiovascular health, it has lately been recognized that different types of exercise exert diverse effects on the cardiovascular system. Therefore, we investigated the acute effects of continuous moderate-intensity aerobic exercise (CAE) and high-intensity interval aerobic exercise (hIAE) on arterial function and inflammation. Methods: Twenty healthy men (mean age 22.6 ± 3.3 years) were recruited in this crossover study. Each of the 20 volunteers participated in two separate sessions (hIAE and CAE). The augmentation index (AIx) of aortic pressure waveforms and serum levels of interleukin-17 (IL-17) were measured before and after each exercise session. Results: There were no significant differences in baseline hemodynamic and inflammatory measurements before CAE and hIAE. Compared to baseline, AIx was significantly improved after CAE (p = 0.04), while there was no significant change after hIAE (p = 0.65). Serum levels of IL-17 were significantly elevated after CAE (p = 0.042), while hIAE had no significant effect on IL-17 levels (p = 0.47). Interestingly, there was an inverse association between the elevation of IL-17 levels and the AIx improvement after CAE (p = 0.05). Conclusion: These findings provide additional evidence concerning the cardiovascular effects of different types of exercise training through modification of peripheral hemodynamics and the inflammatory process.

Acute effects of different types of aerobic exercise on endothelial function and arterial stiffness

BACKGROUND

Chronic aerobic exercise training is associated with improved endothelial function and arterial stiffness and favourable long-term cardiovascular effects.

DESIGN

We investigated the acute effects of continuous moderate intensity aerobic exercise (CAE) and high intensity interval aerobic exercise (hIAE) on endothelial function and arterial stiffness in healthy participants.

METHODS

Twenty healthy men were recruited to this cross-over study. They participated in two exercise sessions: (a) CAE, volume at 50% of maximum aerobic work for 30 minutes; and (b) hIAE, interval maximum aerobic work for 30 minutes. Endothelial function was evaluated by flow-mediated dilation in the brachial artery. The carotid femoral pulse wave velocity and the femoral dorsalis pedis pulse wave velocity were measured as indices of central aortic and peripheral arterial stiffness. Measurements were carried out before and immediately after each exercise session.

RESULTS

There was no statistically significant difference in the baseline measurements before CAE and hIAE with respect to flow-mediated dilation, the carotid femoral pulse wave velocity and the femoral dorsalis pedis pulse wave velocity (p = NS). Both CAE and hIAE significantly improved the flow-mediated dilation compared with baseline (p < 0.001). Similarly, the femoral dorsalis pedis pulse wave velocity was improved after CAE and hIAE (p < 0.005), whereas the carotid femoral pulse wave velocity was not significantly affected (p = NS).

CONCLUSION

Both CAE and hIAE can favourably affect endothelial function, suggesting another cardioprotective effect of acute exercise. These types of aerobic exercise have a different impact on the central and peripheral arterial stiffness.

Novel risk factors related to stable angina

Stable angina (SA) pectoris is a common and disabling disorder in patients with coronary artery disease (CAD), with increasing epidemiology and is associated with myocardial infarction and increased mortality. However, within the population of SA patients, an individual's prognosis can vary considerably. Except from conventional risk factors a variety of biomarkers have been evaluated for their prognostic significance in the settings of SA. Novel biomarkers associated with inflammatory status, such as C reactive protein and tumor necrosis factor alpha, with myocardial performance, such as B-type natriuretic peptide, with extracellular matrix remodeling, with vascular calcification such as osteoprotogerin and osteopontin, with myocardial ischemia, such as ischemia modified albumin have been associated with the progression of CAD and with the prognosis of SA patients. Despite the multiplicity of novel biomarkers there is lack of a clinical useful, highly specific for CAD biomarker with the ability to guide treatment decisions. In the context of this evidence in this review article we summarize the so far acquired knowledge of the most promising biomarkers and we discuss the major clinical correlations of novel risk factors with SA physical history, their predictive value for future cardiovascular events and their use in the treatment monitoring of this population.

Abstract 380: Favorable Effects of Flavonoids on Endothelial Function and Arterial Stiffness in Healthy Smokers

Background: Smoking is associated with impaired vascular function. Consumption of concord grape juice (CGJ), a rich source of flavonoids, has previously been shown to have antithrombotic and antioxidant effects and moreover can modify cardiovascular risk factors. In the present study we assessed the hypothesis that CGJ can improve endothelial function and arterial stiffness in healthy smokers.

Methods: We studied the effect of a 2 weeks oral treatment with 7cc/Kg/day of CGJ (Welch’s 100% Concord Grape) in 20 healthy smokers (aged 26±5y) on two occasions (day 0: baseline and day 14). The study was carried out on two separate arms, one with CGJ and one with placebo, according to a randomized, placebo-controlled, double-blind, cross-over design. Measurements were carried out before (pSm) and immediately after (Sm0) cigarette smoking. Endothelial function was evaluated by flow-mediated dilation (FMD) of the brachial artery. Carotid-femoral pulse wave velocity (PWV) was measured as an index of aortic stiffness and augmentation index (AIx) as a measure of arterial wave reflections.

Results: At baseline measurements, compared to pSm, cigarette smoking decreased FMD values (8.58±3.17% vs.5.65±1.98%, p<0.001) and moreover caused an increase in AIx (4.19±9.13% vs. 6.26±9.81%, p=0.013) and PWV (6.02±0.67m/sec vs. 6.21±0.68m/sec, p<0.046). Treatment with CGJ, improved pSm values of: FMD (7.87±2.79% vs. 9.43±2.62%, p=0.024), PWV (6.11±0.58m/sec vs. 5.70±0.6m/sec, p=0.013) and AIx (3.03±7.70% vs. -0.59±8.56%, p=0.016), while there was no statistically significant difference with placebo administration. Finally, compared with placebo, at day 14, treatment with CGJ, blunted the acute smoking-induced increase in PWV (placebo: from 5.67±0.64m/sec Psm to 6.00±0.78m/sec Sm0), (CGJ: from 6.00±0.73m/sec Psm to 6.23±0.66m/sec Sm0) (p=0.012).

Conclusion: Concord grape juice contains specific flavonoids that may improve endothelium-dependent vasodilation and vascular elastic properties of the arterial tree in healthy smokers. Improved endothelial function and decreased arterial stiffness is a potential mechanism by which flavonoids may prevent cardiovascular events.