Miriam Rodrigues

The TREAT‐NMD Duchenne Muscular Dystrophy Registries: Conception, Design, and Utilization by Industry and Academia

Duchenne muscular dystrophy (DMD) is an X‐linked genetic disease, caused by the absence of the dystrophin protein. Although many novel therapies are under development for DMD, there is currently no cure and affected individuals are often confined to a wheelchair by their teens and die in their twenties/thirties. DMD is a rare disease (prevalence <5/10,000). Even the largest countries do not have enough affected patients to rigorously assess novel therapies, unravel genetic complexities, and determine patient outcomes. TREAT‐NMD is a worldwide network for neuromuscular diseases that provides an infrastructure to support the delivery of promising new therapies for patients. The harmonized implementation of national and ultimately global patient registries has been central to the success of TREAT‐NMD. For the DMD registries within TREAT‐NMD, individual countries have chosen to collect patient information in the form of standardized patient registries to increase the overall patient population on which clinical outcomes and new technologies can be assessed. The registries comprise more than 13,500 patients from 31 different countries. Here, we describe how the TREAT‐NMD national patient registries for DMD were established. We look at their continued growth and assess how successful they have been at fostering collaboration between academia, patient organizations, and industry.

Prevalence of Muscular Dystrophies: A Systematic Literature Review

Background: Determining the prevalence of neuromuscular disorders for the general population is important to identify the scope of burden on society and enable comparisons with other health conditions. This systematic review aims to identify and collate the findings of studies published between 1960 and 2013 on the prevalence of all types of muscular dystrophies. Summary: Relevant articles were identified through electronic database searches and manual searches of reference lists. There were 38 articles from across 19 countries that met the inclusion criteria. The total combined prevalence for all muscular dystrophies for studies classified as having a low risk of bias ranged between 19.8 and 25.1 per 100,000 person-years. Myotonic dystrophy (0.5-18.1 per 100,000), Duchenne muscular dystrophy (1.7-4.2) and facioscapulohumeral muscular dystrophy (3.2-4.6 per 100,000) were found to be the most common types of disorder. There was wide variation in study methodology, case ascertainment, and verification procedures and populations studied, all of which may contribute to the wide prevalence range, in addition to the likely variation in prevalence by country. Key Messages: Greater consistency in the conduct and reporting of neuroepidemiological studies is urgently needed to enable comparisons to be made between studies, countries, and over time.

The New Zealand Neuromuscular Disease Registry

The development of effective treatments for neuromuscular diseases is a significant challenge due to difficulties in identifying adequate numbers of patients for clinical trials. Low patient numbers in these rare diseases also has an effect when establishing sound clinical practices based on experience gained from patients with similar diagnosis. The Muscular Dystrophy Association of New Zealand (MDA), working in consort with interested clinicians has established the New Zealand Neuromuscular Disease (NZ NMD) Registry in order to help address these problems. The NZ NMD Registry is exceptional in that it comprises one registry for all neuromuscular conditions and will significantly benefit both patients with neuromuscular disease and their clinicians.

The New Zealand Neuromuscular Disease Registry: rate of diagnoses confirmed by molecular testing.

The New Zealand Neuromuscular Disease Registry (NZ NMD Registry) is part of the TREAT NMD Alliance, an international network that provides infrastructure ensuring the most promising new therapies reach neuromuscular patients as quickly as possible. Its main aim is to ensure that the most promising new therapies reach patients as quickly as possible. From the perspective of researchers interested in trialling treatments it is useful to have data on the pool of potential research participants. From a patients perspective it is important to know what trials they can take part in. Both of these require a confirmed molecular diagnosis in the patient. Some therapeutic strategies not only require knowledge of which gene is affected but are targeted at specific mutations within the gene. In reviewing data held in the NZ NMD Registry it was noted that, of those diagnosed with a genetic condition, only 51% have a confirmed molecular genetic diagnosis. This low rate of genetic diagnosis is a potential barrier to research participation but can be removed with improved genetic technology and with changes in knowledge about and attitudes towards genetic testing.

Peripheral nerve ultrasound in Friedreich ataxia: Nerve Ultrasound in Friedreich Ataxia

Sensory impairment in Friedreich ataxia (FRDA) is generally accepted as being due to a ganglionopathy. The degree of contribution from axonal pathology remains a matter of debate. Nerve ultrasound may be able to differentiate these processes.

The New Zealand Neuromuscular Disease Patient Registry; Five Years and a Thousand Patients

The New Zealand Neuromuscular Disease Patient Registry has been recruiting for five years. Its primary aim is to enable people with neuromuscular disease to participate in research including clinical trials. It has contributed data to large anonymised cohort studies and many feasibility studies, and has provided practical information and advice to researchers wanting to work with people with neuromuscular conditions. 1019 people have enrolled since the Registry’s launch in August 2011 with over 70 different diagnoses. Of these; 8 patients have been involved in clinical trials, 134 in other disease-specific research and 757 have contributed anonymised data to cohort studies. As a result the Registry is now effectively facilitating almost all neuromuscular research currently taking place in New Zealand.

Knowledge of Sub-Types Important to Understanding of the Prevalence of Myotonic Dystrophy

Whilst muscular dystrophies (MDs) are often described as being ‘rare’, the impact these conditions can have on people’s lives and society can be profound and demand attention. MDs are a group of diseases that involve progressive weakness and degeneration of the muscles caused by a genetic mutation. Myotonic dystrophy is one of the more common types of MDs and has 2 identified sub-types (DM1 and DM2) with differing genetic causes. Symptom onset can occur at a young age, but is more commonly observed in early adulthood. With no known cure, treatments focus on symptom management and delaying progression of the condition; consequently, the burden becomes lifelong and in many cases increases over time [1] . Yet, despite the wide burden, epidemiological studies of overall prevalence and sub-type using agestandardized estimates have been lacking. Indeed, whilst standardized methods of reporting have become widespread with other common conditions, such as stroke, there remains a lack of consistency in conditions such as MD. This may be reflected in the considerable variability found in current reported prevalence between 0.5 and 18.1 per 100,000 [2] . In the current issue of Neuroepidemiology, Vanacore and colleagues present the findings of an epidemiological study of MD conducted in Rome, Italy [3]. The study identified cases through a

Eight years after an international workshop on myotonic dystrophy patient registries: case study of a global collaboration for a rare disease

BackgroundMyotonic Dystrophy is the most common form of muscular dystrophy in adults, affecting an estimated 10 per 100,000 people. It is a multisystemic disorder affecting multiple generations with increasing severity. There are currently no licenced therapies to reverse, slow down or cure its symptoms. In 2009 TREAT-NMD (a global alliance with the mission of improving trial readiness for neuromuscular diseases) and the Marigold Foundation held a workshop of key opinion leaders to agree a minimal dataset for patient registries in myotonic dystrophy. Eight years after this workshop, we surveyed 22 registries collecting information on myotonic dystrophy patients to assess the proliferation and utility the dataset agreed in 2009. These registries represent over 10,000 myotonic dystrophy patients worldwide (Europe, North America, Asia and Oceania).ResultsThe registries use a variety of data collection methods (e.g. online patient surveys or clinician led) and have a variety of budgets (from being run by volunteers to annual budgets over €200,000). All registries collect at least some of the originally agreed data items, and a number of additional items have been suggested in particular items on cognitive impact.ConclusionsThe community should consider how to maximise this collective resource in future therapeutic programmes.

S69. Peripheral nerve ultrasound in Friedreich’s ataxia

Introduction Sensory impairment in Friedreich’s ataxia (FRDA) is generally accepted as being due to a ganglionopathy. The degree of contribution from axonal pathology remains a matter of debate. Nerve ultrasound may be able to differentiate these processes. Methods The ultrasound cross-sectional area of median, ulnar, tibial and sural nerves of 8 patients with FRDA was compared with 8 age- and gender-matched healthy controls and with reference values in our population. Results The nerves of the patients with FRDA were significantly larger than healthy controls’ at all upper limb sites ( p 0.05 ) but not significantly different in the lower limbs. Conclusion Our findings add further weight to the theory that dorsal root ganglionopathy is not the sole cause of peripheral sensory loss in FRDA. Peripheral neuropathic processes are likely to also play a role.

Peripheral nerve ultrasound in friedreich’s ataxia

Objectives To investigate peripheral nerve ultrasound findings in patients with Friedreich’s ataxia (FRDA) and their relationship to the complex neuropathology of the somatosensory system in this condition. Methods The ultrasound cross-sectional area of median and ulnar nerves at mid-forearm and mid-humerus level of eight non-diabetic FRDA patients (confirmed by GAA triplet expansion of the frataxin gene) were compared with eight age- and gender-matched healthy controls and with a reference population. All patients had sensory neuropathy with reduced or absent sensory action potentials on electrophysiological tests. Results The mean cross-sectional area of the FRDA patient group was significantly larger than that of the healthy control group at all sites (p<0.05) with maximal differences at mid-humerus level. Seven of the eight FRDA patients had cross-sectional area measurements>2 SDs above our reference mean at one or more sites. Conclusions The ultrasound finding of enlarged peripheral nerves in FRDA patients points to a structural abnormality at peripheral nerve level. This contrasts with the reduced cross-sectional area seen in the cerebellar ataxia, neuronopathy, vestibular areflexia syndrome (CANVAS) which is thought to be due to a pure sensory ganglionopathy (Pelosi et al, Muscle Nerve 2017, in press). While the specific pathophysiology in FRDA is unknown, nerve enlargement suggests, in agreement with recent neuropathological studies, that axonal loss from dorsal root ganglionopathy is not the sole mechanism underlying sensory neuropathy of FRDA. Myelin and/or stromal abnormality at peripheral nerve level may play a significant role.