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Eriksson MH, Prentice F, Piper RJ, Wagstyl K, Adler S, Chari A, Booth J, Moeller F, Das K, Eltze C, Cooray G, Perez Caballero A, Menzies L, McTague A, Shavel-Jessop S, Tisdall MM, Cross JH, Martin Sanfilippo P, Baldeweg T. Long-term neuropsychological trajectories in children with epilepsy: does surgery halt decline? Brain 2024:awae121. [PMID: 38643018 DOI: 10.1093/brain/awae121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/29/2024] [Accepted: 03/16/2024] [Indexed: 04/22/2024] Open
Abstract
Neuropsychological impairments are common in children with drug-resistant epilepsy. It has been proposed that epilepsy surgery may alleviate these impairments by providing seizure freedom; however, findings from prior studies have been inconsistent. We mapped long-term neuropsychological trajectories in children before and after undergoing epilepsy surgery, to measure the impact of disease course and surgery on functioning. We performed a retrospective cohort study of 882 children who had undergone epilepsy surgery at Great Ormond Street Hospital (1990-2018). We extracted patient information and neuropsychological functioning - obtained from IQ tests (domains: Full-Scale IQ, Verbal IQ, Performance IQ, Working Memory, and Processing Speed) and tests of academic attainment (Reading, Spelling and Numeracy) - and investigated changes in functioning using regression analyses. We identified 500 children (248 females) who had undergone epilepsy surgery (median age at surgery = 11.9 years, interquartile range = [7.8,15.0]) and neuropsychology assessment. These children showed declines in all domains of neuropsychological functioning in the time leading up to surgery (all p-values ≤ 0.001; e.g., βFSIQ = -1.9, SEFSIQ = 0.3, pFSIQ < 0.001). Children lost on average one to four points per year, depending on the domain considered; 27-43% declined by 10 or more points from their first to their last preoperative assessment. At the time of presurgical evaluation, most children (46-60%) scored one or more standard deviations below the mean (<85) on the different neuropsychological domains; 37% of these met the threshold for intellectual disability (Full-Scale IQ < 70). On a group level, there was no change in performance from pre- to postoperative assessment on any of the domains (all p-values > 0.128). However, children who became seizure-free through surgery showed higher postoperative neuropsychological performance (e.g., rrb-FSIQ = 0.37, p < 0.001). These children continued to demonstrate improvements in neuropsychological functioning over the course of their long-term follow-up (e.g., βFSIQ = 0.9, SEFSIQ = 0.3, pFSIQ = 0.004). Children who had discontinued antiseizure medication (ASM) treatment at one-year follow-up showed an eight-to-13-point advantage in postoperative Working Memory, Processing Speed, and Numeracy, and greater improvements in Verbal IQ, Working Memory, Reading, and Spelling (all p-values < 0.034) over the postoperative period compared to children who were seizure-free and still receiving ASMs. In conclusion, by providing seizure freedom and the opportunity for ASM cessation, epilepsy surgery may not only halt but reverse the downward trajectory that children with drug-resistant epilepsy display in neuropsychological functioning. To halt this decline as soon as possible, or potentially prevent it from occurring in the first place, children with focal epilepsy should be considered for epilepsy surgery as early as possible after diagnosis.
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Affiliation(s)
- Maria H Eriksson
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Department of Neurology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Freya Prentice
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Rory J Piper
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Konrad Wagstyl
- Imaging Neuroscience, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
| | - Sophie Adler
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Aswin Chari
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - John Booth
- Digital Research Environment, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Friederike Moeller
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Krishna Das
- Department of Neurology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Christin Eltze
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Gerald Cooray
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Clinical Neuroscience, Karolinska Institutet, Solna 171 77, Sweden
| | - Ana Perez Caballero
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Lara Menzies
- Department of Clinical Genetics, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Amy McTague
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Clinical Genetics, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Sara Shavel-Jessop
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Martin M Tisdall
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - J Helen Cross
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neurology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Young Epilepsy, Lingfield RH7 6PW, UK
| | - Patricia Martin Sanfilippo
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Torsten Baldeweg
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
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Sidpra J, Sudhakar S, Biswas A, Massey F, Turchetti V, Lau T, Cook E, Alvi JR, Elbendary HM, Jewell JL, Riva A, Orsini A, Vignoli A, Federico Z, Rosenblum J, Schoonjans AS, de Wachter M, Delgado Alvarez I, Felipe-Rucián A, Haridy NA, Haider S, Zaman M, Banu S, Anwaar N, Rahman F, Maqbool S, Yadav R, Salpietro V, Maroofian R, Patel R, Radhakrishnan R, Prabhu SP, Lichtenbelt K, Stewart H, Murakami Y, Löbel U, D'Arco F, Wakeling E, Jones W, Hay E, Bhate S, Jacques TS, Mirsky DM, Whitehead MT, Zaki MS, Sultan T, Striano P, Jansen AC, Lequin M, de Vries LS, Severino M, Edmondson AC, Menzies L, Campeau PM, Houlden H, McTague A, Efthymiou S, Mankad K. The clinical and genetic spectrum of inherited glycosylphosphatidylinositol deficiency disorders. Brain 2024:awae056. [PMID: 38456468 DOI: 10.1093/brain/awae056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/31/2023] [Accepted: 01/28/2024] [Indexed: 03/09/2024] Open
Abstract
Inherited glycosylphosphatidylinositol deficiency disorders (IGDs) are a group of rare multisystem disorders arising from pathogenic variants in glycosylphosphatidylinositol anchor pathway (GPI-AP) genes. Despite associating 24 of at least 31 GPI-AP genes with human neurogenetic disease, prior reports are limited to single genes without consideration of the GPI-AP as a whole and with limited natural history data. In this multinational retrospective observational study, we systematically analyse the molecular spectrum, phenotypic characteristics, and natural history of 83 individuals from 75 unique families with IGDs, including 70 newly reported individuals: the largest single cohort to date. Core clinical features were developmental delay or intellectual disability (DD/ID, 90%), seizures (83%), hypotonia (72%), and motor symptoms (64%). Prognostic and biologically significant neuroimaging features included cerebral atrophy (75%), cerebellar atrophy (60%), callosal anomalies (57%), and symmetric restricted diffusion of the central tegmental tracts (60%). Sixty-one individuals had multisystem involvement including gastrointestinal (66%), cardiac (19%), and renal (14%) anomalies. Though dysmorphic features were appreciated in 82%, no single dysmorphic feature had a prevalence >30%, indicating substantial phenotypic heterogeneity. Follow-up data were available for all individuals, 15 of whom were deceased at the time of writing. Median age at seizure onset was 6 months. Individuals with variants in synthesis stage genes of the GPI-AP exhibited a significantly shorter time to seizure onset than individuals with variants in transamidase and remodelling stage genes of the GPI-AP (P=0.046). Forty individuals had intractable epilepsy. The majority of individuals experienced delayed or absent speech (95%); motor delay with non-ambulance (64%); and severe-to-profound DD/ID (59%). Individuals with a developmental epileptic encephalopathy (51%) were at greater risk of intractable epilepsy (P=0.003), non-ambulance (P=0.035), ongoing enteral feeds (P<0.001), and cortical visual impairment (P=0.007). Serial neuroimaging showed progressive cerebral volume loss in 87.5% and progressive cerebellar atrophy in 70.8%, indicating a neurodegenerative process. Genetic analyses identified 93 unique variants (106 total), including 22 novel variants. Exploratory analyses of genotype-phenotype correlations using unsupervised hierarchical clustering identified novel genotypic predictors of clinical phenotype and long-term outcome with meaningful implications for management. In summary, we expand both the mild and severe phenotypic extremities of the IGDs; provide insights into their neurological basis; and, vitally, enable meaningful genetic counselling for affected individuals and their families.
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Affiliation(s)
- Jai Sidpra
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
| | - Sniya Sudhakar
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Asthik Biswas
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Flavia Massey
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery, London, WC1N 3BG, UK
| | - Valentina Turchetti
- Department of Neuromuscular Disorders, University College London Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Tracy Lau
- Department of Neuromuscular Disorders, University College London Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Edward Cook
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Javeria Raza Alvi
- Department of Paediatric Neurology, The Children's Hospital and the University of Child Health Sciences, Lahore, Punjab 54000, Pakistan
| | - Hasnaa M Elbendary
- Department of Clinical Genetics, Human Genetics and Genome Research Institute, National Research Centre, Dokki, Cairo 12622, Egypt
| | - Jerry L Jewell
- Department of Paediatric Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Antonella Riva
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova and IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy
| | - Alessandro Orsini
- Department of Paediatric Neurology, University Hospital of Pisa, 56126 Pisa, Italy
| | - Aglaia Vignoli
- Childhood and Adolescence Neurology and Psychiatry Unit, ASST GOM Niguarda, Health Sciences Department, Università degli Studi di Milano, 20142 Milano, Italy
| | - Zara Federico
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova and IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy
- Childhood and Adolescence Neurology and Psychiatry Unit, ASST GOM Niguarda, Health Sciences Department, Università degli Studi di Milano, 20142 Milano, Italy
| | - Jessica Rosenblum
- Department of Clinical Genetics, Antwerp University Hospital, University of Antwerp, 2650 Edegem, Belgium
| | - An-Sofie Schoonjans
- Department of Paediatric Neurology, Antwerp University Hospital, University of Antwerp, 2650 Edegem, Belgium
| | - Matthias de Wachter
- Department of Paediatric Neurology, Antwerp University Hospital, University of Antwerp, 2650 Edegem, Belgium
| | | | - Ana Felipe-Rucián
- Department of Paediatric Neurology, Vall d'Hebron University Hospital, 08035 Barcelona, Spain
| | - Nourelhoda A Haridy
- Department of Neurology, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Shahzad Haider
- Department of Paediatrics, Wah Medical College NUMS, Wah Cantonment, Punjab 47000, Pakistan
| | - Mashaya Zaman
- Department of Paediatric Neurology and Development, Dr M.R. Khan Shishu Hospital and Institute of Child Health, Dhaka 1216, Bangladesh
| | - Selina Banu
- Department of Paediatric Neurology and Development, Dr M.R. Khan Shishu Hospital and Institute of Child Health, Dhaka 1216, Bangladesh
| | - Najwa Anwaar
- Department of Paediatrics, The Children's Hospital and the University of Child Health Sciences, Lahore, Punjab 54000, Pakistan
| | - Fatima Rahman
- Department of Paediatrics, The Children's Hospital and the University of Child Health Sciences, Lahore, Punjab 54000, Pakistan
| | - Shazia Maqbool
- Department of Paediatrics, The Children's Hospital and the University of Child Health Sciences, Lahore, Punjab 54000, Pakistan
| | - Rashmi Yadav
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Vincenzo Salpietro
- Department of Neuromuscular Disorders, University College London Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Reza Maroofian
- Department of Neuromuscular Disorders, University College London Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Rajan Patel
- Department of Paediatric Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Houston, TX 77030, USA
| | - Rupa Radhakrishnan
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Sanjay P Prabhu
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Klaske Lichtenbelt
- Department of Clinical Genetics, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Helen Stewart
- Oxford Centre for Genomic Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7HE, UK
| | - Yoshiko Murakami
- Laboratory of Immunoglycobiology, Research Institute for Microbial Diseases, Osaka University, Osaka 565, Japan
| | - Ulrike Löbel
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Felice D'Arco
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Emma Wakeling
- Department of Clinical Genetics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Wendy Jones
- Department of Clinical Genetics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Eleanor Hay
- Department of Clinical Genetics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Sanjay Bhate
- Department of Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Thomas S Jacques
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - David M Mirsky
- Department of Neuroradiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Matthew T Whitehead
- Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Maha S Zaki
- Department of Clinical Genetics, Human Genetics and Genome Research Institute, National Research Centre, Dokki, Cairo 12622, Egypt
| | - Tipu Sultan
- Department of Paediatric Neurology, The Children's Hospital and the University of Child Health Sciences, Lahore, Punjab 54000, Pakistan
| | - Pasquale Striano
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova and IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy
| | - Anna C Jansen
- Department of Paediatric Neurology, Antwerp University Hospital, University of Antwerp, 2650 Edegem, Belgium
| | - Maarten Lequin
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | | | - Andrew C Edmondson
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Lara Menzies
- Department of Clinical Genetics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Philippe M Campeau
- Department of Paediatrics, CHU Sainte Justine Research Centre, University of Montreal, Montreal, Canada, QC H3T 1C5
| | - Henry Houlden
- Department of Neuromuscular Disorders, University College London Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Amy McTague
- Department of Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
- Developmental Neurosciences, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
| | - Stephanie Efthymiou
- Department of Neuromuscular Disorders, University College London Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Kshitij Mankad
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK
- Department of Neuroradiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
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3
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Lee S, Menzies L, Hay E, Ochoa E, Docquier F, Rodger F, Deshpande C, Foulds NC, Jacquemont S, Jizi K, Kiep H, Kraus A, Löhner K, Morrison PJ, Popp B, Richardson R, van Haeringen A, Martin E, Toribio A, Li F, Jones WD, Sansbury FH, Maher ER. Epigenotype-genotype-phenotype correlations in SETD1A and SETD2 chromatin disorders. Hum Mol Genet 2023; 32:3123-3134. [PMID: 37166351 PMCID: PMC10630252 DOI: 10.1093/hmg/ddad079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/07/2023] [Accepted: 05/09/2023] [Indexed: 05/12/2023] Open
Abstract
Germline pathogenic variants in two genes encoding the lysine-specific histone methyltransferase genes SETD1A and SETD2 are associated with neurodevelopmental disorders (NDDs) characterized by developmental delay and congenital anomalies. The SETD1A and SETD2 gene products play a critical role in chromatin-mediated regulation of gene expression. Specific methylation episignatures have been detected for a range of chromatin gene-related NDDs and have impacted clinical practice by improving the interpretation of variant pathogenicity. To investigate if SETD1A and/or SETD2-related NDDs are associated with a detectable episignature, we undertook targeted genome-wide methylation profiling of > 2 M CpGs using a next-generation sequencing-based assay. A comparison of methylation profiles in patients with SETD1A variants (n = 6) did not reveal evidence of a strong methylation episignature. A review of the clinical and genetic features of the SETD2 patient group revealed that, as reported previously, there were phenotypic differences between patients with truncating mutations (n = 4, Luscan-Lumish syndrome; MIM:616831) and those with missense codon 1740 variants [p.Arg1740Trp (n = 4) and p.Arg1740Gln (n = 2)]. Both SETD2 subgroups demonstrated a methylation episignature, which was characterized by hypomethylation and hypermethylation events, respectively. Within the codon 1740 subgroup, both the methylation changes and clinical phenotype were more severe in those with p.Arg1740Trp variants. We also noted that two of 10 cases with a SETD2-NDD had developed a neoplasm. These findings reveal novel epigenotype-genotype-phenotype correlations in SETD2-NDDs and predict a gain-of-function mechanism for SETD2 codon 1740 pathogenic variants.
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Affiliation(s)
- Sunwoo Lee
- Department of Medical Genetics, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Lara Menzies
- Department of Clinical Genetics, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - Eleanor Hay
- Department of Clinical Genetics, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - Eguzkine Ochoa
- Department of Medical Genetics, University of Cambridge, Cambridge CB2 0QQ, UK
| | - France Docquier
- Department of Medical Genetics, University of Cambridge, Cambridge CB2 0QQ, UK
- Stratified Medicine Core Laboratory NGS Hub, Department of Medical Genetics, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Fay Rodger
- Department of Medical Genetics, University of Cambridge, Cambridge CB2 0QQ, UK
- Stratified Medicine Core Laboratory NGS Hub, Department of Medical Genetics, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Charu Deshpande
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Saint Mary’s Hospital, Manchester, UK
| | - Nicola C Foulds
- Wessex Clinical Genetics Services, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sébastien Jacquemont
- CHU Sainte-Justine Research Centre, Montreal, Quebec, Canada
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Khadije Jizi
- CHU Sainte-Justine Research Centre, Montreal, Quebec, Canada
| | - Henriette Kiep
- Department of Neuropediatrics, University Hospital for Children and Adolescents, Leipzig, Germany
| | - Alison Kraus
- Yorkshire Regional Genetics Service, Chapel Allerton Hospital, Leeds, UK
| | - Katharina Löhner
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Patrick J Morrison
- Patrick G Johnston Centre for Cancer Research and Cell Biology, Queens University Belfast, Belfast, UK
| | - Bernt Popp
- Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
- Center of Functional Genomics, Berlin Institute of Health at Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Ruth Richardson
- Northern Genetics Service, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Arie van Haeringen
- Department of Clinical Genetics, Leiden University Hospital, Leiden, The Netherlands
| | - Ezequiel Martin
- Department of Medical Genetics, University of Cambridge, Cambridge CB2 0QQ, UK
- Stratified Medicine Core Laboratory NGS Hub, Department of Medical Genetics, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Ana Toribio
- Department of Medical Genetics, University of Cambridge, Cambridge CB2 0QQ, UK
- Stratified Medicine Core Laboratory NGS Hub, Department of Medical Genetics, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Fudong Li
- MOE Key Laboratory for Cellular Dynamics, The School of Life Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230026, China
| | - Wendy D Jones
- Department of Clinical Genetics, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - Francis H Sansbury
- All Wales Medical Genomics Service, NHS Wales Cardiff and Vale University Health Board and Institute of Medical Genetics, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Eamonn R Maher
- Department of Medical Genetics, University of Cambridge, Cambridge CB2 0QQ, UK
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4
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Eriksson MH, Whitaker KJ, Booth J, Piper RJ, Chari A, Sanfilippo PM, Caballero AP, Menzies L, McTague A, Adler S, Wagstyl K, Tisdall MM, Cross JH, Baldeweg T. Pediatric epilepsy surgery from 2000 to 2018: Changes in referral and surgical volumes, patient characteristics, genetic testing, and postsurgical outcomes. Epilepsia 2023; 64:2260-2273. [PMID: 37264783 PMCID: PMC7615891 DOI: 10.1111/epi.17670] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Neurosurgery is a safe and effective form of treatment for select children with drug-resistant epilepsy. Still, there is concern that it remains underutilized, and that seizure freedom rates have not improved over time. We investigated referral and surgical practices, patient characteristics, and postoperative outcomes over the past two decades. METHODS We performed a retrospective cohort study of children referred for epilepsy surgery at a tertiary center between 2000 and 2018. We extracted information from medical records and analyzed temporal trends using regression analyses. RESULTS A total of 1443 children were evaluated for surgery. Of these, 859 (402 females) underwent surgical resection or disconnection at a median age of 8.5 years (interquartile range [IQR] = 4.6-13.4). Excluding palliative procedures, 67% of patients were seizure-free and 15% were on no antiseizure medication (ASM) at 1-year follow-up. There was an annual increase in the number of referrals (7%, 95% confidence interval [CI] = 5.3-8.6; p < .001) and surgeries (4% [95% CI = 2.9-5.6], p < .001) over time. Duration of epilepsy and total number of different ASMs trialed from epilepsy onset to surgery were, however, unchanged, and continued to exceed guidelines. Seizure freedom rates were also unchanged overall but showed improvement (odds ratio [OR] 1.09, 95% CI = 1.01-1.18; p = .027) after adjustment for an observed increase in complex cases. Children who underwent surgery more recently were more likely to be off ASMs postoperatively (OR 1.04, 95% CI = 1.01-1.08; p = .013). There was a 17% annual increase (95% CI = 8.4-28.4, p < .001) in children identified to have a genetic cause of epilepsy, which was associated with poor outcome. SIGNIFICANCE Children with drug-resistant epilepsy continue to be put forward for surgery late, despite national and international guidelines urging prompt referral. Seizure freedom rates have improved over the past decades, but only after adjustment for a concurrent increase in complex cases. Finally, genetic testing in epilepsy surgery patients has expanded considerably over time and shows promise in identifying patients in whom surgery is less likely to be successful.
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Affiliation(s)
- Maria H Eriksson
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neuropsychology, Great Ormond Street Hospital NHS Trust, London, UK
- The Alan Turing Institute, London, UK
- Department of Neurology, Great Ormond Street Hospital NHS Trust, London, UK
| | | | - John Booth
- Digital Research Environment, Great Ormond Street Hospital NHS Trust, London, UK
| | - Rory J Piper
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurosurgery, Great Ormond Street Hospital NHS Trust, London, UK
| | - Aswin Chari
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurosurgery, Great Ormond Street Hospital NHS Trust, London, UK
| | - Patricia Martin Sanfilippo
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neuropsychology, Great Ormond Street Hospital NHS Trust, London, UK
| | - Ana Perez Caballero
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital NHS Trust, London, UK
| | - Lara Menzies
- Department of Clinical Genetics, Great Ormond Street Hospital NHS Trust, London, UK
| | - Amy McTague
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital NHS Trust, London, UK
| | - Sophie Adler
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Konrad Wagstyl
- Imaging Neuroscience, UCL Queen Square Institute of Neurology, London, UK
| | - Martin M Tisdall
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurosurgery, Great Ormond Street Hospital NHS Trust, London, UK
| | - J Helen Cross
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital NHS Trust, London, UK
- Young Epilepsy, Lingfield, UK
| | - Torsten Baldeweg
- Developmental Neurosciences Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Neuropsychology, Great Ormond Street Hospital NHS Trust, London, UK
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5
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Eriksson MH, Ripart M, Piper RJ, Moeller F, Das KB, Eltze C, Cooray G, Booth J, Whitaker KJ, Chari A, Martin Sanfilippo P, Perez Caballero A, Menzies L, McTague A, Tisdall MM, Cross JH, Baldeweg T, Adler S, Wagstyl K. Predicting seizure outcome after epilepsy surgery: Do we need more complex models, larger samples, or better data? Epilepsia 2023; 64:2014-2026. [PMID: 37129087 PMCID: PMC10952307 DOI: 10.1111/epi.17637] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/30/2023] [Accepted: 05/01/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE The accurate prediction of seizure freedom after epilepsy surgery remains challenging. We investigated if (1) training more complex models, (2) recruiting larger sample sizes, or (3) using data-driven selection of clinical predictors would improve our ability to predict postoperative seizure outcome using clinical features. We also conducted the first substantial external validation of a machine learning model trained to predict postoperative seizure outcome. METHODS We performed a retrospective cohort study of 797 children who had undergone resective or disconnective epilepsy surgery at a tertiary center. We extracted patient information from medical records and trained three models-a logistic regression, a multilayer perceptron, and an XGBoost model-to predict 1-year postoperative seizure outcome on our data set. We evaluated the performance of a recently published XGBoost model on the same patients. We further investigated the impact of sample size on model performance, using learning curve analysis to estimate performance at samples up to N = 2000. Finally, we examined the impact of predictor selection on model performance. RESULTS Our logistic regression achieved an accuracy of 72% (95% confidence interval [CI] = 68%-75%, area under the curve [AUC] = .72), whereas our multilayer perceptron and XGBoost both achieved accuracies of 71% (95% CIMLP = 67%-74%, AUCMLP = .70; 95% CIXGBoost own = 68%-75%, AUCXGBoost own = .70). There was no significant difference in performance between our three models (all p > .4) and they all performed better than the external XGBoost, which achieved an accuracy of 63% (95% CI = 59%-67%, AUC = .62; pLR = .005, pMLP = .01, pXGBoost own = .01) on our data. All models showed improved performance with increasing sample size, but limited improvements beyond our current sample. The best model performance was achieved with data-driven feature selection. SIGNIFICANCE We show that neither the deployment of complex machine learning models nor the assembly of thousands of patients alone is likely to generate significant improvements in our ability to predict postoperative seizure freedom. We instead propose that improved feature selection alongside collaboration, data standardization, and model sharing is required to advance the field.
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Affiliation(s)
- Maria H. Eriksson
- Developmental Neurosciences Research & Teaching DepartmentUCL Great Ormond Street Institute of Child HealthLondonUK
- Department of NeuropsychologyGreat Ormond Street HospitalLondonUK
- Department of NeurologyGreat Ormond Street HospitalLondonUK
- The Alan Turing InstituteLondonUK
| | - Mathilde Ripart
- Developmental Neurosciences Research & Teaching DepartmentUCL Great Ormond Street Institute of Child HealthLondonUK
| | - Rory J. Piper
- Developmental Neurosciences Research & Teaching DepartmentUCL Great Ormond Street Institute of Child HealthLondonUK
- Department of NeurosurgeryGreat Ormond Street HospitalLondonUK
| | | | - Krishna B. Das
- Department of NeurologyGreat Ormond Street HospitalLondonUK
- Department of NeurophysiologyGreat Ormond Street HospitalLondonUK
| | - Christin Eltze
- Department of NeurophysiologyGreat Ormond Street HospitalLondonUK
| | - Gerald Cooray
- Department of NeurophysiologyGreat Ormond Street HospitalLondonUK
- Clinical NeuroscienceKarolinska InstituteSolnaSweden
| | - John Booth
- Digital Research EnvironmentGreat Ormond Street HospitalLondonUK
| | | | - Aswin Chari
- Developmental Neurosciences Research & Teaching DepartmentUCL Great Ormond Street Institute of Child HealthLondonUK
- Department of NeurosurgeryGreat Ormond Street HospitalLondonUK
| | - Patricia Martin Sanfilippo
- Developmental Neurosciences Research & Teaching DepartmentUCL Great Ormond Street Institute of Child HealthLondonUK
- Department of NeuropsychologyGreat Ormond Street HospitalLondonUK
| | | | - Lara Menzies
- Department of Clinical GeneticsGreat Ormond Street HospitalLondonUK
| | - Amy McTague
- Developmental Neurosciences Research & Teaching DepartmentUCL Great Ormond Street Institute of Child HealthLondonUK
- Department of NeurologyGreat Ormond Street HospitalLondonUK
| | - Martin M. Tisdall
- Developmental Neurosciences Research & Teaching DepartmentUCL Great Ormond Street Institute of Child HealthLondonUK
- Department of NeurosurgeryGreat Ormond Street HospitalLondonUK
| | - J. Helen Cross
- Developmental Neurosciences Research & Teaching DepartmentUCL Great Ormond Street Institute of Child HealthLondonUK
- Department of NeurologyGreat Ormond Street HospitalLondonUK
- Department of NeurosurgeryGreat Ormond Street HospitalLondonUK
- Young EpilepsyLingfieldUK
| | - Torsten Baldeweg
- Developmental Neurosciences Research & Teaching DepartmentUCL Great Ormond Street Institute of Child HealthLondonUK
- Department of NeuropsychologyGreat Ormond Street HospitalLondonUK
| | - Sophie Adler
- Developmental Neurosciences Research & Teaching DepartmentUCL Great Ormond Street Institute of Child HealthLondonUK
| | - Konrad Wagstyl
- Imaging NeuroscienceUCL Queen Square Institute of NeurologyLondonUK
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6
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Ververi A, Zagaglia S, Menzies L, Baptista J, Caswell R, Baulac S, Ellard S, Lynch S, Jacques TS, Chawla MS, Heier M, Kulseth MA, Mero IL, Våtevik AK, Kraoua I, Ben Rhouma H, Ben Younes T, Miladi Z, Ben Youssef Turki I, Jones WD, Clement E, Eltze C, Mankad K, Merve A, Parker J, Hoskins B, Pressler R, Sudhakar S, DeVile C, Homfray T, Kaliakatsos M, Robinson R, Keim SMB, Habibi I, Reymond A, Sisodiya SM, Hurst JA. Germline homozygous missense DEPDC5 variants cause severe refractory early-onset epilepsy, macrocephaly and bilateral polymicrogyria. Hum Mol Genet 2022; 32:580-594. [PMID: 36067010 PMCID: PMC9896472 DOI: 10.1093/hmg/ddac225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/16/2022] [Accepted: 08/31/2022] [Indexed: 02/07/2023] Open
Abstract
DEPDC5 (DEP Domain-Containing Protein 5) encodes an inhibitory component of the mammalian target of rapamycin (mTOR) pathway and is commonly implicated in sporadic and familial focal epilepsies, both non-lesional and in association with focal cortical dysplasia. Germline pathogenic variants are typically heterozygous and inactivating. We describe a novel phenotype caused by germline biallelic missense variants in DEPDC5. Cases were identified clinically. Available records, including magnetic resonance imaging and electroencephalography, were reviewed. Genetic testing was performed by whole exome and whole-genome sequencing and cascade screening. In addition, immunohistochemistry was performed on skin biopsy. The phenotype was identified in nine children, eight of which are described in detail herein. Six of the children were of Irish Traveller, two of Tunisian and one of Lebanese origin. The Irish Traveller children shared the same DEPDC5 germline homozygous missense variant (p.Thr337Arg), whereas the Lebanese and Tunisian children shared a different germline homozygous variant (p.Arg806Cys). Consistent phenotypic features included extensive bilateral polymicrogyria, congenital macrocephaly and early-onset refractory epilepsy, in keeping with other mTOR-opathies. Eye and cardiac involvement and severe neutropenia were also observed in one or more patients. Five of the children died in infancy or childhood; the other four are currently aged between 5 months and 6 years. Skin biopsy immunohistochemistry was supportive of hyperactivation of the mTOR pathway. The clinical, histopathological and genetic evidence supports a causal role for the homozygous DEPDC5 variants, expanding our understanding of the biology of this gene.
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Affiliation(s)
| | | | | | | | - Richard Caswell
- Exeter Genomics Laboratory, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Stephanie Baulac
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, F-75013 Paris, France
| | - Sian Ellard
- Exeter Genomics Laboratory, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Sally Lynch
- Academic Centre on Rare Diseases, University College Dublin School of Medicine and Medical Science, Dublin, Ireland,Department of Clinical Genetics, Children's Health Ireland (CHI) at Crumlin, Dublin, Ireland
| | | | - Thomas S Jacques
- Developmental Biology and Cancer Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK,Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Martin Heier
- Department of Clinical Neuroscience for Children, Oslo University Hospital, Oslo, Norway
| | - Mari Ann Kulseth
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Inger-Lise Mero
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | | | - Ichraf Kraoua
- Research Laboratory LR18SP04, Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia. Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Hanene Ben Rhouma
- Research Laboratory LR18SP04, Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia. Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Thouraya Ben Younes
- Research Laboratory LR18SP04, Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia. Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Zouhour Miladi
- Research Laboratory LR18SP04, Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia. Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ilhem Ben Youssef Turki
- Research Laboratory LR18SP04, Department of Child and Adolescent Neurology, National Institute Mongi Ben Hmida of Neurology, Tunis, Tunisia. Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Wendy D Jones
- Department of Clinical Genetics & Genomic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Emma Clement
- Department of Clinical Genetics & Genomic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Christin Eltze
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ashirwad Merve
- Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jennifer Parker
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Bethan Hoskins
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ronit Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sniya Sudhakar
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Catherine DeVile
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Tessa Homfray
- SW Thames Regional Genetics Service, St George's Hospital, St George's University of London, London, UK
| | - Marios Kaliakatsos
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ponnudas (Prab) Prabhakar
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Robert Robinson
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Imen Habibi
- Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland
| | - Alexandre Reymond
- Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland
| | - Sanjay M Sisodiya
- To whom correspondence should be addressed at: Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.
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7
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Abstract
Rare diseases are individually rare but collectively common, with a combined prevalence of 3.5–5.9%. A common feature of many diseases is a substantial delay in patients receiving a correct diagnosis; this protracted path to diagnosis is termed ‘the diagnostic odyssey’. During the COVID-19 pandemic, significant concerns have emerged from both clinicians and patients regarding a disproportionate effect of the pandemic on diagnosis and management of rare disease. Such concerns prompted a study to explore this question further, the results of which are presented here.
A cross-sector multi-stakeholder coalition was formed, Action for Rare Disease Empowerment (ARDEnt), with representation from patients with rare diseases and carers, patient advocacy groups, clinicians, academics, data scientists, and industry. A mixed methods approach was used to collect and collate information about the impact of the pandemic on diagnostic delay in rare disease. Currently, there is a lack of systematic recording and reporting of rare disease diagnosis in the UK, which created challenges in directly measuring diagnosis rates. Therefore, the group was dependent on a mix of data sources to reflect healthcare provided during 2020 compared with previous years. The findings were synthesised to describe the impact of the pandemic along the path to diagnosis, from the moment of first concern and engagement with health services, to the availability of definitive testing.
In conclusion, evidence suggests the pandemic has exacerbated the problem of diagnostic delay for rare diseases, affecting all points on the path to diagnosis. The authors recommend three actions to help address this: optimising remote clinical consultations; enhancing the use of health informatics in rare diseases; and proactively identifying patients with undiagnosed rare diseases missed due to the pandemic. This study also highlights the need for better reporting of rare disease diagnoses, a core metric to measure the impact of health system changes that may be put into place to address the priorities of The UK Rare Diseases Framework, also published this year.
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Affiliation(s)
| | - William Evans
- School of Medicine, Nottingham University, UK; Niemann–Pick, Washington, Tyne and Wear, UK
| | - Lucy McKay
- Clinical Genetics Department, Great Ormond Street Hospital, London, UK
| | - Lara Menzies
- Medics4RareDiseases Charity, Loudwater, Buckinghamshire, UK; The Royal Society of Medicine, London, UK
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8
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Buendia O, Shankar S, Mahon H, Toal C, Menzies L, Ravichandran P, Roper J, Takhar J, Benfredj R, Evans W. Is it possible to implement a rare disease case-finding tool in primary care? A UK-based pilot study. Orphanet J Rare Dis 2022; 17:54. [PMID: 35172857 PMCID: PMC8848904 DOI: 10.1186/s13023-022-02216-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 02/06/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION This study implemented MendelScan, a primary care rare disease case-finding tool, into a UK National Health Service population. Rare disease diagnosis is challenging due to disease complexity and low physician awareness. The 2021 UK Rare Diseases Framework highlights as a key priority the need for faster diagnosis to improve clinical outcomes. METHODS AND RESULTS A UK primary care locality with 68,705 patients was examined. MendelScan encodes diagnostic/screening criteria for multiple rare diseases, mapping clinical terms to appropriate SNOMED CT codes (UK primary care standardised clinical terminology) to create digital algorithms. These algorithms were applied to a pseudo-anonymised structured data extract of the electronic health records (EHR) in this locality to "flag" at-risk patients who may require further evaluation. All flagged patients then underwent internal clinical review (a doctor reviewing each EHR flagged by the algorithm, removing all cases with a clear diagnosis/diagnoses that explains the clinical features that led to the patient being flagged); for those that passed this review, a report was returned to their GP. 55 of 76 disease criteria flagged at least one patient. 227 (0.33%) of the total 68,705 of EHR were flagged; 18 EHR were already diagnosed with the disease (the highlighted EHR had a diagnostic code for the same RD it was screened for, e.g. Behcet's disease algorithm identifying an EHR with a SNOMED CT code Behcet's disease). 75/227 (33%) EHR passed our internal review. Thirty-six reports were returned to the GP. Feedback was available for 28/36 of the reports sent. GP categorised nine reports as "Reasonable possible diagnosis" (advance for investigation), six reports as "diagnosis has already been excluded", ten reports as "patient has a clear alternative aetiology", and three reports as "Other" (patient left study locality, unable to re-identify accurately). All the 9 cases considered as "reasonable possible diagnosis" had further evaluation. CONCLUSIONS This pilot demonstrates that implementing such a tool is feasible at a population level. The case-finding tool identified credible cases which were subsequently referred for further investigation. Future work includes performance-based validation studies of diagnostic algorithms and the scalability of the tool.
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Affiliation(s)
| | | | | | | | | | | | - Jane Roper
- Mendelian, 239 Old St, London, EC1V9EY, UK
| | - Jag Takhar
- Mendelian, 239 Old St, London, EC1V9EY, UK
| | | | - Will Evans
- Mendelian, 239 Old St, London, EC1V9EY, UK
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9
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Accogli A, Goergen S, Izzo G, Mankad K, Krajden Haratz K, Parazzini C, Fahey M, Menzies L, Baptista J, Carpineta L, Tortora D, Fulcheri E, Gaetano Vellone V, Paladini D, Spaccini L, Toto V, Trayers C, Ben Sira L, Reches A, Malinger G, Salpietro V, De Marco P, Srour M, Zara F, Capra V, Rossi A, Severino M. L1CAM variants cause two distinct imaging phenotypes on fetal MRI. Ann Clin Transl Neurol 2021; 8:2004-2012. [PMID: 34510796 PMCID: PMC8528460 DOI: 10.1002/acn3.51448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 01/10/2023] Open
Abstract
Data on fetal MRI in L1 syndrome are scarce with relevant implications for parental counseling and surgical planning. We identified two fetal MR imaging patterns in 10 fetuses harboring L1CAM mutations: the first, observed in 9 fetuses was characterized by callosal anomalies, diencephalosynapsis, and a distinct brainstem malformation with diencephalic–mesencephalic junction dysplasia and brainstem kinking. Cerebellar vermis hypoplasia, aqueductal stenosis, obstructive hydrocephalus, and pontine hypoplasia were variably associated. The second pattern observed in one fetus was characterized by callosal dysgenesis, reduced white matter, and pontine hypoplasia. The identification of these features should alert clinicians to offer a prenatal L1CAM testing.
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Affiliation(s)
- Andrea Accogli
- Medical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Stacy Goergen
- Monash Imaging, Monash Health, Clayton, Victoria, Australia
| | - Giana Izzo
- Department of Pediatric Radiology and Neuroradiology, V. Buzzi Children's Hospital, Milan, Italy
| | - Kshitij Mankad
- Neuroradiology Unit, Great Ormond Street Hospital for Children, London, UK
| | - Karina Krajden Haratz
- Division of Ultrasound in ObGyn, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cecilia Parazzini
- Department of Pediatric Radiology and Neuroradiology, V. Buzzi Children's Hospital, Milan, Italy
| | - Michael Fahey
- Paediatric Neurology and Neurogenetics Units, Monash Children's Hospital Clayton, Clayton, Victoria, Australia
| | - Lara Menzies
- Department of Clinical Genetics, Great Ormond Street Hospital, London, UK
| | - Julia Baptista
- Exeter Genomics Laboratory, Royal Devon and Exeter NHS Hospital, Exeter, UK.,College of Medicine and Health, University of Exeter, Exeter, UK
| | - Lucia Carpineta
- Department of Pediatric Medical Imaging, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Ezio Fulcheri
- Fetal-Perinatal Pathology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, Università di Genova, Genoa, Italy
| | - Valerio Gaetano Vellone
- Department of Surgical Sciences and Integrated Diagnostics, Università di Genova, Genoa, Italy
| | - Dario Paladini
- Fetal Medicine and Surgery Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Luigina Spaccini
- Clinical Genetics Unit, Department of Obstetrics and Gynecology, V. Buzzi Children's Hospital, Milan, Italy
| | - Valentina Toto
- Pathology Division, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Claire Trayers
- Department of Paediatric Pathology, Addenbrooke's Hospital, Cambridge, UK
| | - Liat Ben Sira
- Pediatric Radiology, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Reches
- Wolfe PGD- Stem Cell Lab, Racine IVF Unit Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv Israel, Genetic Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Gustavo Malinger
- Division of Ultrasound in ObGyn, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vincenzo Salpietro
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Patrizia De Marco
- Medical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Myriam Srour
- Department of Pediatrics, Montreal Children's Hospital, McGill University Health Center (MUHC), Montreal, Canada
| | - Federico Zara
- Medical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Valeria Capra
- Medical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Department of Health Sciences DISSAL, University of Genoa, Genoa, Italy
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10
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Rabin R, Radmanesh A, Glass IA, Dobyns WB, Aldinger KA, Shieh JT, Romoser S, Bombei H, Dowsett L, Trapane P, Bernat JA, Baker J, Mendelsohn NJ, Popp B, Siekmeyer M, Sorge I, Sansbury FH, Watts P, Foulds NC, Burton J, Hoganson G, Hurst JA, Menzies L, Osio D, Kerecuk L, Cobben JM, Jizi K, Jacquemont S, Bélanger SA, Löhner K, Veenstra-Knol HE, Lemmink HH, Keller-Ramey J, Wentzensen IM, Punj S, McWalter K, Lenberg J, Ellsworth KA, Radtke K, Akbarian S, Pappas J. Genotype-phenotype correlation at codon 1740 of SETD2. Am J Med Genet A 2020; 182:2037-2048. [PMID: 32710489 DOI: 10.1002/ajmg.a.61724] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 03/10/2020] [Accepted: 05/08/2020] [Indexed: 11/06/2022]
Abstract
The SET domain containing 2, histone lysine methyltransferase encoded by SETD2 is a dual-function methyltransferase for histones and microtubules and plays an important role for transcriptional regulation, genomic stability, and cytoskeletal functions. Specifically, SETD2 is associated with trimethylation of histone H3 at lysine 36 (H3K36me3) and methylation of α-tubulin at lysine 40. Heterozygous loss of function and missense variants have previously been described with Luscan-Lumish syndrome (LLS), which is characterized by overgrowth, neurodevelopmental features, and absence of overt congenital anomalies. We have identified 15 individuals with de novo variants in codon 1740 of SETD2 whose features differ from those with LLS. Group 1 consists of 12 individuals with heterozygous variant c.5218C>T p.(Arg1740Trp) and Group 2 consists of 3 individuals with heterozygous variant c.5219G>A p.(Arg1740Gln). The phenotype of Group 1 includes microcephaly, profound intellectual disability, congenital anomalies affecting several organ systems, and similar facial features. Individuals in Group 2 had moderate to severe intellectual disability, low normal head circumference, and absence of additional major congenital anomalies. While LLS is likely due to loss of function of SETD2, the clinical features seen in individuals with variants affecting codon 1740 are more severe suggesting an alternative mechanism, such as gain of function, effects on epigenetic regulation, or posttranslational modification of the cytoskeleton. Our report is a prime example of different mutations in the same gene causing diverging phenotypes and the features observed in Group 1 suggest a new clinically recognizable syndrome uniquely associated with the heterozygous variant c.5218C>T p.(Arg1740Trp) in SETD2.
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Affiliation(s)
- Rachel Rabin
- Clinical Genetic Services, Department of Pediatrics, NYU School of Medicine, New York, New York, USA
| | - Alireza Radmanesh
- Division of Pediatric Neuroradiology, Department of Radiology, NYU School of Medicine, New York, New York, USA
| | - Ian A Glass
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington, USA.,Department of Pediatrics, Division of Medical Genetics, University of Washington, Seattle, Washington, USA
| | - William B Dobyns
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington, USA.,Department of Pediatrics, Division of Medical Genetics, University of Washington, Seattle, Washington, USA.,Department of Neurology, University of Washington, Seattle, Washington, USA
| | - Kimberly A Aldinger
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Joseph T Shieh
- Institute for Human Genetics, Division of Medical Genetics, Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, California, USA
| | - Shelby Romoser
- Division of Medical Genetics and Genomics, Stead Family Department of Pediatrics, University of Iowa Hospitals, Iowa City, Iowa, USA
| | - Hannah Bombei
- Division of Medical Genetics and Genomics, Stead Family Department of Pediatrics, University of Iowa Hospitals, Iowa City, Iowa, USA
| | - Leah Dowsett
- Kapi'olani Medical Specialists and Department of Pediatrics, University of Hawai'i John A. Burns School of Medicine, Honolulu, Hawaii, USA
| | - Pamela Trapane
- Division of Pediatric Genetics, Department of Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - John A Bernat
- Division of Medical Genetics and Genomics, Stead Family Department of Pediatrics, University of Iowa Hospitals, Iowa City, Iowa, USA
| | - Janice Baker
- Genomic Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | | | - Bernt Popp
- Institute of Human Genetics, University of Leipzig Hospitals and Clinics, Leipzig, Germany
| | - Manuela Siekmeyer
- Department of Pediatrics Hospital for Children and Adolescents, University of Leipzig Hospitals and Clinics, Leipzig, Germany
| | - Ina Sorge
- Department of Pediatric Radiology, University of Leipzig Hospitals and Clinics, Leipzig, Germany
| | - Francis Hugh Sansbury
- All Wales Medical Genomics Service, Institute of Medical Genetics, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Patrick Watts
- Department of Ophthalmology, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Nicola C Foulds
- Wessex Clinical Genetics Services, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Jennifer Burton
- University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - George Hoganson
- University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Jane A Hurst
- Department of Clinical Genetics, Great Ormond Street Hospital, London, UK
| | - Lara Menzies
- Department of Clinical Genetics, Great Ormond Street Hospital, London, UK
| | - Deborah Osio
- Department of Clinical Genetics, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Larissa Kerecuk
- Renal Department, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Jan M Cobben
- North West Thames Regional Genetic Services, Northwick Park Hospitals NHS Foundation Trust, London, UK.,Emma Children Hospital, Amsterdam, The Netherlands
| | - Khadijé Jizi
- CHU Sainte-Justine Hospital, Montreal, Quebec, Canada
| | - Sebastien Jacquemont
- CHU Sainte-Justine Research Centre, Montreal, Quebec, Canada.,Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Stacey A Bélanger
- Development Clinic, CHU Sainte-Justine Hospital, Montreal, Quebec, Canada.,Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Katharina Löhner
- Department of Genetics, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hermine E Veenstra-Knol
- Department of Genetics, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Henny H Lemmink
- Department of Genetics, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | | | | | | | - Jerica Lenberg
- Rady Children's Hospital Institute for Genomic Medicine, San Diego, California, USA
| | | | - Kelly Radtke
- Department of Clinical Diagnostics, Ambry Genetics, Aliso Viejo, California, USA
| | - Schahram Akbarian
- Friedman Brain Institute and Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Pappas
- Clinical Genetic Services, Department of Pediatrics, NYU School of Medicine, New York, New York, USA.,Clinical Genetics, NYU Orthopedic Hospital, New York, New York, USA
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11
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Knight H, Pyrah M, Hunter-Jones P, Sudbury-Riley L, Menzies L. P-136 Hospice blueprinting: an innovative technique for improving service delivery. BMJ Support Palliat Care 2015. [DOI: 10.1136/bmjspcare-2015-001026.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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12
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Menzies L, Minson S, Brightwell A, Davies-Muir A, Long A, Fertleman C. An evaluation of demographic factors affecting performance in a paediatric membership multiple-choice examination. Postgrad Med J 2015; 91:72-6. [DOI: 10.1136/postgradmedj-2014-132967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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13
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Menzies L, Cullen L, Greenslade J, Leong A, Than M, Pemberton C, Aldous S, Pickering J, Crosling B, Foreman R, Parsonage W. The association of delay in presentation and 12-month health outcomes in emergency patients with symptoms of possible acute coronary syndromes. Heart Lung Circ 2015. [DOI: 10.1016/j.hlc.2015.06.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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14
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Menzies L, Goddings AL, Whitaker KJ, Blakemore SJ, Viner RM. The effects of puberty on white matter development in boys. Dev Cogn Neurosci 2014; 11:116-28. [PMID: 25454416 PMCID: PMC4352899 DOI: 10.1016/j.dcn.2014.10.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 08/28/2014] [Accepted: 10/10/2014] [Indexed: 01/07/2023] Open
Abstract
White matter microstructural differences occurred between early and late puberty. White matter regions showed reduced mean diffusivity from early to late puberty. Regression models showed that pubertal effects could not simply be ascribed to age. Mean diffusivity decreases were associated with increasing salivary testosterone levels.
Neuroimaging studies demonstrate considerable changes in white matter volume and microstructure during adolescence. Most studies have focused on age-related effects, whilst puberty-related changes are not well understood. Using diffusion tensor imaging and tract-based spatial statistics, we investigated the effects of pubertal status on white matter mean diffusivity (MD) and fractional anisotropy (FA) in 61 males aged 12.7–16.0 years. Participants were grouped into early-mid puberty (≤Tanner Stage 3 in pubic hair and gonadal development; n = 22) and late-post puberty (≥Tanner Stage 4 in pubic hair or gonadal development; n = 39). Salivary levels of pubertal hormones (testosterone, DHEA and oestradiol) were also measured. Pubertal stage was significantly related to MD in diverse white matter regions. No relationship was observed between pubertal status and FA. Regression modelling of MD in the significant regions demonstrated that an interaction model incorporating puberty, age and puberty × age best explained our findings. In addition, testosterone was correlated with MD in these pubertally significant regions. No relationship was observed between oestradiol or DHEA and MD. In conclusion, pubertal status was significantly related to MD, but not FA, and this relationship cannot be explained by changes in chronological age alone.
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Affiliation(s)
- Lara Menzies
- University College London Institute of Cognitive Neuroscience, Alexandra House, 17 Queen Square, London WC1N 3AR, UK; General Adolescent and Paediatric Unit, University College London Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
| | - Anne-Lise Goddings
- University College London Institute of Cognitive Neuroscience, Alexandra House, 17 Queen Square, London WC1N 3AR, UK; General Adolescent and Paediatric Unit, University College London Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Kirstie J Whitaker
- Brain Mapping Unit, Department of Psychiatry, Sir William Hardy Building, Downing Street, Cambridge Biomedical Campus, Cambridge CB2 3ED, UK
| | - Sarah-Jayne Blakemore
- University College London Institute of Cognitive Neuroscience, Alexandra House, 17 Queen Square, London WC1N 3AR, UK
| | - Russell M Viner
- General Adolescent and Paediatric Unit, University College London Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
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15
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Abstract
Obsessive-compulsive disorder (OCD) is a heritable and debilitating neuropsychiatric condition. Attempts to delineate genetic contributions have met with limited success, and there is an ongoing search for intermediate trait or vulnerability markers rooted in the neurosciences. Such markers would be valuable for detecting people at risk of developing the condition, clarifying etiological factors and targeting novel treatments. This review begins with brief coverage of the epidemiology of OCD, and presents a hierarchical model of the condition. The advantages of neuropsychological assessment and neuroimaging as objective measures of brain integrity and function are discussed. We describe the concept of endophenotypes and examples of their successful use in medicine and psychiatry. Key areas of focus in the search for OCD endophenotypes are identified, such as measures of inhibitory control and probes of the integrity of orbitofrontal and posterior parietal cortices. Finally, we discuss exciting findings in unaffected first-degree relatives of patients with OCD that have led to the identification of several candidate endophenotypes of the disorder, with important implications for neurobiological understanding and treatment of this and related conditions.
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Affiliation(s)
- Samuel R Chamberlain
- Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK.
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16
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Menzies L, Williams GB, Chamberlain SR, Ooi C, Fineberg N, Suckling J, Sahakian BJ, Robbins TW, Bullmore ET. White matter abnormalities in patients with obsessive-compulsive disorder and their first-degree relatives. Am J Psychiatry 2008; 165:1308-15. [PMID: 18519525 DOI: 10.1176/appi.ajp.2008.07101677] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Obsessive-compulsive disorder (OCD) is a common, heritable neuropsychiatric disorder, hypothetically underpinned by dysconnectivity of large-scale brain systems. The extent of white matter abnormalities in OCD is unknown, and the genetic basis of this disorder is poorly understood. The authors used diffusion tensor imaging, a magnetic resonance imaging technique, for examining white matter abnormalities in brain structure through quantification of water diffusion, to confirm whether white matter abnormalities exist in OCD. They also explored whether such abnormalities occur in healthy first-degree relatives of patients, indicating they may be endophenotypes representing increased genetic risk for OCD. METHOD The authors used diffusion tensor imaging to measure fractional anisotropy of white matter in 30 patients with OCD, 30 unaffected first-degree relatives, and 30 matched healthy comparison subjects. Regions of significantly abnormal fractional anisotropy in patients in relation to healthy comparison subjects were identified by permutation tests. The authors assessed whether these abnormalities were also evident in the first-degree relatives. A secondary region-of-interest analysis was undertaken to assess the extent of replication between our data and previous relevant literature. RESULTS Patients with OCD demonstrated significantly reduced fractional anisotropy in a large region of right inferior parietal white matter and significantly increased fractional anisotropy in a right medial frontal region. Relatives also exhibited significant abnormalities of fractional anisotropy in these regions. CONCLUSIONS These findings indicate that OCD is associated with white matter abnormalities in parietal and frontal regions. Similar abnormalities in unaffected first-degree relatives suggest these may be white matter endophenotypes for OCD.
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Affiliation(s)
- Lara Menzies
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, Cambridge CB22QQ, UK.
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17
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Chamberlain SR, Menzies L, Hampshire A, Suckling J, Fineberg NA, del Campo N, Aitken M, Craig K, Owen AM, Bullmore ET, Robbins TW, Sahakian BJ. Orbitofrontal dysfunction in patients with obsessive-compulsive disorder and their unaffected relatives. Science 2008; 321:421-2. [PMID: 18635808 DOI: 10.1126/science.1154433] [Citation(s) in RCA: 374] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Obsessive-compulsive disorder (OCD) is characterized by repetitive thoughts and behaviors associated with underlying dysregulation of frontostriatal circuitry. Central to neurobiological models of OCD is the orbitofrontal cortex, a neural region that facilitates behavioral flexibility after negative feedback (reversal learning). We identified abnormally reduced activation of several cortical regions, including the lateral orbitofrontal cortex, during reversal learning in OCD patients and their clinically unaffected close relatives, supporting the existence of an underlying previously undiscovered endophenotype for this disorder.
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Affiliation(s)
- Samuel R Chamberlain
- Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, Box 189, Cambridge CB2 0QQ, UK.
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18
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Menzies L, Chamberlain SR, Laird AR, Thelen SM, Sahakian BJ, Bullmore ET. Integrating evidence from neuroimaging and neuropsychological studies of obsessive-compulsive disorder: the orbitofronto-striatal model revisited. Neurosci Biobehav Rev 2007; 32:525-49. [PMID: 18061263 DOI: 10.1016/j.neubiorev.2007.09.005] [Citation(s) in RCA: 810] [Impact Index Per Article: 47.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Revised: 09/24/2007] [Accepted: 09/28/2007] [Indexed: 12/16/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a common, heritable and disabling neuropsychiatric disorder. Theoretical models suggest that OCD is underpinned by functional and structural abnormalities in orbitofronto-striatal circuits. Evidence from cognitive and neuroimaging studies (functional and structural magnetic resonance imaging (MRI) and positron emission tomography (PET)) have generally been taken to be supportive of these theoretical models; however, results from these studies have not been entirely congruent with each other. With the advent of whole brain-based structural imaging techniques, such as voxel-based morphometry and multivoxel analyses, we consider it timely to assess neuroimaging findings to date, and to examine their compatibility with cognitive studies and orbitofronto-striatal models. As part of this assessment, we performed a quantitative, voxel-level meta-analysis of functional MRI findings, which revealed consistent abnormalities in orbitofronto-striatal and other additional areas in OCD. This review also considers the evidence for involvement of other brain areas outside orbitofronto-striatal regions in OCD, the limitations of current imaging techniques, and how future developments in imaging may aid our understanding of OCD.
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Affiliation(s)
- Lara Menzies
- Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK.
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19
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Menzies L, Achard S, Chamberlain SR, Fineberg N, Chen CH, del Campo N, Sahakian BJ, Robbins TW, Bullmore E. Neurocognitive endophenotypes of obsessive-compulsive disorder. Brain 2007; 130:3223-36. [PMID: 17855376 DOI: 10.1093/brain/awm205] [Citation(s) in RCA: 330] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Endophenotypes (intermediate phenotypes) are objective, heritable, quantitative traits hypothesized to represent genetic risk for polygenic disorders at more biologically tractable levels than distal behavioural and clinical phenotypes. It is theorized that endophenotype models of disease will help to clarify both diagnostic classification and aetiological understanding of complex brain disorders such as obsessive-compulsive disorder (OCD). To investigate endophenotypes in OCD, we measured brain structure using magnetic resonance imaging (MRI), and behavioural performance on a response inhibition task (Stop-Signal) in 31 OCD patients, 31 of their unaffected first-degree relatives, and 31 unrelated matched controls. Both patients and relatives had delayed response inhibition on the Stop-Signal task compared with healthy controls. We used a multivoxel analysis method (partial least squares) to identify large-scale brain systems in which anatomical variation was associated with variation in performance on the response inhibition task. Behavioural impairment on the Stop-Signal task, occurring predominantly in patients and relatives, was significantly associated with reduced grey matter in orbitofrontal and right inferior frontal regions and increased grey matter in cingulate, parietal and striatal regions. A novel permutation test indicated significant familial effects on variation of the MRI markers of inhibitory processing, supporting the candidacy of these brain structural systems as endophenotypes of OCD. In summary, structural variation in large-scale brain systems related to motor inhibitory control may mediate genetic risk for OCD, representing the first evidence for a neurocognitive endophenotype of OCD.
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Affiliation(s)
- Lara Menzies
- Brain Mapping Unit, University of Cambridge, Cambridge, UK
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20
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Menzies L, Ooi C, Kamath S, Suckling J, McKenna P, Fletcher P, Bullmore E, Stephenson C. Effects of gamma-aminobutyric acid-modulating drugs on working memory and brain function in patients with schizophrenia. ACTA ACUST UNITED AC 2007; 64:156-67. [PMID: 17283283 DOI: 10.1001/archpsyc.64.2.156] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Cognitive impairment causes morbidity in schizophrenia and could be due to abnormalities of cortical interneurons using the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). OBJECTIVES To test the predictions that cognitive and brain functional responses to GABA-modulating drugs are correlated and abnormal in schizophrenia. DESIGN Pharmacological functional magnetic resonance imaging study of 2 groups, each undergoing scanning 3 times, using an N-back working memory task, after placebo, lorazepam, or flumazenil administration. SETTING AND PARTICIPANTS Eleven patients with chronic schizophrenia were recruited from a rehabilitation service, and 11 healthy volunteers matched for age, sex, and premorbid IQ were recruited from the local community. Intervention Participants received 2 mg of oral lorazepam, a 0.9-mg intravenous flumazenil bolus followed by a flumazenil infusion of 0.0102 mg/min, or oral and intravenous placebo. MAIN OUTCOME MEASURES Working memory performance was summarized by the target discrimination index at several levels of difficulty. Increasing (or decreasing) brain functional activation in response to increasing task difficulty was summarized by the positive (or negative) load response. RESULTS Lorazepam impaired performance and flumazenil enhanced it; these cognitive effects were more salient in schizophrenic patients. Functional magnetic resonance imaging demonstrated positive load response in a frontoparietal system and negative load response in the temporal and posterior cingulate regions; activation of the frontoparietal cortex was positively correlated with deactivation of the temporocingulate cortex. After placebo administration, schizophrenic patients had abnormally attenuated activation of the frontoparietal cortex and deactivation of the temporocingulate cortex; this pattern was mimicked in healthy volunteers and exacerbated in schizophrenic patients by lorazepam. However, in schizophrenic patients, flumazenil enhanced deactivation of the temporocingulate and activation of the anterior cingulate cortices. CONCLUSIONS The GABA-modulating drugs differentially affect working memory performance and brain function in schizophrenia. Cognitive impairment in schizophrenia may reflect abnormal inhibitory function and could be treated by drugs targeting GABA neurotransmission.
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Affiliation(s)
- Lara Menzies
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, Cambridge, England
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21
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Affiliation(s)
- Samuel R Chamberlain
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Box 189, Cambridge, CB2 2QQ UK.
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22
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Chamberlain S, Fineberg N, del Campo N, Menzies L, Blackwell A, Bullmore E, Robbins T, Sahakian B. Seeking out candidate endophenotypes for OCD. Neurocognitive findings in unaffected relatives. Eur Psychiatry 2007. [DOI: 10.1016/j.eurpsy.2007.01.988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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23
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Cools R, Blackwell A, Clark L, Menzies L, Cox S, Robbins TW. Tryptophan depletion disrupts the motivational guidance of goal-directed behavior as a function of trait impulsivity. Neuropsychopharmacology 2005; 30:1362-73. [PMID: 15770237 DOI: 10.1038/sj.npp.1300704] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Serotonin (5-HT) is well known to affect the motivational properties of stimuli predictive of rewards as well as the inhibitory control of behavior. Here, central 5-HT depletion was induced by the acute tryptophan (TRP) depletion (ATD) procedure in young healthy volunteers to examine the role of 5-HT in motivated action and prepotent response inhibition. A novel reaction-time task, tailored to individual differences in general cognitive speed, was employed to measure the guidance of behavior by motivationally relevant signals predictive of reinforcement likelihood, while the stop-signal reaction-time task was used to measure response inhibition. Following the TRP-balancing control drink, cues predictive of high-reinforcement certainty induced faster, but less accurate responses compared with cues predictive of lower reinforcement certainty. Depletion of central 5-HT modulated this coupling between motivation and action by slowing responses and increasing accuracy as a function of incentive certainty. These effects of ATD on motivated action correlated highly with individual differences in the personality trait of Nonplanning Impulsiveness (Barratt Impulsivity Scale (BIS-11)), so that strongest effects on motivated action were observed in high-impulsive individuals. By contrast, ATD left unaltered the ability to inhibit prepotent responses. Our findings may have implications for a variety of neuropsychiatric disorders including impulsive aggressive disorders and depression.
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Affiliation(s)
- Roshan Cools
- Department of Experimental Psychology, University of Cambridge, Cambridge, UK.
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