Application of a Clinical Workflow May Lead to Increased Diagnostic Precision in Hereditary Spastic Paraplegias and Cerebellar Ataxias: A Single Center Experience

The molecular characterization of Hereditary Spastic Paraplegias (HSP) and inherited cerebellar ataxias (CA) is challenged by their clinical and molecular heterogeneity. The recent application of Next Generation Sequencing (NGS) technologies is increasing the diagnostic rate, which can be influenced by patients\u2019 selection. To assess if a clinical diagnosis of CA/HSP received in a third-level reference center might impact the molecular diagnostic yield, we retrospectively evaluated the molecular diagnostic rate reached in our center on 192 unrelated families (90 HSP and 102 CA) (i) before NGS and (ii) with the use of NGS gene panels. Overall, 46.3% of families received a genetic diagnosis by first-tier individual gene screening: 43.3% HSP and 50% spinocerebellar ataxias (SCA). The diagnostic rate was 56.7% in AD-HSP, 55.5% in AR-HSP, and 21.2% in sporadic HSP. On the other hand, 75% AD-, 52% AR- and 33% sporadic CA were diagnosed. So far, 32 patients (24 CA and 8 HSP) were further assessed by NGS gene panels, and 34.4% were diagnosed, including 29.2% CA and 50% HSP patients. Eleven novel gene variants classified as (likely) pathogenic were identified. Our results support the role of experienced clinicians in the diagnostic assessment and the clinical research of CA and HSP even in the next generation era

Ataxia, Intellectual Disability, and Ocular Apraxia with Cerebellar Cysts: A New Disease?

Cerebellar cysts are rare findings in pediatric neuroimaging and rather characteristic for dystroglycanopathies and GPR56-related encephalopathy. We aim to report on seven children with cerebellar cysts showing absence of weakness and ruling out mutations within eight dystroglycanopathy genes and GPR56. Data about neurological and ophthalmological features, outcome, and creatine kinase values were collected from clinical histories and follow-up examinations. All MR images were qualitatively evaluated for infra- and supratentorial abnormalities. A SNP 6.0-Array was performed in three children. The POMT1, POMT2, POMGnT1, FKRP, FKTN, LARGE, ISPD, B3GALNT2, and GPR56 genes were screened in all patients by Sanger sequencing. Seven children from five families were studied. Ataxia, intellectual disability, and language impairment were found in all patients, ocular motor apraxia in five, and severe myopia in three. None of the patients had weakness, only three a minimally increased creatine kinase value. Qualitative neuroimaging evaluation showed cerebellar cysts and dysplasia in the cerebellar hemispheres and vermis in all children. Additional findings were an enlarged fourth ventricle in all children, vermian hypoplasia and brain stem morphological abnormalities in five. The SNP array showed no pathogenetic imbalances in all children evaluated. In all patients, no mutations were found in POMT1, POMT2, POMGnT1, FKRP, FKTN, LARGE, ISPD, B3GALNT2, and GPR56. The peculiar combination of the same clinical and neuroimaging findings in our patients highly suggests that this phenotype may represent a novel entity, possibly falling within the spectrum of dystroglycanopathies

The ARCA Registry: A Collaborative Global Platform for Advancing Trial Readiness in Autosomal Recessive Cerebellar Ataxias.

Autosomal recessive cerebellar ataxias (ARCAs) form an ultrarare yet expanding group of neurodegenerative multisystemic diseases affecting the cerebellum and other neurological or non-neurological systems. With the advent of targeted therapies for ARCAs, disease registries have become a precious source of real-world quantitative and qualitative data complementing knowledge from preclinical studies and clinical trials. Here, we review the ARCA Registry, a global collaborative multicenter platform (>15 countries, >30 sites) with the overarching goal to advance trial readiness in ARCAs. It presents a good clinical practice (GCP)- and general data protection regulation (GDPR)-compliant professional-reported registry for multicenter web-based capture of cross-center standardized longitudinal data. Modular electronic case report forms (eCRFs) with core, extended, and optional datasets allow data capture tailored to the participating site's variable interests and resources. The eCRFs cover all key data elements required by regulatory authorities [European Medicines Agency (EMA)] and the European Rare Disease (ERD) platform. They capture genotype, phenotype, and progression and include demographic data, biomarkers, comorbidity, medication, magnetic resonance imaging (MRI), and longitudinal clinician- or patient-reported ratings of ataxia severity, non-ataxia features, disease stage, activities of daily living, and (mental) health status. Moreover, they are aligned to major autosomal-dominant spinocerebellar ataxia (SCA) and sporadic ataxia (SPORTAX) registries in the field, thus allowing for joint and comparative analyses not only across ARCAs but also with SCAs and sporadic ataxias. The registry is at the core of a systematic multi-component ARCA database cluster with a linked biobank and an evolving study database for digital outcome measures. Currently, the registry contains more than 800 patients with almost 1,500 visits representing all ages and disease stages; 65% of patients with established genetic diagnoses capture all the main ARCA genes, and 35% with unsolved diagnoses are targets for advanced next-generation sequencing. The ARCA Registry serves as the backbone of many major European and transatlantic consortia, such as PREPARE, PROSPAX, and the Ataxia Global Initiative, with additional data input from SPORTAX. It has thus become the largest global trial-readiness registry in the ARCA field

Clinico-Genetic, Imaging and Molecular Delineation of COQ8A-Ataxia: A Multicenter Study of 59 Patients.

OBJECTIVE: To foster trial-readiness of coenzyme Q8A (COQ8A)-ataxia, we map the clinicogenetic, molecular, and neuroimaging spectrum of COQ8A-ataxia in a large worldwide cohort, and provide first progression data, including treatment response to coenzyme Q10 (CoQ10). METHODS: Cross-modal analysis of a multicenter cohort of 59 COQ8A patients, including genotype-phenotype correlations, 3D-protein modeling, in vitro mutation analyses, magnetic resonance imaging (MRI) markers, disease progression, and CoQ10 response data. RESULTS: Fifty-nine patients (39 novel) with 44 pathogenic COQ8A variants (18 novel) were identified. Missense variants demonstrated a pleiotropic range of detrimental effects upon protein modeling and in vitro analysis of purified variants. COQ8A-ataxia presented as variable multisystemic, early-onset cerebellar ataxia, with complicating features ranging from epilepsy (32%) and cognitive impairment (49%) to exercise intolerance (25%) and hyperkinetic movement disorders (41%), including dystonia and myoclonus as presenting symptoms. Multisystemic involvement was more prevalent in missense than biallelic loss-of-function variants (82-93% vs 53%; p = 0.029). Cerebellar atrophy was universal on MRI (100%), with cerebral atrophy or dentate and pontine T2 hyperintensities observed in 28%. Cross-sectional (n = 34) and longitudinal (n = 7) assessments consistently indicated mild-to-moderate progression of ataxia (SARA: 0.45/year). CoQ10 treatment led to improvement by clinical report in 14 of 30 patients, and by quantitative longitudinal assessments in 8 of 11 patients (SARA: -0.81/year). Explorative sample size calculations indicate that ≥48 patients per arm may suffice to demonstrate efficacy for interventions that reduce progression by 50%. INTERPRETATION: This study provides a deeper understanding of the disease, and paves the way toward large-scale natural history studies and treatment trials in COQ8A-ataxia. ANN NEUROL 2020;88:251-263

Autosomal Recessive Cerebellar Ataxias in Europe: Frequency, Onset, and Severity in 677 Patients

© 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.This work was supported by the European Union's Horizon 2020 research and innovation program as part of the innovation project EVIDENCE-RND under the EJP RD COFUND-EJP (825575 to M.S.), as part of Solve-RD (779257 to J.B., M.S., and B.P.v.d.W.), by the DFG under the frame of EJP-RD network PROSPAX (441409627 to M.S. and B.P.v.d.W.), and by the Clinician Scientist program “PRECISE.net” funded by the Else Kröner-Fresenius-Stiftung (to A.T.). The study was further funded by the Federal Ministry of Education and Research, Germany, and through the TreatHSP network (01GM1905 to L.S.). B.P.v.d.W. receives additional research support from ZonMW, NWO, Hersenstichting, Brugling fonds, Gossweiler Foundation, and Radboud university medical center. L.S., T.K., G.Z., B.P.v.d.W., and M.S. are members of the European Reference Network for Rare Neurological Diseases—Project ID 739510. A.T. receives funding from the University of Tübingen, medical faculty, for the Clinician Scientist Program Grant 439-0-0. P.K. receives funding from University of Szeged (Hetényi Géza: 5S330 A202) and Ministry of Innovation and Technology of Hungary, National Research, Development and Innovation Fund (TKP2021-EGA). J.B. was supported by a Senior Clinical Researcher mandate of the Research Fund—Flanders (FWO) under grant agreement number 1805021N and is a member of the μNEURO Research Centre of Excellence of the University of Antwerp. F.M.S. was supported by the Italian Ministry of Health (the EJP-RD network PROSPAX; Ricerca Finalizzata RF-2016-02361610; RF-2019-12370417; Ricerca Corrente, RC 5x1000). Several authors of this publication are members of the European Reference Network for Rare Neuromuscular Diseases (ERN EURO-NMD) and of the European Reference Network for Rare Neurological Diseases (ERN-RND). Open Access funding enabled and organized by Projekt DEAL.Peer reviewe

Responsiveness of the Scale for the Assessment and Rating of Ataxia and Natural History in 884 Recessive and Early Onset Ataxia Patients

© 2023 The Authors. Annals of Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.[Objective] The Scale for the Assessment and Rating of Ataxia (SARA) is the most widely applied clinical outcome assessment (COA) for genetic ataxias, but presents metrological and regulatory challenges. To facilitate trial planning, we characterize its responsiveness (including subitem-level relations to ataxia severity and patient-focused outcomes) across a large number of ataxias, and provide first natural history data for several of them.[Methods] Subitem-level correlation and distribution-based analysis of 1,637 SARA assessments in 884 patients with autosomal recessive/early onset ataxia (370 with 2–8 longitudinal assessments) were complemented by linear mixed effects modeling to estimate progression and sample sizes.[Results] Although SARA subitem responsiveness varied between ataxia severities, gait/stance showed a robust granular linear scaling across the broadest range (SARA  25; 2.7-fold sample size). Use of a novel rank-optimized SARA without subitems finger-chase and nose-finger reduces sample sizes by 20 to 25%.[Interpretation] This study comprehensively characterizes COA properties and annualized changes of the SARA across and within a large number of ataxias. It suggests specific approaches for optimizing its responsiveness that might facilitate regulatory qualification and trial design. ANN NEUROL 2023;94:470–485This work was supported via the European Union's Horizon 2020 research and innovation program as part of the innovation project EVIDENCE-RND under the EJP RD COFUND-EJP (No. 825575, to R.-D.H. and M.S.), as part of Solve-RD (No. 779257, to J.B., M.S., and B.P.v.d.W.), by the DFG under the framework of EJP-RD network PROSPAX (No. 441409627; M.S., B.P.v.d.W.), and by the Clinician Scientist program PRECISE.net, funded by the Else Kröner-Fresenius-Stiftung (to A.Tr. and M.S.). The study was further funded by the Federal Ministry of Education and Research, Germany, and through the TreatHSP network (01GM1905 to L.S.). B.P.v.d.W. receives additional research support from ZonMW, Hersenstichting, Gossweiler Foundation, and Radboud University Medical Center. L.S., T.Klop., T.Kloc., G.Z., B.P.v.d.W., and M.S. are members of the European Reference Network for Rare Neurological Diseases–Project ID No. 739510. A.Tr. receives funding from the University of Tübingen, medical faculty, for the Clinician Scientist Program Grant #439-0-0. P.K. receives funding from University of Szeged (Hetényi Géza: 5S330 A202) and Ministry of Innovation and Technology of Hungary, National Research, Development and Innovation Fund (TKP2021-EGA). J.B. is supported by a Senior Clinical Researcher mandate of the Research Fund–Flanders (FWO) under grant agreement number 1805021N, and is a member of the μNEURO Research Center of Excellence of the University of Antwerp. F.M.S. is supported in part by the Italian Ministry of Health (EJP-RD network PROSPAX; Ricerca Finalizzata RF-2016-02361610; RF-2019-12370417; Ricerca Corrente RC 5x1000). Several authors of this publication are members of the European Reference Network for Rare Neuromuscular Diseases and of the European Reference Network for Rare Neurological Diseases.We are grateful to S. Reich for her coordinating support as part of the EOA/PREPARE consortium and to T. Heger for monitoring the datasets of the ARCA registry. Open Access funding enabled and organized by Projekt DEAL.Peer reviewe

TURNING WATER, STAYING WATER

Quanto può cambiare un territorio nel tempo, conteso nell'eterna lotta tra le acque, naturali dominatrici e modellatrici della superficie terrestre dal momento del loro contatto con essa, e l'uomo che a queste contende il diritto di gestire i luoghi a lui opportuni? Quelli che sono stati e spesso ancora sono i luoghi delle acque vengono ricordati dalle serie di carte storiche tracciate prima da pazienti agrimensori, poi dai militari ed ora, nelle carte recenti, da tecnici specializzati; il confronto della documentazione disponibile racconta quale sia il grado di variabilità ambientale in questo confronto mai finito, in cui a Volte vince la natura, a volte l'uomo, ma sempre qualcosa si trasforma. Le mutazioni del paesaggio in riferimento alla trasformazione del sistema delle acque possono essere anche di enorme importanza – l'uomo, si sa, è molto industrioso – e della forma più antica del territorio forse nemmeno le carte ci possono dir nulla: troppo recenti sono per recare memoria di un lontano passato. A meno che, anche sulle carte più recenti, non resti «scritto tra le righe » quella che era la struttura dell'acqua, mai disegnata: allora, tra i tanti segni riportati sulla carta, si potranno analizzare quelli che raccontano la forma dell'acqua nel tempo antico: questi segni sono i toponimi. Infine, anche se l'acqua non c'è più, resta a volte la sua impronta, tanto evidente quanto ignorata nella sua genesi; impronta direttamente leggibile o desumibile «per scarto», laddove la contesa tra acqua e uomo non ha lasciato né vinti né vincitori, in una contesa durata più di un millennio.How much can land change over time, caught in the eternal struggle between water, natural dominator and modeller of the earth's surface from the moment of its contact with the latter, and man, who claims the right to control the places most convenient for him? What were, and often still are, places of water are immortalized in a series of historical maps traced first by patient surveyors, then by the military and now, more recently by specialised technicians, a comparison of the available documentation reveals to what degree the environment can change in this never-ending contest, in which sometimes nature wins and sometimes man, but something is always transformed. The changes in the landscape deriving from the transformation of the water system may also be of enormous importance – man, as we all know, is very industrious – and not even maps can tell us much about the ancient conformation of land: they are too recent to bear evidence of a remote past. Unless even in more recent maps the former never depicted structure of water may be read between the lines; in such a case, among the numerous clues shown on the map we can analyze those that recount the form of water in ancient times: these clues are the toponyms

Muramic and dipicolinic acids in atmospheric particulate matter as biomarkers of bacteria and bacterial spores

Airborne bacteria are components of the atmospheric aerosol particles and can be responsible of allergic disease, regardless of their viability. In this paper, we report a method for the determination of total (viable and nonviable) bacterial content in airborne particles, using muramic and dipicolinic acids as biomarkers of bacteria and bacterial spores, respectively. The analytical procedure was optimized with bacteria and spores of Bacillus subtilis. After extraction and purification, the two biomarkers were analyzed by HPLC-ESI-MS/MS and their percentage was evaluated to be used as conversion factor. The present method for the determination of the total bacterial content was then applied to environmental samples, after a proper collection in an urban site. Thanks to the use of a low pressure impactor, capable of fractionating particles into the range of 0.03–10 μm, it was also possible to study the bacterial content in ultrafine, fine, and coarse particulate matter. The results from this study showed that muramic and dipicolinic acids can be determined together in one chromatographic run in reversed phase ion pair chromatography. Bacteria were more abundant than bacterial spores in the urban atmosphere, both showing a higher concentration in the coarse fraction of particles, although bacteria and bacterial spore amounts per unit mass of ultrafine particles were higher than in fine and coarse particles. © 2016, Springer-Verlag Berlin Heidelberg

Analisi dell'evoluzione dell'uso del suolo e del sistema rurale nei territori dei comuni della pianura bolognese nell'ultimo cinquantennio

Analisi degli aspetti geomorfologici, delle dinamiche dell'uso e della copertura del suolo nonché delle trasformazioni geo-idrologiche avvenute dal dopoguerra ad oggi, al fine di mettere in luce le criticità e le potenzialità di sviluppo del territorio. Difatti, una visione di insieme del territorio nelle sue componenti antropiche e naturali, associata a sua volta ad una rappresentazione evolutiva dell'uso del suolo e della geomorfologia può rappresentare lo strumento di base per pianificare mirate e corrette azioni di sviluppo sostenibile ed a seconda delle scelte adottate nell'utilizzo dei suoli, semplificare la programmazione di qualsiasi intervento gestionale. Dal primo dopoguerra ad oggi, la graduale perdita di territorio naturale è stata accompagnata da una altrettanto graduale alterazione e fossilizzazione delle dinamiche. I processi naturali dell'ambiente e la capacità dei suoi elementi di interagire, trasformarsi e costruire il paesaggio, si sono progressivamente perduti nel tempo, in modo talmente drastico, che in molti casi hanno invertito il proprio senso evolutivo. I molti casi di irrazionale sfruttamento dei suoli possono divenire decisamente preoccupanti soprattutto quando la destinazione d'uso di un luogo viene disposta senza conoscere a fondo il contesto territoriale di riferimento e le sue tendenze evolutive e senza avere bene chiare le possibili alternative e/o misure di compensazione.Il gruppo di ricerca, si propone attraverso le analisi GIS e la costruzione di modelli DEM del territorio, di analizzare le complesse interazioni tra l'evoluzione dell'antropico e del territorio naturale per scomporre le potenzialità dei suoli in funzione dell'utilizzo agricolo e nello specifico valutare le buone pratiche di gestione integrata agroambientale.Il presente progetto nasce quindi dall'esigenza di valorizzare gli aspetti territoriali tipici del paesaggio rurale ed extraurbano, attraverso la definizione di misure e procedure di "best-practice" secondo i principi dello sviluppo rurale sostenibile ed anche in relazione a quanto previsto dalle Misure Agroambientali di cui al REGOLAMENTO (CE) N. 1257/1999 del CONSIGLIO del 17 maggio 1999. E' proprio nella politica agricola comunitaria che sono state introdotte le prime misure intese a sostenere il miglioramento delle strutture agrarie tenendo in debita considerazione l'inserimento ambientale delle produzioni, secondo i principi dello sviluppo sostenibile e dell'Agenda 21 Locale (Rio, 1992).Il target della ricerca è stato quello di valutare lo scenario evolutivo dell'uso del suolo e del tessuto urbano e naturale e proporre modelli di gestione sostenibile ambientale, economica e di sviluppo sociale finalizzati ad una valorizzazione ambientale e culturale del territorio in genere, nonché delle attività antropiche compatibili (con particolare riferimento all'agricoltura) che ad esso afferiscono

Riqualificazione integrata con esoscheletro in ottica lyfe cycle thinking: applicazione a un edificio esistente

A relevant part of the Italian building heritage is characterized by shortcomings in terms of ener- gy, structure, living comfort and architecture. This implies a high environmental impact due to the energy consumption and to the repair actions, demolition and disposal following a possible earth- quake. Improving the performance of buildings through interventions focused on solving individ- ual problems at the time is not the best solution both from the economic and the sustainability point of view. The approach proposed herein is to operate in an integrated manner on the build- ings, planning holistic interventions that overcome the drawbacks of traditional interventions and guarantee maximum benefits with minimum costs, thereby representing an effective way for the rehabilitation of the existing building stock. This paper illustrates the intervention criteria and the advantages that may be achieved with a holistic approach conceived within a Life Cycle Thinking perspective, on a typical residential building built in the 1950s. The goal is to achieve a high building performance by also taking advantage of tax rewards and real estate benefits to obtain a substantial reduction of the cost of the intervention