The Experience of the first adult Neurogenetics Clinic in

The Experience of the first adult

Neurogenetics Clinic in Ireland

Dr Diana Olszewska (Neurology), Dr Terri McVeigh (Genetics), Professor Tim Lynch (Neurology)

Heritable Neurological Disease

• A number of neurological conditions have a genetic aetiology – Implications for wider family– Incurable disease

• Most can be handled appropriately within a routine neurology clinic with onward referral for genetic counselling if necessary

• e.g. Huntington’s disease

• However, some specific cases are complex, rare or uncertain and benefit from multi-disciplinary input

• It is recommended that there be a minimum of 1 clinical genetics post and 1 neurology post designated for Neurogenetics service for a population of 2 million1

1. Genetic Services for Neurological Disorders, ABN and Clinical Genetics Society Report, 2003

Neurology

• Rare disorders require extensive literature review and specialist diagnostic approach• Time constraints in routine clinics does not

facilitate this easily

• Limited time for explanation of inheritance, recurrence risks• Patient concerns regarding family planning,

prenatal diagnosis

• Practical issues regarding send-out of samples to specialist laboratories

Genetics

• Complex genetic conditions require careful explanation regarding natural history and implications for prognosis, family planning, and recurrence risk

• Genetic testing can be directed based on careful phenotyping

• Waiting list – Priority <4 months

– Routine ..6-18 months!

• Frequent failure to attend

• Hesitance in proceeding with pre-symptomatic testing

https://www.eshg.org/111.0.html.

Teamwork!

• Can combined clinic address these issues?

• Neurogenetics clinic

– 1 neurologist + 1 geneticist

• Real-time phenotyping

• Active discussion regarding possible differential diagnoses

• Valuable opportunity for detecting important or unresolved genetic issues

• Foundation for genetic counselling

Patient simultaneously reviewed by Registrars

1 Neurology

1 Genetics

Simultaneous review by Consultants

1 Neurology

1 Genetics

Brainstorming!

Likely diagnosis suggested

Workflow

• Detailed history • Personal and familial

• Pedigree drawing • Thorough neurological examination • Review of investigations performed to date

• Review of case

• Active patient input in discussion• Literature review • Differential diagnosis

• Specialist tests requested

• Inheritance pattern and recurrence risks outlined

Benefits

• Two heads are better than one! – Widens differential diagnosis

• One clinic visit – Reduced repetition for patient– Time efficient – Family members can attend together or separately

• Familiarity with Dublin Neurological Institute – Less anxiety

• Improves doctor-patient relationship• Active participation in discussion • Patient understands the process better• Dedicated “team” of doctors working on rare disorder

A bridge to Crumlin

• Introduction of concept of genetic counselling and/or pre-symptomatic testing for unaffected family members

– Can explain process

– Allay anxiety surrounding “the test”

• Explain no obligation

• Define risk to patient and family members

– Continuity of care

• Genetic registrar working in Department of clinical genetics

The Adult Neurogenetic ClinicDublin Neurological Institute

• First and only one in Ireland

• Once a month

• Commenced November 2014

• 1.5h dedicated per patient

– Reviewed by 4 doctors

Neurogenetic clinic

• 25 patients

– 16 families

– 3 returns

• Age 22-78

All-Ireland Service

Disorder N Action

Frontotemporal Dementia 10 Referral for Genetic Counselling /Pre-symptomatic testing Different genes in different families: MAPT, GRNAdvice re prenatal pre-implantation diagnosis Referral for psychology input 1 patient: Review of diagnosis - personality later attributed to organic (reversible) cause!

Leucodystrophy 1 Referral to international specialist

Ataxia-Telangiectasia 1 Referral for genetic counselling Advice for cancer risk for heterozygous carriers in family

Parkinson’s disease 3 Young onset – Parkin testing (n=2, 1 positive, 1 negative)Older onset (familial) – LRRK2 testing

Pure ataxia 2 Extensive diagnostic work up

Spastic Ataxia 2 Further testing (unknown genetic aetiology after multiple tests)

GLUT 1 deficiency 1 Referral for genetic counsellingConsideration: Triheptanoin therapy

Spinocerebellar ataxia with writer’s cramp

1 Diagnosis – SCA6

Familial MS 1 Counselling regarding potential genetic contribution Discussion re limitations of available genetic investigations

• Multiple family members affected• New mutation “+15”, dominant inheritance

– 50-50 chance

• Numerous members of the family: – 4 siblings – 1 cousin – 1 son

• Referral to Crumlin for counselling and pre-symptomatic testing

Brain. 2015 Oct;138(Pt 10):3100-9. By Prof T Lynch

Glut 1 deficiency

• 22 year old female • Episodic Myoclonic dystonia and tremor

– Increasing frequency with stress, fatigue, heat– Significant impact on quality of life

• No family history of note • Test:

– Next generation panel: Dystonia and Parkinsonism – Mutation identified in SLC2A1

• ? De novo event (father is deceased, mother unaffected)• 50/50 recurrence risk

• Declined referral for genetic counselling– Felt she had enough information for now

By Dr T McVeigh

Summary of outcomes

• Twenty-five patients have attended a pilot clinic

• Identification of pathogenic mutations directed screening and treatment, and facilitated onward referral of family members for genetic counselling (n=8, 33%).

• A number of novel mutations were identified in MAPT (“missing tau” mutation), SLCA1 and Progranulin.

• A number of patients had phenotypic features not previously reported; e.g. writer’s cramp in SCA6; paroxysmal myoclonus in GLUT1 deficiency.

Summary of outcomes II

• Appropriate referrals were made for non-neurological sequelae of genetic mutations, e.g. breast cancer screening for carriers of ATM mutations.

• New treatments were considered based on genetic diagnoses, e.g. triheptanoin in GLUT1 deficiency.

• We appropriately referred undiagnosed complex patients (n=2) to international experts.

Conclusions

• The Neurogenetics clinic

– Addresses a gap in service provision for complex families with neurogenetic disorders

– Allows timely identification of rare and atypical diagnoses.

• Role for other disciplines

– Psychology

– Cardiology for muscular dystrophies?

Neurogenetics

• Rare single gene disorders account for a small proportion of neurological presentations

– But require specific awareness, recognition and specialist referral

• Thank you