Exciting new bloodspot screening

(The following is a summary from James O'Brien, IPWSO Board member, from Australia, who attended the recent IPWSO Conference in Toronto)

A Novel FMR1/SNRPN methlation test for Fragile X Syndrome and chromosome 15 imprinting disorder screening of symptomatic children and newborns.

By David Godler, Cyto-Molecular Diagnostics Research Laboratory, Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Melbourne, Australia.

David Godler spoke about his research into newborn bloodspot screening over the past 18 months, primarily into Fragile X diagnostic. Recent funding from the Foundation for Prader-Willi Research, USA, has enabled David to expand his work with fragile X to include the Chromosome 15 imprinting disorders: Prader-Willi Syndrome (PWS), Angelman Syndrome and 15Q Duplication Syndrome.

The presentation was about David’s two new methods of testing blood collected in a tube and blood spots from adults, children and newborns. A newborn blood spot is the tiny spot of dried blood on blotting paper that is already taken through a heel pin prick for almost all newborns within the first few days of life in many countries. The tests currently performed on this material identify 30 or so conditions including phenylketonuria, hypothyroidism and cystic fibrosis, but not PWS.

Initially David and his team developed a new Methylated Specific Quantitate Melt Analysis (MS-QMA) test for Fragile X. To enable him to test 100,000 newborn bloodspots he also developed technologies to automate the process and to confirm positive findings. He is now able to test 100 samples in 90 minutes rather than the old 2 to 3 day turnaround for each test. At the same time his team developed new software to monitor both the results and accuracy of the test, and this method had been published for Fragile X. Accuracy of this test appears to be nearing 100%.

The beauty of his new test is that it can be performed on blood spot material left over from other routine testing. This means that the babies suspected of PWS would not be required to undergo collection of another blood sample required for more traditional diagnostic methods. It would also mean that the PWS babies that may not be tested for PWS and initially missed because they may be premature or may not have typical PWS, would be picked up by this new test. This would be because newborn blood spot testing reaches virtually all babies born irrespective of symptoms, but current PWS testing is only performed on babies that show symptoms that are recognized by doctors to be associated with PWS.

David’s first step in PWS test development was to analyse blood DNA samples from patients that had PWS symptoms, with only 9 patients confirmed to have PWS by standard DNa testing. From the first 30 symptomatic referral samples tested, his MS-QMA test confirmed 100% agreement for samples positive by standard testing. In addition to these  3 previously undiagnosed cases of PWS were identified. In order to prove that his new test was not simply showing false positives, David needed to develop an even more accurate second line confirmation test.

His second test he has called CINQ Droplet Digital PCR, which looks at individual methylated and unmethylated chromosomes suspended in miniature droplets. Exact details of how this new test works (or what the letters even stand for) are not yet published, however, its accuracy appears to be much higher again than standard testing, able to detect abnormal methylation down to an unprecedented less than 0.1% in the PWS deletion group. Furthermore, the new test has confirmed positive MS-QMA results missed by standard testing, and is showing that a number of previously diagnosed Uni Paternal Disomy (UPD) individuals may actually be Triasomi 15. The unexpressed male 15 chromosome appears to be hiding in the background rather than showing up on previous more traditional tests.

Furthermore, a new group of Mosaic PWS is likely to emerge. David is doing some further work on this subset. (With mosacizm PWS may not be present in every cell in the body. Depending on which cells in the body have the PWS variations may result in changes in how the characteristics of the Syndrome present, especially in UPD).

So, what does this mean for children with PWS?

• ·       David and his team have come up with two new and seemingly very accurate methods of testing for PWS using blood spots and other sample types.

• ·       The tests appear to be picking up previously unconfirmed cases of PWS.

• ·       A new subset of T15 within the UPD group seems likely.

• ·       A new phenotype of Mosacizm is possible.

• ·       Bloodspots can be taken at newborn or at any age, resulting in a less invasive, more accessible and sensitive method of obtaining a PWS DNA test than is currently available.

 Where to from here?

 In 2015 David and his team have been awarded a large NHMRC grant to test 100,000 newborns for fragile X (the world’s largest fragile X prevalence study), and is hoping to use the remaining materials and expensive infrastructure initially developed for Fragile X, for PWS testing. Funding is currently an issue for this larger project, and David is now applying to multiple granting bodies to make this possible. In a less expensive project, over the next 3 years David and his team has started recruiting and assessing PWS patients to perform analysis of how the low level mosaicism identified by his two new tests related to variation in severity of PWS, especially in UPD. Concurrently, PWSA Australia has commissioned a Health Economics Report to analyse the financial benefit of early diagnosis. If the test is proven accurate, David and PWSA Australia will approach State or National Newborn Bloodspot Screening Programs with his two tests and our Health Economics Report to apply for the inclusion of PWS in their testing programs for all babies born in Australia.

If admission to the NBS programs is successful:

·       We should start to see a diagnosis within a few days of birth avoiding unnecessary multiple tests and prolonged family stress when waiting for a diagnosis.

·       Doctors, specialists and scientists will be able to develop a more detailed understanding of the various phenotypes of PWS, possibly enabling better targeted clinical interventions.

·       Testing of all babies will give a definitive answer regarding the prevalence of PWS live births in Australia.

David cited individual colleges that are assisting in the research from Cyto-Molecular Diagnostic Research Group, Victorian Clinical Genetics Services, Royal Children’s Hospital, Victorian and New South Wales Newborn and Metabolic Screening laboratories, Genetics and Learning Disabilities Services (Newcastle and The Children’s Hospital (Westmead, Sydney).

David also acknowledged assistance from a number of organisations including VCGS, Royal Children’s Hospital Foundation, The Marion and EH Flick Trust, Australian Government, Thrasher Research Fund, and Foundation for Prader Willi Research

Note: This report is James O’Brien’s understanding of David Golder’s presentation and may contain inaccuracies in its interpretation. 4 August 2016

Don't let Eugenia down!

Not so very long ago, let's say 20 years ago, these were the most well-known photographs of someone with Prader-Willi syndrome.

Who was she?
Some time in 1680, this young girl, just 6 years old, was painted by the Spanish royal court painter because of her 'unusual deformity'.  Her name was Eugenia Martinez Valleja, but no one really knew her name she was just known as La Monstrua. Even today, if asked, few would remember her real name - Eugenia.  Poor kid, never to be understood.

When Dr Andrea Prader (who, along with Drs Willi and Labhart, first wrote about the syndrome and later gave it their name) first saw this painting he declared that in all likelihood Eugenia had Prader Willi syndrome.   Some stories tell of her very bad temper and how she would be given into in order to avoid her strenuous wrath.  But we don't know what became of her, or how long she lived we just recognise her as an early icon of Prader-Willi syndrome.

Eugenia's portrait was painted 336 years ago.  It was to take another 277 years before our Doctor friends Prader, Willi, and Labhart were to distinguish a cluster of features that led to the naming of the syndrome.  This occurred in 1957 and the life expectancy was still very low with most children dying before the age of 20.  Why was this?  Well, it certainly had something to do with the knowledge we have today simply not being available. Literacy itself was a challenge and life expectancy in 1600s was only 35 if you were lucky and healthy.  Infant mortality was extremely high.  So Eugenia was lucky to even live as long as 6 years.

Was Eugenia the only one?
Well, no.  Today we know that the incidence rate of PWS is 1:12,000.  So one might expect that in a country like Spain where Eugenia was born and where today's population is just short of 47 million, that there might theoretically be a PWS population of 39,000.  Let's take it further; on earth live approximately 7 billion people.  Using the same incidence rate, that gives us, theoretically, 5.8 million  people with PWS.  Where do they all live?  Answer - in every country and everywhere.

How can we reach out to nearly 6 million people?  We do it country by country, PW Association by PW Association, family by family, person by person, one day at a time.

Many die before we can reach them.   Young Sultan from Kazakhstan was not able to access the medical treatment he needed.  There was no parent support group, very little medical knowledge and Sultan's condition gradually became worse.  Sadly, he died on February 2, 2011. Sultan was much loved by his family.

He was 18 years old.

His family had only just been able to contact IPWSO shortly before he died and through our medical consultants had been able to learn about the syndrome. 








This is Shelly.  She died when she was 21 years old,  Life for Shelly and her family was incredibly hard.  PWS was not understood until it was already too late.  There have been many cases like this, far too many.

I am showing you these photos because this is what life is like, still, for many families around our world.  I am showing you because in the last 60 years since PWS has been described, we have come a long long way, but we still have a long way to go before we can claim parity amongst nations.


IPWSO has been around for 25 years.  What have we done?

• Helped country after country claim the right to a better health care programme for PWS.
• Supported research and helped fight for the right to have GHT available for children around the world 
• Hosted international conferences (9 to date) where research has been encouraged and shared
• Collected together 103 countries to form our very large 'family' of support
• Translated information into over 15 different languages
• Supplied up-to-date information on scientific research papers, distributed quarterly
• Supported families, teachers, residential caregivers and provided information and training

By doing this, we can see the results we have achieved in the faces of those with PWS, their families, teachers and caregivers.  We know we are making a difference.



Where do we go to from here?   

We can see the benefit of all of our work around the world:   Happy, healthy young children, the greater majority of whom are able to access Growth Hormone treatment, attend school and be supported by their teachers, thanks to the information that their families provide, that their country PW Associations provide, that IPWSO provides.

We encourage research by continuing to support our own IPWSO conferences,

We support growing PW Associations by sending internationally renowned speakers to meetings, seminars and first-time conferences where there has previously been none.

We continue to translate information

We continue to support families.

How does IPWSO operate?

Very simply!  We have two part-time paid workers, a Programme Director and a Communications Coordinator.  We have a Board of Directors and a Clinical & Scientific Advisory Board, we have a residential care-providers' Board (PPCB) and a Family Support Board (Famcare) all of these people work pro bono for us.

We have delegates (a parent delegate, medical delegate and caregiver delegate) from each our member countries who make up the backbone of IPWSO.  We are in regular contact with our member countries and rely on them to help us spread information around the world.

How is IPWSO funded?
When IPWSO held its very first international conference, funding was granted from the World Health Organisation.  After that, and when it became obvious that there would be a demand for Growth Hormone treatment, Pfizer gave IPWSO an unrestricted grant for many years.  But nowadays funding is much harder to find.  We no longer receive grants from Pfizer and we rely simply on the subscriptions from our member countries and donations from many of our philanthropic friends to whom we are hugely indebted.

Frankly, finding funding is very difficult!
If you feel you could support us in any way at all, would you please either contact us directly, or donate via our iDonate page which will take donations both small and large!

Don't forget, every dollar donated before the end of the year will be matched by the KB Anderson Trust!

Is it too much to ask?

What's our greatest wish?
To find ways of helping everyone, every family, every country where there is a need to support people with PWS live a fulfilled and happy life.  Forever.  We owe it to Eugenia not to let her down.

Don't let Eugenia down!

Not so very long ago, let's say 20 years ago, these were the most well-known photographs of someone with Prader-Willi syndrome.

Who was she?
Some time in 1680, this young girl, just 6 years old, was painted by the Spanish royal court painter because of her 'unusual deformity'.  Her name was Eugenia Martinez Valleja, but no one really knew her name she was just known as La Monstrua. Even today, if asked, few would remember Eugenia.

When Dr Andrea Prader (who, along with Drs Willi and Labhart, first wrote about the syndrome and later gave it their name) first saw this painting he declared that in all likelihood Eugenia had Prader Willi syndrome.   Some stories tell of her very bad temper and how she would be given into in order to avoid her strenuous wrath.  But we don't know what became of her, or how long she lived we just recognise her as an early icon of Prader-Willi syndrome.

Eugenia's portrait was painted 336 years ago.  It was to take another 277 years before our Doctor friends Prader, Willi, and Labhart were to distinguish a cluster of features that led to the naming of the syndrome.  This occurred in 1957 and the life expectancy was still very low with most children dying before the age of 20.  Why was this?  Well, it certainly had something to do with the knowledge we have today simply not being available. Literacy itself was a challenge and life expectancy in 1600s was only 35 if you were lucky and healthy.  Infant mortality was extremely high.  So Eugenia was lucky to even live as long as 6 years.

Was Eugenia the only one?
Well, no.  Today we know that the incidence rate of PWS is 1:12,000.  So one might expect that in a country like Spain where Eugenia was born and where today's population is just short of 47 million, that there might theoretically be a PWS population of 39,000.  Let's take it further; on earth live approximately 7 billion people.  Using the same incidence rate, that gives us, theoretically, 5.8 million  people with PWS.  Where do they all live?  Answer - in every country and everywhere.

How can we reach out to nearly 6 million people?  We do it country by country, PW Association by PW Association, family by family, person by person, one day at a time.

Many die before we can reach them.   Young Sultan from Kazakhstan was not able to access the medical treatment he needed.  There was no parent support group, very little medical knowledge and Sultan's condition gradually became worse.  Sadly, he died on February 2, 2011. Sultan was much loved by his family.

He was 18 years old.

His family had only just been able to contact IPWSO shortly before he died and through our medical consultants had been able to learn about the syndrome. 








This is Shelly.  She died when she was 21 years old,  Life for Shelly and her family was incredibly hard.  PWS was not understood until it was already too late.  There have been many cases like this, far too many.

I am showing you these photos because this is what life is like, still, for many families around our world.  I am showing you because in the last 60 years since PWS has been described, we have come a long long way, but we still have a long way to go before we can claim parity amongst nations.


IPWSO has been around for 25 years.  What have we done?

• Helped country after country claim the right to a better health care programme for PWS.
• Supported research and helped fight for the right to have GHT available for children around the world 
• Hosted international conferences (9 to date) where research has been encouraged and shared
• Collected together 103 countries to form our very large 'family' of support
• Translated information into over 15 different languages
• Supplied up-to-date information on scientific research papers, distributed quarterly
• Supported families, teachers, residential caregivers and provided information and training

By doing this, we can see the results we have achieved in the faces of those with PWS, their families, teachers and caregivers.  We know we are making a difference.



Where do we go to from here?   
 
We can see the benefit of all of our work around the world:   Happy, healthy young children, the greater majority of whom are able to access Growth Hormone treatment, attend school and be supported by their teachers, thanks to the information that their families provide, that their country PW Associations provide, that IPWSO provides. 

We encourage research by continuing to support our own IPWSO conferences,

We support growing PW Associations by sending internationally renowned speakers to meetings, seminars and first-time conferences where there has previously been none.

We continue to translate information

We continue to support families.

How does IPWSO operate?

Very simply!  We have two part-time paid workers, a Programme Director and a Communications Coordinator.  We have a Board of Directors and a Clinical & Scientific Advisory Board, we have a residential care-providers' Board (PPCB) and a Family Support Board (Famcare) all of these people work pro bono for us. 

We have delegates (a parent delegate, medical delegate and caregiver delegate) from each our member countries who make up the backbone of IPWSO.  We are in regular contact with our member countries and rely on them to help us spread information around the world.

How is IPWSO funded?
When IPWSO held its very first international conference, funding was granted from the World Health Organisation.  After that, and when it became obvious that there would be a demand for Growth Hormone treatment, Pfizer gave IPWSO an unrestricted grant for many years.  But nowadays funding is much harder to find.  We no longer receive grants from Pfizer and we rely simply on the subscriptions from our member countries and donations from many of our philanthropic friends to whom we are hugely indebted.

Frankly, finding funding is very difficult!
If you feel you could support us in any way at all, would you please either contact us directly, or donate via our iDonate page which will take donations both small and large!

What's our greatest wish?
To find ways of helping everyone, every family, every country where there is a need to support people with PWS live a fulfilled and happy life.  Forever.  We owe it to Eugenia not to let her down.

Is it too much to ask?

Body Composition, Associated Conditions, Causes of Deaths

Contributed by

Charlotte Höybye (IPWSO Clinical Scientific Advisory Board member)

Department of Endocrinology, Metabolism and Diabetology

Karolinska University Hospital

Stockholm, Sweden

It is well known that health improves with less obesity and increased physical fitness. However, in PWS much is unknown and there are many ongoing studies on these topics providing new and updated information.

In the following I have summarized some of the presentations that I found useful for clinical practice and for future studies.  

A detailed knowledge of body composition in children with PWS is scarce. Camila E. Orsso and colleagues from USA carefully examined body composition in 17 children with PWS compared to 16 obese controls. They showed that PWS children have similar amounts of fat in the abdomen, but reduced quantity of skeletal muscle mass compared to healthy, obese children. These findings might be some of the explanation for the difficulties with coordination, balance and posture observed in PWS.

All studies on growth hormone treatment in adults with PWS have uniformly shown improvement in body composition. Graziano Grugni and colleagues from Italy studied the effect of a mean of 7.5 years of growth hormone treatment in 21 adults with PWS compared to 20 adults with PWS without growth hormone treatment.  Improvements were observed in body composition, total cholesterol levels, IGF-I levels, liver morphology, and pulmonary function, in the absence of negative effects on carbohydrate metabolism and cardiac function. The present study adds to previous studies all showing beneficial effects of GH therapy in adults with PWS. This treatment is however not a registered treatment for adults with PWS in any country as yet.  

The presence of latent central adrenal insufficiency (CAI) in PWS remains unclear as well as whether PWS individuals have an alternation of the HPA (Hypothalamus-Pituitary-Adrenal; HPA) axis or not. Yuji Oto and colleagues from Japan evaluated the HPA axis in 36 children and adults with PWS using the insulin tolerance test. All 36 participants had normal baseline levels of ACTH and cortisol as well as a normal response to the test, however, in 25 peak cortisol was delayed. The clinical consequences of these findings are unclear and further studies are needed. 

Jorgelina Stegmann and colleagues from Argentina presented data regarding gallstones in PWS. They had examined 19 individuals with PWS and found that 36.84% had gallstones, as compared to approximately 15% in the general population. Similar risk factors for gall stones as for general population were noted, being obesity, sudden weight loss and family history of gallstones. Gallstones might result in abdominal pain and discomfort and it is important in the clinical evaluation of patients with PWS to be aware of the high reported frequency of gall stones.

Ann M. Manzardo and colleagues from USA presented data on the frequency of blood clots obtained from a 66 item survey distributed electronically to active members of the Prader-Willi Association (USA). Interim results from 539 responders identified 22 (4%) with a history of clots. The preliminary results suggest an increased risk of blood clots in PWS with increased age, obesity, leg edema, vasculitis, and family history of clots whereas individuals with clots were less likely to have received growth hormone. Further studies are needed to evaluate the effectiveness of interventions such as weight loss, anticoagulation, risks associated with genetic predisposition and PWS subtype and potential benefits of growth hormone therapy on the causation and development of blood clots in PWS.

P Lemoine and colleagues from France retrospectively collected deaths certificates from 2004 to 2012. They documented younger age at death in PWS 31 years vs. 73 years in the general population. The first cause of death was respiratory failures representing 48.2% (33% in children and 50.6% in adults) in PWS vs. 6% in the general population. The second cause of death was sudden death 17.7% (25% in children and 16.4% in adults) and the third cause cardiac disease 11.7% (8.3% in children and 12.3% in adults). Prospective studies are required in different countries in order to describe more precisely the causes of deaths and for implementation of specific prevention strategies.

In this context systematic recording is important to get information on health and function of individuals with PWS. Jessica Bohonowych and colleagues from USA presented The Global Prader-Willi Syndrome registry, which is managed and funded by the Foundation for Prader-Willi Research, is hosted by the National Organization of Rare Disorders (NORD), and is a participant in the NIH-supported Global Rare Disease Registry. The Global PWS Registry was launched in May 2015 and has ~800 participants as of early 2016. It is comprised of a series of 37 web-based surveys covering natural history. Data is self-reported by a parent or guardian of individuals with PWS. Future plans for the registry is to continue enrollment, promote survey completion, and begin leveraging de-identified data through collaborations with researchers, companies, and other parties involved in advancing solutions for PWS.