Healthcare utilization and clinical characteristics of genetic epilepsy in electronic health records

Understanding the clinical characteristics and medical treatment of individuals affected by genetic epilepsies is instrumental in guiding selection for genetic testing, defining the phenotype range of these rare disorders, optimizing patient care pathways and pinpointing unaddressed medical need by quantifying healthcare resource utilization. To date, a matched longitudinal cohort study encompassing the entire spectrum of clinical characteristics and medical treatment from childhood through adolescence has not been performed. We identified individuals with genetic and non-genetic epilepsies and onset at ages 0-5 years by linkage across the Cleveland Clinic Health System. We used natural language processing to extract medical terms and procedures from longitudinal electronic health records and tested for cross-sectional and temporal associations with genetic epilepsy. We implemented a two-stage design: in the discovery cohort, individuals were stratified as being 'likely genetic' or 'non-genetic' by a natural language processing algorithm, and controls did not receive genetic testing. The validation cohort consisted of cases with genetic epilepsy confirmed by manual chart review and an independent set of controls who received negative genetic testing. The discovery and validation cohorts consisted of 503 and 344 individuals with genetic epilepsy and matched controls, respectively. The median age at the first encounter was 0.1 years and 7.9 years at the last encounter, and the mean duration of follow-up was 8.2 years. We extracted 188,295 Unified Medical Language System annotations for statistical analysis across 9659 encounters. Individuals with genetic epilepsy received an earlier epilepsy diagnosis and had more frequent and complex encounters with the healthcare system. Notably, the highest enrichment of encounters compared with the non-genetic groups was found during the transition from paediatric to adult care. Our computational approach could validate established comorbidities of genetic epilepsies, such as behavioural abnormality and intellectual disability. We also revealed novel associations for genitourinary abnormalities (odds ratio 1.91, 95% confidence interval: 1.66-2.20, P = 6.16 × 10-19) linked to a spectrum of underrecognized epilepsy-associated genetic disorders. This case-control study leveraged real-world data to identify novel features associated with the likelihood of a genetic aetiology and quantified the healthcare utilization of genetic epilepsies compared with matched controls. Our results strongly recommend early genetic testing to stratify individuals into specialized care paths, thus improving the clinical management of people with genetic epilepsies.

Heuristic automation for decluttering tactical displays

Tactical displays can quickly become cluttered with large numbers of symbols that can compromise effective monitoring. Here, we studied how heuristic automation can aid users by intelligently "decluttering" the display. In a realistic simulated naval air defense task, 27 experienced U.S. Navy users monitored a cluttered airspace and executed defensive responses against significant threats. An algorithm continuously evaluated aircraft for their levels of threat and decluttered the less threatening ones by dimming their symbols. Users appropriately distrusted and spot-checked the automation's assessments, and decluttering had very little effect on which aircraft were judged as significantly threatening. Nonetheless, decluttering improved the timeliness of responses to threatening aircraft by 25% as compared with a baseline display with no decluttering; it was especially beneficial for threats in more peripheral locations, and 25 of 27 participants preferred decluttering. Heuristic automation, when properly designed to guide users' attention by decluttering less important objects, may prove valuable in many cluttered monitoring situations, including air traffic management, crisis team management, and tactical situation awareness in general.

A fiber optic biosensor (FOBS) to monitor mutans streptococci in human saliva

A fiber optic biosensor (FOBS) to monitor mutans streptococci activity in human saliva is developed. The biosensor utilizes e fiber optic evanescent wave spectroscopy to monitor a bacterial mediated biochemical reaction. To achieve this, a short length of the cladding is removed; the fiber core surface is treated and coated with a thin film of porous glass medium using sol-gel technique. The mutans streptococci mediated reaction with sucrose is monitored using a photosensitive indicator, which is immobilized within the porous glass coating. Spectroscopic analysis shows that the transmitted intensity at 597 nm increases conspicuously when monitored for 120 min. Two distinct phases are observed, one from 0 to 60 min and the other from 60 to 120 min. A negative correlation coefficient between the rate of increase in absorption peak intensity recorded by the FOBS and the decrease in pH measured using the pH meter, was calculated to be rho=-0.994. This investigation highlights the potential benefits of this sensor to monitor mutans streptococci activity in saliva.

Efficient Stimuli for Evoking Auditory Steady-State Responses

OBJECTIVE

To compare the magnitudes of the steady-state responses evoked by several types of stimuli, and the times required to recognize these responses as significant.

DESIGN

In the first two experiments, we examined auditory steady-state responses to pure tones, broadband noise and band-limited noise. The stimuli were amplitude modulated in the 75 to 100 Hz range with sinusoidal or exponential envelopes. A third experiment investigated the effects of exponential envelopes on the responses to broadband noise. The final experiment examined auditory steady-state responses evoked by rapidly presented transient stimuli, such as clicks, brief tones and brief noise-bursts. All stimuli were presented dichotically at intensities 30 to 50 dB above behavioral thresholds. The subjects were adults, who drowsed or slept during the recording sessions.

RESULTS

The responses to the noise were larger than the responses to the tones. At an intensity of 32 dB nHL, the average amount of time needed to obtain significant responses for the amplitude-modulated noise was 43 sec and the maximum time was 2 minutes. The average time for pure tone stimuli was approximately 2 minutes but 25% of the responses remained undetected after 5 minutes. Combining the responses to all the frequency-specific stimuli showed results similar to using noise stimuli. Using exponential envelopes did not increase response amplitudes for noise stimuli. At 45 dB nHL, the steady-state responses to clicks and other transient stimuli were larger than responses to the broadband noise. The average time to detect steady-state responses to transient stimuli was approximately 20 sec, which was a little faster than for amplitude modulated noise.

CONCLUSIONS

Auditory steady-state potentials evoked by amplitude modulated noise or transient stimuli might be useful in providing rapid and objective tests of hearing during screening procedures. Another approach might be to record responses to multiple frequency-specific stimuli and to evaluate the combined responses for a rapid indication that some hearing is present.

Total protein measurement using a fiber-optic evanescent wave-based biosensor

A novel method and instrumental system to determine the total protein concentration in a liquid sample is described. It uses a fiber optic total protein sensor (FOPS) based on the principles of fiber optic evanescent wave spectroscopy. The FOPS applies a dye-immobilized porous glass coating on a multi-mode optical fiber. The evanescent waves at the fiber optic core-cladding interface are used to monitor the protein-induced changes in the sensor element. The FOPS offers a single-step method for quantifying protein concentrations without destroying the sample. The response time and reusability of the FOPS are evaluated. This unique sensing method presents a sensitive and accurate platform for the quantification of protein.

The use of phase in the detection of auditory steady-state responses

OBJECTIVE

To investigate how phase measurements might facilitate the detection of auditory steady-state responses.

METHODS

Multiple steady-state responses were evoked by auditory stimuli modulated at rates between 78 and 95 Hz and with intensities between 50 and 0 dB SPL. The responses were evaluated in 20 subjects after 1, 2, 4, and 6 min. The responses were analyzed in the frequency domain using 4 different detection protocols: (1) phase-coherence, (2) phase-weighted coherence, (3) F test for hidden periodicity, and (4) phase-weighted t test. The phase-weighted measurements were either based on the mean phase of a group of normal subjects or derived for each subject from the phase of the response at higher intensities.

RESULTS

Detection protocols based on both phase and amplitude (F test and phase-weighted t test) were more effective than those based on phase alone (phase coherence and phase-weighted coherence) although the difference was small. Protocols using phase-weighting were more effective than those without phase-weighting. The lowest thresholds for the steady-state responses were obtained using the phase-weighted t test.

CONCLUSION

Threshold detection can be improved by weighting the detection protocols toward an expected phase, provided that the expected phase can be reliably predicted.

Human auditory steady-state responses to tones independently modulated in both frequency and amplitude

OBJECTIVE

Independent amplitude and frequency modulation (IAFM) of a carrier tone uses two different modulating frequencies, one for amplitude modulation (AM) and one for frequency modulation (FM). This study measured the human steady-state responses to multiple IAFM tones. The first question was whether the IAFM responses could be recorded without attenuation of the AM and FM components. The second question was whether IAFM stimuli would provide a more effective demonstration of responses at intensities near threshold than the responses to AM tones. The third question was whether the responses to multiple IAFM stimuli would relate to the discrimination of words at different intensities.

DESIGN

Multiple AM, FM, or IAFM stimuli were presented simultaneously. Responses were recorded between the vertex and the neck and analysed in the frequency domain. The first experiment compared IAFM responses with AM and FM responses. The second experiment compared IAFM responses with AM responses between intensities 20 to 50 dB SPL. The third experiment related the IAFM responses to the discrimination of monosyllabic words at intensities between 20 and 70 dB SPL.

RESULTS

Steady-state responses to the individual component of the IAFM stimuli were clearly recognizable although attenuated a little (14%) from the responses to AM or FM alone. Using IAFM stimuli was not different than simply using AM stimuli when trying to recognize responses at low intensities. The number of responses detected during multiple IAFM stimulation and the amplitudes of these responses correlated significantly with word discrimination.

CONCLUSIONS

IAFM of a carrier using two different modulating frequencies (one for AM and one for FM) elicits separate AM and FM responses that are relatively independent of each other. These separate responses can be used to detect whether a particular carrier has been processed in the cochlea, but they are not as effective as measuring responses to carriers that have been modulated in both amplitude and frequency at the same modulation frequency (mixed modulation). The detectability of eight different responses (four AM and four FM) to an IAFM stimuli relates well to the ability of subjects to discriminate words. IAFM stimuli therefore show promise as an objective test for assessing suprathreshold hearing.

Weighted averaging of steady-state responses

OBJECTIVE

To compare weighted averaging and artifact-rejection to normal averaging in the detection of steady-state responses.

METHODS

Multiple steady-state responses were evoked by auditory stimuli modulated at rates between 78 and 95 Hz. The responses were evaluated after recording periods of 3, 6 and 10 min, using 5 averaging protocols: (1) normal averaging; (2) sample-weighted averaging; (3) noise-weighted averaging; (4) amplitude-based artifact-rejection; and (5) percentage-based artifact rejection. The responses were analyzed in the frequency domain and the signal-to-noise ratio was estimated by comparing the signals at the modulation-frequencies to the noise at adjacent frequencies.

RESULTS

Weighted averaging gave the best signal-to-noise ratios. Artifact-rejection was better than normal averaging but not as good as weighted averaging. Responses that were not significant with normal averaging became significant with weighted averaging much more frequently than vice versa. False alarm rates did not significantly differ among the protocols. The advantage of weighted averaging was especially evident when stimuli were presented at lower intensities or when smaller amounts (e.g. only 3 or 6 min) of data were evaluated. Weighted averaging was most effective when the background noise levels were variable. Weighted averaging underestimated the amplitude of the responses by about 2%.

CONCLUSION

Weighted averaging should be used instead of normal averaging for detecting steady-state responses.

Multiple auditory steady-state responses to AM and FM stimuli

Multiple auditory steady-state responses were recorded using tonal stimuli that were amplitude-modulated (AM), frequency-modulated (FM) or modulated simultaneously in both amplitude and frequency (mixed modulation or MM). When MM stimuli combined 100% AM and 25% FM (12.5% above and below the carrier frequency) and the maximum frequency occurred simultaneously with maximum amplitude, the MM response was one third larger than the simple AM response. This enhancement occurred at intensities between 50 and 30 dB SPL and at carrier frequencies between 500 and 4000 Hz. The AM and FM components of a MM stimulus generate independent responses that add together to give the MM response. Since AM responses generally occur with a slightly later phase delay than FM responses, the largest MM response is recorded when the maximum frequency of the MM stimulus occurs just after the maximum amplitude.

Human auditory steady-state responses to amplitude-modulated tones: phase and latency measurements

Human auditory steady-state responses were recorded to four stimuli, with carrier frequencies (f(c)) of 750, 1500, 3000 and 6000 Hz, presented simultaneously at 60 dB SPL. Each carrier frequency was modulated by a specific modulation frequency (f(m)) of 80.6, 85.5, 90.3 or 95.2 Hz. By using four different recording conditions we obtained responses for all permutations of f(m) and f(c). The phase delays (P) of the responses were unwrapped and converted to latency (L) using the equation: L=P/(360xf(m)). The number of cycles of the stimulus that occurred prior to the recorded response was estimated by analyzing the effect of modulation frequency on the responses. These calculations provided latencies of 20.7, 17.7, 16.1 and 16.1 ms for carrier frequencies 750, 1500, 3000 and 6000 Hz. This latency difference of about 4.5 ms between low and high carrier frequencies remained constant over many different manipulations of the stimuli: faster modulation rates (150-190 Hz), binaural rather than monaural presentation, different intensities, stimuli presented alone or in conjunction with other stimuli, and modulation frequencies that were separated by as little as 0.24 Hz. This frequency-related delay is greater than that measured using transient evoked potentials, most likely because of differences in how transient and steady-state responses are generated and how their latencies are determined.

MASTER: a Windows program for recording multiple auditory steady-state responses

MASTER is a Windows-based data acquisition system designed to assess human hearing by recording auditory steady-state responses. The system simultaneously generates multiple amplitude-modulated and/or frequency-modulated auditory stimuli, acquires electrophysiological responses to these stimuli, displays these responses in the frequency-domain, and determines whether or not the responses are significantly larger than background electroencephalographic activity. The operator can print out the results, store the data on disk for more extensive analysis by other programs, review stored data, and combine results. The system design follows clear principles concerning the generation of acoustic signals, the acquisition of artifact-free data, the analysis of electrophysiological responses in the frequency-domain, and the objective detection of signals in noise. The instrument uses a popular programming language (LabVIEW) and a commercial data acquisition board (AT-MIO-16E-10), both of which are available from National Instruments.

Intracerebral sources of human auditory-evoked potentials

Evoked potentials to brief 1,000-Hz tones presented to either the left or the right ear were recorded from 30 electrodes arrayed over the head. These recordings were submitted to two different forms of source analysis: brain electric source analysis (BESA) and variable-resolution electromagnetic tomography (VARETA). Both analyses showed that the dominant intracerebral sources for the late auditory-evoked potentials (50-300 ms) were in the supratemporal plane and lateral temporal lobe contralateral to the ear of stimulation. The analyses also suggested the possibility of additional sources in the frontal lobes.

Multiple auditory steady-state responses (MASTER): stimulus and recording parameters

Steady-state responses evoked by simultaneously presented amplitude-modulated tones were measured by examining the spectral components in the recording that corresponded to the different modulation frequencies. When using modulation frequencies between 70 and 110 Hz and an intensity of 60 dB SPL, there were significant interactions between two stimuli when the carrier frequencies were closer than one half of an octave apart, with attenuation of the response to the lower carrier frequency. However, there were no significant decreases in response amplitude with four simultaneous stimuli provided the carrier frequencies differed by one octave or more. Higher intensities (70 dB SPL) resulted in greater interactions between the stimuli than when low intensities (35 dB SPL) were used. Modulation frequencies could be as closely spaced as 1.3 Hz without affecting the responses. Using broad-band noise as a carrier instead of a pure tone resulted in a significantly larger response when the stimuli were presented at the same sound pressure level. At modulation frequencies between 30 and 50 Hz, there were greater interactions between stimuli than at faster modulation frequencies. These results support the following recommendations for using multiple stimuli in evoked potential audiometry: (1) The multiple stimulus technique works well for steady state responses at frequencies between 70 and 110 Hz. (2) Up to four stimuli can be simultaneously presented to an ear without significant loss in amplitude of the response, provided the carrier frequencies are separated by an octave and the intensities are 60 dB SPL or less. (3) Bandpass noise might serve as a better carrier signal than pure tones.

Temperature and pressure dependence of viscosity of quantum liquid He according to significant structure theory

Both solid-like and gas-like flow structures are considered in the calculation of viscosity of liquid (4)He using the significant structure theory of liquids. The predominance of quantum mechanical zero-point motion over that arising from thermal excitation is taken into account for the solid-like motion of molecules. The viscosity of liquid (4)He under its own vapor pressure calculated over its whole temperature range is in reasonably good agreement with experimental data. The pressure dependence of viscosity also was obtained. The calculation does not yield good results at high densities where the free jumping of molecules into the nearest neighboring vacancies through the kinetic zero-point motion is no longer plausible.