Developmental epileptic encephalopathy in DLG4-related synaptopathy

OBJECTIVE

The postsynaptic density protein of excitatory neurons PSD-95 is encoded by discs large MAGUK scaffold protein 4 (DLG4), de novo pathogenic variants of which lead to DLG4-related synaptopathy. The major clinical features are developmental delay, intellectual disability (ID), hypotonia, sleep disturbances, movement disorders, and epilepsy. Even though epilepsy is present in 50% of the individuals, it has not been investigated in detail. We describe here the phenotypic spectrum of epilepsy and associated comorbidities in patients with DLG4-related synaptopathy.

METHODS

We included 35 individuals with a DLG4 variant and epilepsy as part of a multicenter study. The DLG4 variants were detected by the referring laboratories. The degree of ID, hypotonia, developmental delay, and motor disturbances were evaluated by the referring clinician. Data on awake and sleep electroencephalography (EEG) and/or video-polygraphy and brain magnetic resonance imaging were collected. Antiseizure medication response was retrospectively assessed by the referring clinician.

RESULTS

A large variety of seizure types was reported, although focal seizures were the most common. Encephalopathy related to status epilepticus during slow-wave sleep (ESES)/developmental epileptic encephalopathy with spike-wave activation during sleep (DEE-SWAS) was diagnosed in >25% of the individuals. All but one individual presented with neurodevelopmental delay. Regression in verbal and/or motor domains was observed in all individuals who suffered from ESES/DEE-SWAS, as well as some who did not. We could not identify a clear genotype-phenotype relationship even between individuals with the same DLG4 variants.

SIGNIFICANCE

Our study shows that a subgroup of individuals with DLG4-related synaptopathy have DEE, and approximately one fourth of them have ESES/DEE-SWAS. Our study confirms DEE as part of the DLG4-related phenotypic spectrum. Occurrence of ESES/DEE-SWAS in DLG4-related synaptopathy requires proper investigation with sleep EEG.

Pre-notifications increase retention in a 17-year follow-up of adolescents born very preterm

OBJECTIVE

Retention is essential in follow-up studies to reduce missing data, which can cause bias and limit the generalizability of the results. We investigated whether pre-notification letters would increase the response rates of approval forms and questionnaires and reduce the need for post-notifications in a prospective follow-up study of 17-year-old adolescents.

STUDY DESIGN

and settings This long-term follow-up study included 269 adolescents were randomized (1:1) into a pre-notification group (n = 132) and a no pre-notification group (n = 137). The pre-notification letter was sent prior to the approval form and questionnaires. The outcome measures were the response rates to the approval forms and questionnaires and the rate of post-notifications required.

RESULTS

The adolescents who received the pre-notifications were more likely to return approval forms (n = 88/132, 67%) than the adolescents who did not receive the pre-notifications (n = 79/137, 58%) (OR 1.5, 95% CI 0.9-2.4). The rates of returned questionnaires were higher in the pre-notification group (n = 82/88, 93%) than in the no pre-notification group (n = 68/79, 86%) (OR 2.2, 95% CI 0.8-6.3). The adolescents who did not receive the pre-notifications were more likely to need the post-notifications than the adolescents who received the pre-notifications (OR 3.0, 95% CI 1.4 to 6.5).

CONCLUSIONS

Pre-notifications decreased the need for post-notifications and may increase retention in 17-year-old adolescents. Based on our findings, pre-notification letters are recommended in future follow-up studies in adolescents.

TRIAL REGISTRATION

The Ethics Review Committee of the Hospital District of South-West Finland approved the 17-year PIPARI Study protocol in January 2018 (23.1.2018; 2/180/2012). The study has been registered to the SWAT repository as SWAT 179. Filetoupload,1457904,en.pdf (qub.ac.uk).

Visual Stimulator for Eye Movement Studies Based on a Microcomputer System

A visual stimulator system for studies of eye movements has been developed. The system is controlled by an inexpensive microcomputer. It is employed for otoneurological studies both in clinical work and in research, but can also be applied for studies of eye movements in other medical areas. Three types of eye movements are produced, viz. saccadic and smooth pursuit eye movements and optokinetic nystagmus. The stimulator system can be connected to another computer for an analysis of eye movements.

Efficacy and tolerability of isradipine and metoprolol in treatment of hypertension: the Finnish Isradipine Study in Hypertension (FISH)

Eight hundred seventy-six men and women with diastolic blood pressure (DBP) of 95-115 mm Hg during a 4-week placebo period were included in a multicenter trial; 479 patients had previously been treated for hypertension. The patients were randomized to receive isradipine or metoprolol; both groups were comparable for age, weight, height, smoking habits, and duration of hypertension. By the end of the placebo period, 79 patients did not fulfill the final entry criteria and were withdrawn. The isradipine group consisted of 398 patients (164 women and 234 men), and the metoprolol group consisted of 399 patients (173 women and 226 men). The initial dose of isradipine was 1.25 mg twice daily (b.i.d.), and the initial dose of metoprolol was 50 mg b.i.d.; the doses were doubled after 4 weeks if DBP had not decreased to less than or equal to 90 mm Hg. After 8 weeks, the isradipine group began combination therapy with metoprolol 50 mg b.i.d. and the metoprolol group began combination therapy with isradipine 1.25 mg b.i.d. if DBP was not less than or equal to 90 mm Hg. After 8 weeks monotherapy, mean BP (MBP) was reduced by 13/11 mm Hg (161/104 to 148/93) in the isradipine group and by 15/12 mm Hg (160/103 to 145/91) in the metoprolol group. Monotherapy with isradipine normalized DBP to less than or equal to 90 mm Hg in 52% with a mean dose of 4.26 mg daily, and monotherapy with metoprolol normalized DBP in 58% with a mean dose of 155 mg daily.1+

Clinical outcome and left ventricular function 23 years after acute coxsackie virus myopericarditis

The clinical outcome of 18 patients, who presented with a Coxsackie virus myopericarditis in 1965, was evaluated 23 years later. Five patients had died, two of them had had heart failure. Thirteen patients and 23 healthy control subjects underwent exercise testing with gas exchange analysis. Left ventricular (LV) peak filling rate (PFR) was estimated by digitized M-mode echocardiography. Left ventricular ejection fraction was measured at rest and during exercise by radionuclide angiography. All patients were free of cardiac symptoms. Their clinical examination and the chest X-ray were normal. Peak oxygen consumption was not decreased in the patient group compared with the control group. PFR was significantly lower in the patient group than in the control group, 10.2 +/- 0.4 vs 13.2 +/- 0.4 cm s-1, P less than 0.001 (mean +/- SEM). LV ejection fraction was normal at rest in all patients (58 +/- 1%). An abnormal LV ejection fraction response to exercise was observed in two patients. Our data indicate that long-term prognosis after acute Coxsackie virus myopericarditis is good in a majority of patients.

Immunohistochemical versus biochemical estrogen-receptor and progesterone-receptor analysis: correlation with histological parameters

Human breast carcinomas were evaluated for estrogen and progesterone receptors by immunohistochemistry using monoclonal anti-receptor antibodies (n = 267) and by cytosol steroid-binding assays (n = 212). The estrogen and progesterone receptor contents of the tumors correlated with histological features of differentiation, such as histological and nuclear grade, and with the amount of tumor necrosis and lymphoid infiltration. The correlation of immunohistochemically determined steroid receptor values with histological characteristics was somewhat better than that of biochemically assessed concentrations.

Clinical characteristics and coronary anatomy in refractory unstable angina pectoris leading to coronary artery bypass grafting. The Kuopio experience

One hundred patients with high-risk unstable and medication-resistant angina pectoris underwent coronary artery by-pass grafting. In 35 cases the angina was of early post-infarction type, in 60 it was progressive after previous stability and in five it was of recent onset. All had abnormal ECG in association with anginal attacks (ST depression in 76, ST elevation in 5, T-wave inversion in 15 and left bundle branch block in 4). The left main coronary artery was stenosed in 33 patients, and the respective figures for three-vessel, two-vessel and one-vessel disease were 53, 9 and 5. The average number of inserted peripheral grafts/patient was 4.6. The perioperative mortality rate was 1%. Seven patients had confirmed or probable perioperative myocardial infarction and two had late infarction during the hospital stay, but none had angina pectoris on discharge. Of 60 patients re-examined after 1 year, 47 were angina-free. Five had NYHA class III angina, but all were improved. In refractory unstable angina pectoris there is severe coronary artery involvement, but bypass grafting can give good results.

Assessment of the safety margin of vadocaine hydrochloride in man

Vadocaine hydrochloride (2',4'-dimethyl-6'-methoxy-3-(2-methylpiperidyl)propionanilide+ ++ hydrochloride, OR K-242-HCl; INN: vadocaine) is an anilide derivative with antitussive and local anaesthetic action. The safety of this new compound was studied in 8 healthy male volunteers in a Phase I clinical trial. Vadocaine was administered orally as a single dose of 50, 100, 200, 300, 400 and 500 mg. At the two highest dose levels used, 400 and 500 mg, vadocaine induced side-effects originating in the central nervous system; ECG analysis revealed small prolongations in the P-Q interval and QRS complex after 400 and 500 mg. At a dose of 500 mg the P-Q interval was prolonged by a maximum of 38% (184 ms at 0.5 h; 134 ms pre-dose). The compound had no effect on blood and urinary parameters measured for safety evaluation. On the basis of these results, a 300 mg dose of vadocaine appears to be safe in man in all respects. This dose level is 10 times the therapeutic dose (30 mg). Vadocaine is sufficiently safe for future clinical trials in patients with cough.

Early pronounced ST segment depression with marked J point decline heralding acute lethal clinical myocardial infarction: Necropsy-electrocardiographic correlative study

Marked ST segment depression (greater than or equal to 2 mm J point decline with horizontal or downsloping ST) was correlated with necropsy findings in 105 cases. Acute myocardial infarction (AMI) was most frequently (70%) responsible for development of the abnormal ST pattern, thereby indicating the diagnosis and severe prognosis of the AMI. In 23% of patients the ST segment depression pattern was associated with chronic heart disease without AMI; all were severely ill with 92% receiving digitalis. Sudden worsening of the basic heart disease or circulatory shock were frequently found to coincide with the abnormal ST pattern; necropsy revealed extensive old MI or myocardial fibrosis in these patients. Marked ST segment depression was also found in five patients without underlying heart disease at autopsy; an acute cerebral accident or circulatory shock was considered to have produced the abnormal ST segment pattern.

In-hospital death from ischaemic heart disease

The clinical course and the clinical and pathological factors were studied in a series of 112 in-hospital patients who died of acute myocardial infarction. A necropsy was performed in 101 cases. 44% of the victims were concluded to have been past the possibility of recovery at the time of admission, as the treatment of early ventricular fibrillation or asystole did not lead to a satisfactory result, or as a refractory heart failure or shock dominated from admission to death. Resuscitations due to early ventricular fibrillation were performed in the emergency department mainly on patients living near the hospital. On the other hand, an early heart failure was more frequent among those whose transit distance was over 15 km. Prior use of beta-receptor blockers seemed to protect against early complications. The cardiac functions of the remaining patients were normal or could be normalized at the beginning of the hospitalization. The great majority of them were later lost as a result of extensive damage of the myocardium leading to a refractory heart failure and some due to a rupture caused by infarction (8%) or due to embolic complications (10%). Only 11 patients (10%) succumbed to late ventricular fibrillation without heart failure, rupture, or embolism. The cardiac disease revealed by the necropsy was more severe in patients with a refractory heart failure than in those who died of late ventricular fibrillation or rupture without a preceding heart failure. Various arrhythmias were frequent during the hospitalization. 74% of the dysrhythmias were preceded or followed by symptoms of a heart failure.

Elastic tissue injury in human acute pancreatitis

Pancreatic vessel wall alterations were studied in tissue material obtained from six patients subjected to resection of the gland for acute necrotizing pancreatitis. Special attention was paid to elastic tissue damage, which was studied using special stains in light and electron microscopy. Vascular wall elastic laminae showed changes varying from fragmentation to complete dissolution. The outer elastic lamina was more consistently affected. Elastic tissue damage was observed in pancreatic areas with minor acinar alterations and in vessels with otherwise relatively well-preserved walls. These observations suggest 1/ an early participation of elastase in the production of tissue damage in human acute pancreatitis and 2/ a primary role for elastic tissue injury in the vascular alterations leading to haemorrhage and tissue necrosis through ischaemia.

Pancreatic acinar ultrastructure in human acute pancreatitis

Ultrastructural alterations in pancreatic acini from six patients operated for acute necrotizing pancreatitis are described. One of the patients suffered from biliary tract disease, the rest had excessive alcohol intake as the presumed aetiology. Areas of the pancreatic parenchyma showing oedematous inflammation in light microscopy were studied in the electron microscope. Findings in acinar cells included changes in zymogen granules and an increased autophagocytosis in addition to unspecific organelle alterations. Zymogen granules showed increase in size and number, loss or variation of electron-density and peripheral dissolution. Increased autophagic activity was indicated by several autophagic vacuoles and residual bodies. Acinar lumina were dilated showing effacement of microvilli and invaginations in the luminal plasma membrane of the acinar cells. In acinar lumina and in the interstitium fibrillar material was observed, with an increasing frequency in those areas showing severe cellular disintegration. These findings suggest: 1) an increased activity of zymogen granules, 2) an increased autophagocytosis, and 3) penetration of acinar luminal contents into the interstitium.

Fixation and embedding variables in the immuno-electron microscopic study of rat Heymann nephritis

Fixation and embedding variables were compared in immuno-electron microscopic localization of rat IgG in an autologous immune complex-type nephritis. Specimens from kidney cortex were fixed for 3, 6 or 9 h in the following fixatives made in 0.1 M phosphate buffer at pH 7.4: 4% paraformaldehyde, 2.5% glutaraldehyde, periodate- lysine-paraformaldehyde or modified Karnovsky's fixative. Localization of IgG was performed on tissue sections cut with a tissue chopper, cryostat or sliding microtome, using agarose, Ames O.C.T. Compound or polyethylene glycol respectively as cutting matrixes. The sections were incubated in peroxidase-labelled antirat IgG antiserum (diluted 1:20 with phosphate-buffered saline) for 60 h. Peroxidase activity was then revealed and the sections embedded in Epon. Exact localization of IgG throughout the sections and good ultrastructure were achieved when paraformaldehyde and agarose were used. Periodatelysine-paraformaldehyde proved almost as useful as paraformaldehyde in connection with agarose in respect of peroxidase reaction and ultrastructure. Fixatives containing glutaraldehyde gave a mostly weak and unevenly distributed peroxidase reaction product. In the cryostat sections breaking of the tissue structure could not be avoided. When polyethylene glycol was used as cutting matrix no peroxidase reaction was achieved.

Changes in the QRS complex and ST segment in transmural and subendocardial myocardial infarctions. A clinicopathologic study

The QRS complex and ST segment in the ECGs of 80 patients who died of an acute myocardial infarction (MI) were studied in relation to the extent of the MI (subendocardial vs. transmural). Changes in the QRS complex developed in nine out of the 15 cases with an acute subendocardial MI. Five of these cases fulfilled the conventional QRS criteria for a myocardial infarction. A definite ST segment depression (a J point depression of 2 mm. or more in at least one lead, and a horizontal or downward sloping ST segment with a minimum duration of 0.08 sec.) occurred most frequently in connection with a circumferential subendocardial MI (88 per cent), but it was also found in a regional subendocardial (43 per cent) and transmural MI (43 per cent). In 17 per cent of the cases with a transmural MI, this was the only ECG abnormality. It is concluded that cases with a subendocardial MI cannot always be distinguished from transmural MI on the basis of the presence or absence of the QRS changes, and that an ST segment depression, as defined in this study, can give additional information in the evaluation of an acute phase of an MI.

Numerical analysis of cardiopulmonary blood volumes in 113In(m) radiocardiography

A theory of streamline flow of a viscous liquid was applied to the calculation of cardiac and pulmonary parameters (minute volume, stroke volume, right heart, pulmonary and left heart blood volumes) in a radiocardiographic model based on the modified gamma function. The practical feasibility of the formulations was tested using a physical flow model. The cardiopulmonary blood volumes measured from 14 normal subjects were consistent with the results obtained by more complex techniques. The present method is manageable on a small computer and is well suited to clinical routine use in connection with standard single detector 113In(m) radiocardiography.

Assessment of immediate prognosis in acute myocardial infarction by a new noninvasive hemodynamic index

A prognostic index for acute myocardial infarction was developed from noninvasively accessible parameters, gathered prospectively within 24 h from the onset of symptoms in 185 consecutive patients. Of the 35 patients who died in hospital, 30 had power failure. The items subjected to discriminant function analysis were: sex, age, number of previous infarctions, present infarction transor nontransmural, heart rate, systolic arterial pressure (SAP), left ventricular ejection time (LVET), cardiothoracic ratio, and grade of pulmonary venous congestion scored 0-3 (PVC0-3). The items possessing the best predictive power were, in the order of their strength: age, SAP, LVET and PVCO-3; i.e., hemodynamically, afterload, stroke volume and preload. The discriminant function (DF) giving the prognostic score was: DF=3.9Xage(yr)-1.3X SAP (mm Hg) - 1.4 X LVET (msec) + 25.3 X PVC0-3 + 775.3 Score 550 was exceeded by 87% of the patients dying of power failure and only 16% of the survivors, and it was less in 84% of the survivors and 13% of those dying. To test the validity of the index it was applied to another series consisting of 100 consecutive patients and very similar results were obtained, suggesting that the index is of practical value in predicting hemodynamic deterioration early and by simple noninvasive means.

Cardiac manifestations during a Coxsackie B5 epidemic

During a widespread Coxsackie B5 epidemic which occurred in Finland in the autumn of 1965 18 patients with acute myopericarditis were admitted to Kuopio Central Hospital (530 beds, representing a hospital district with 270,000 inhabitants) within a period of three months.The mean age of these patients was 28 years. Twelve were males and six were females.In 12 cases Coxsackie B5 virus and in one case Coxsackie A9 virus were isolated from the faeces. A significant increase in neutralizing antibodies or high antibody titres (>/=1:128) were noted in 16 cases against Coxsackie B5 and in one case against Coxsackie A9. In two cases the cause of the myopericarditis remained obscure.All the patients had fever. Six showed all classical criteria of pericarditis: chest pain, pericardial rub, E.C.G. changes, and radiologically observable enlargement of the heart. As regards the various criteria, E.C.G. changes were found in all cases. Signs of cardiac tamponade were observed in one patient. Five, in addition, showed aseptic meningitis.All the patients recovered. Twelve were re-examined at an average of seven months after discharge from hospital. All were symptom-free except one, who still showed E.C.G. changes.