Automated Interictal Epileptiform Discharge Detection from Scalp EEG Using Scalable Time-series Classification Approaches

Deep learning for automated interictal epileptiform discharge (IED) detection has been topical with many published papers in recent years. All existing works viewed EEG signals as time-series and developed specific models for IED classification; however, general time-series classification (TSC) methods were not considered. Moreover, none of these methods were evaluated on any public datasets, making direct comparisons challenging. This paper explored two state-of-the-art convolutional-based TSC algorithms, InceptionTime and Minirocket, on IED detection. We fine-tuned and cross-evaluated them on a public (Temple University Events - TUEV) and two private datasets and provided ready metrics for benchmarking future work. We observed that the optimal parameters correlated with the clinical duration of an IED and achieved the best area under precision-recall curve (AUPRC) of 0.98 and F1 of 0.80 on the private datasets, respectively. The AUPRC and F1 on the TUEV dataset were 0.99 and 0.97, respectively. While algorithms trained on the private sets maintained their performance when tested on the TUEV data, those trained on TUEV could not generalize well to the private data. These results emerge from differences in the class distributions across datasets and indicate a need for public datasets with a better diversity of IED waveforms, background activities and artifacts to facilitate standardization and benchmarking of algorithms.

A114 QUALITY AND EFFICACY OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY: A RETROSPECTIVE CHART REVIEW STUDY

Background

Passage of food along the digestive tract can be compromised by a number of conditions. Nasogastric tube (NGT) feeding is used in these cases but prolonged use can lead to various complications. Percutaneous endoscopy gastrostomy (PEG) has been reported as an effective and safe alternative to NGT. Clinical efficacy and adverse events related to PEG insertion are largely dependent on post-procedure care.

Aims

To assess the clinical significance of PEG tube insertion procedure and impact of post-procedure care and diet protocol on associated adverse events and success rate at two Canadian tertiary care units.

Methods

The retrospective electronic chart review was conducted on all patients who underwent endoscopic PEG fixation or replacement procedure at University of British Columbia Gastroenterology clinic and Vancouver General hospital Endoscopy Unit from 1st April 2020 to 31st March 2021. Data related to patient demographics, indications for insertion, insertion technique, quality of PEG insertion protocol, antibiotic prophylaxis, success rate, and rate of PEG-related complications were collected and analysed. An evaluation protocol was devised to evaluate the impact of indication-based diet protocols on frequency of adverse events and success rate. Results are suggested to be analysed using SPSS v 2021 with significance threshold of P-value < 0.05.

Results

43 PEG insertion procedures were performed, of which 3 failed due to structural reasonsincluding post gastric sleeve surgery, small stomach and difficulty in finding transillumination point. 25 cases underwent PEG insertion endoscopically for the first time, and 14 required exchanges, of which 2 underwent non-endoscopic exchange. Of 37 patients who underwent endoscopic PEG insertion 18(48.64%) were males and 19(51.36%) were females. Acute infection was reported in 6(14%) and chronic infection in 4 patients (9.3%). Tube dislodgment was reported in 10(23%), peristomal leak in 4(9.3%), miinor bleeding in 3(6.9%), and post-operative granulation in 4(9%) procedures. The evaluation protocol divides patients into two groups: Group a included d subjects who would receive low-volume (≤150 mL/d) and Group b who would receive a high-volume (≥300 mL/d) of feeding formula.

Conclusions

PEG tube insertion is a very successful procedure with high clinical significance and low complications rate at VGH and UBC. A follow-up plan is therefore being initiated to evaluate impact of feeding volumes on rate of success and adverse events. Combined, the previous studies, suggest that the high-feeding volumes can be safely administered to rapidly attain calorie targets to increase the procedure efficacy. .

Funding Agencies

CAG

Comparing two classification schemes for seizures and epilepsy in rural China

BACKGROUND AND PURPOSE

The International League against Epilepsy (ILAE) updated the classifications of seizures and epilepsies in 2017. The 2017 classifications were compared with the 1980s classifications in rural China.

METHODS

People with epilepsy receiving treatment under the National Epilepsy Control Programme were recruited from rural areas in China. Their seizures and epileptic syndrome were classified using the 1980s ILAE classification system and then re-classified according to the 2017 system. Differences in seizure, epilepsy and aetiology classifications were identified.

RESULTS

A total of 597 individuals (58% males, aged 6-78 years) were included. Amongst them 535 (90%) had a single seizure type, 57 (9.55%) had two types and five (0.84%) had three. There was complete agreement between the 1981 and 2017 classifications for the 525 individuals with focal seizures. Seizures originally classified as generalized in 10 of 65 individuals were re-classified as unknown in the 2017 classification. Compared to the 1980s classifications, the proportion of individuals with unknown seizures and unknown epilepsy increased from 1.2% (7/597) to 2.8% (17/597, P = 0.002), and unknown aetiology increased from 32% (189/597: 182 cryptogenic and seven unclassified) to 39% (230/597; P < 0.001) in the 2017 classifications.

CONCLUSIONS

The 1980s and 2017 classifications had 100% agreement in classifying focal seizures and epilepsy in rural China. A small but significant proportion of generalized seizures and epilepsy and aetiologies classified in the old classifications were re-classified to unknown in the new classifications. These results highlight the need for improvement in clinical evaluation of people with epilepsy in resource-poor settings.

Sample-to-answer on molecular diagnosis of bacterial infection using integrated lab--on--a--disc

Sepsis by bacterial infection causes high mortality in patients in intensive care unit (ICU). Rapid identification of bacterial infection is essential to ensure early appropriate administration of antibiotics to save lives of patients, yet the present benchtop molecular diagnosis is time-consuming and labor-intensive, which limits the treatment efficiency especially when the number of samples to be tested is extensive. Therefore, we hereby report a microfluidic platform lab-on-a-disc (LOAD) to provide a sample-to-answer solution. Our LOAD customized design of microfluidic channels allows automation to mimic sequential analytical steps in benchtop environment. It relies on a simple but controllable centrifugation force for the actuation of samples and reagents. Our LOAD system performs three major functions, namely DNA extraction, isothermal DNA amplification and real-time signal detection, in a predefined sequence. The disc is self-contained for conducting sample heating with chemical lysis buffer and silica microbeads are employed for DNA extraction from clinical specimens. Molecular diagnosis of specific target bacteria DNA sequences is then performed using a real-time loop-mediated isothermal amplification (RT-LAMP) with SYTO-9 as the signal reporter. Our LOAD system capable of bacterial identification of Mycobacterium tuberculosis (TB) and Acinetobacter baumanii (Ab) with the detection limits 103cfu/mL TB in sputum and 102cfu/mL Ab in blood within 2h after sample loading. The reported LOAD based on an integrated approach should address the growing needs for rapid point-of-care medical diagnosis in ICU.

Association between CYP2C19 Polymorphisms and Outcomes in Cerebral Endovascular Therapy

BACKGROUND AND PURPOSE

Differing responses to clopidogrel following endovascular treatment of cerebrovascular diseases may increase the risk of vascular complications. CYP2C19 gene polymorphisms influence clopidogrel activity. We aimed to study the clinical impact of CYP2C19 gene polymorphisms in patients undergoing endovascular treatment.

MATERIALS AND METHODS

This was a prospective, longitudinal, observational study. Information on demographics and cerebrovascular status was collected as baseline. Clopidogrel response was tested by the VerifyNow P2Y12 assay. CYP2C19 genotyping was undertaken by polymerase chain reaction-restriction fragment length polymorphism. Three-month follow-up data included vascular complications, mortality, and modified Rankin Scale score. Associations were investigated among CYP2C19 genotypes, clopidogrel responsiveness, and clinical outcomes.

RESULTS

One hundred and eight participants were included. Median age was 56 years (interquartile range, 48.8-65.0 years), and 35 (32.4%) were male. Forty-four participants were classified into group 1 (homozygous CYP2C19*1/*1); 31, into group 2 (25 with CYP2C19*1/*2, two with CYP2C19*1/*3, three with CYP2C19*3/*3, one with CYP2C19*2/*3); 28, into group 3 (24 with CYP2C19*1/*17, four with CYP2C19*17/*17); and 5, into group 4 (CYP2C19*2/*17). A significantly higher proportion of participants in group 3 experienced ischemic events (9 of 28, 32.1%) compared with group 1 (5 of 44, 11.4%; P = .04; odds ratio, 3.7; 95% confidence interval, 1.1-12.6). There was no significant difference in clopidogrel response among the 4 genotype groups.

CONCLUSIONS

Individuals with CYP2C19*17 may have increased risk of ischemic events following endovascular treatment, independent of clopidogrel responsiveness. Larger studies are required to confirm the influence of CYP2C19*17 on clinical outcomes and to understand the mechanisms for increased ischemic events.

Curcumin modulation of high fat diet-induced atherosclerosis and steatohepatosis in LDL receptor deficient mice

OBJECTIVE

Consuming curcumin may benefit health by modulating lipid metabolism and suppressing atherogenesis. Fatty acid binding proteins (FABP-4/aP2) and CD36 expression are key factors in lipid accumulation in macrophages and foam cell formation in atherogenesis. Our earlier observations suggest that curcumin's suppression of atherogenesis might be mediated through changes in aP2 and CD36 expression in macrophages. Thus, this study aimed to further elucidate the impact of increasing doses of curcumin on modulation of these molecular mediators on high fat diet-induced atherogenesis, inflammation, and steatohepatosis in Ldlr(-/-) mice.

METHODS

Ldlr(-/-) mice were fed low fat (LF) or high fat (HF) diet supplemented with curcumin (500 HF + LC; 1000 HF + MC; 1500 HF + HC mg/kg diet) for 16 wks. Fecal samples were analyzed for total lipid content. Lipids accumulation in THP-1 cells and expression of aP2, CD36 and lipid accumulation in peritoneal macrophages were measured. Fatty streak lesions and expression of IL-6 and MCP-1 in descending aortas were quantified. Aortic root was stained for fatty and fibrotic deposits and for the expression of aP2 and VCAM-1. Total free fatty acids, insulin, glucose, triglycerides, and cholesterol as well as several inflammatory cytokines were measured in plasma. The liver's total lipids, cholesterol, triglycerides, and HDL content were measured, and the presence of fat droplets, peri-portal fibrosis and glycogen was examined histologically.

RESULTS

Curcumin dose-dependently reduced uptake of oxLDL in THP-1 cells. Curcumin also reduced body weight gain and body fat without affecting fat distribution. During early intervention, curcumin decreased fecal fat, but at later stages, it increased fat excretion. Curcumin at medium doses of 500-1000 mg/kg diet was effective at reducing fatty streak formation and suppressing aortic expression of IL-6 in the descending aorta and blood levels of several inflammatory cytokines, but at a higher dose (HF + HC, 1500 mg/kg diet), it had adverse effects on some of these parameters. This U-shape like trend was also present when aortic root sections were examined histologically. However, at a high dose, curcumin suppressed development of steatohepatosis, reduced fibrotic tissue, and preserved glycogen levels in liver.

CONCLUSION

Curcumin through a series of complex mechanisms, alleviated the adverse effects of high fat diet on weight gain, fatty liver development, dyslipidemia, expression of inflammatory cytokines and atherosclerosis in Ldlr(-/-) mouse model of human atherosclerosis. One of the mechanisms by which low dose curcumin modulates atherogenesis is through suppression of aP2 and CD36 expression in macrophages, which are the key players in atherogenesis. Overall, these effects of curcumin are dose-dependent; specifically, a medium dose of curcumin in HF diet appears to be more effective than a higher dose of curcumin.

Genome-wide association study in a Chinese population identifies a susceptibility locus for type 2 diabetes at 7q32 near PAX4

AIMS/HYPOTHESIS

Most genetic variants identified for type 2 diabetes have been discovered in European populations. We performed genome-wide association studies (GWAS) in a Chinese population with the aim of identifying novel variants for type 2 diabetes in Asians.

METHODS

We performed a meta-analysis of three GWAS comprising 684 patients with type 2 diabetes and 955 controls of Southern Han Chinese descent. We followed up the top signals in two independent Southern Han Chinese cohorts (totalling 10,383 cases and 6,974 controls), and performed in silico replication in multiple populations.

RESULTS

We identified CDKN2A/B and four novel type 2 diabetes association signals with p < 1 × 10(-5) from the meta-analysis. Thirteen variants within these four loci were followed up in two independent Chinese cohorts, and rs10229583 at 7q32 was found to be associated with type 2 diabetes in a combined analysis of 11,067 cases and 7,929 controls (p meta = 2.6 × 10(-8); OR [95% CI] 1.18 [1.11, 1.25]). In silico replication revealed consistent associations across multiethnic groups, including five East Asian populations (p meta = 2.3 × 10(-10)) and a population of European descent (p = 8.6 × 10(-3)). The rs10229583 risk variant was associated with elevated fasting plasma glucose, impaired beta cell function in controls, and an earlier age at diagnosis for the cases. The novel variant lies within an islet-selective cluster of open regulatory elements. There was significant heterogeneity of effect between Han Chinese and individuals of European descent, Malaysians and Indians.

CONCLUSIONS/INTERPRETATION

Our study identifies rs10229583 near PAX4 as a novel locus for type 2 diabetes in Chinese and other populations and provides new insights into the pathogenesis of type 2 diabetes.

Prediction for relapse and prognosis of newly diagnosed epilepsy

OBJECTIVE

The objective of this study was to investigate the timing of therapy initiation and other clinical factors as potential predictors for relapse and prognosis of epilepsy, based on hospital-based prospective observational data in China.

METHODS

One hundred and seventy-one newly diagnosed patients with one or more seizures were recruited and followed for at least 2 years. Kaplan-Meier survival analysis was used for calculating recurrence and remission rates. Univariate and multivariate analyses for risk factors were performed using Cox proportional hazards model.

RESULTS

Among the 171 patients analyzed, more patients had partial (54.4%) than generalized seizures (45.6%). The range of patients' age was 6-70 years, but 70% were under 16 years of age. Multiple seizure types (HR = 2.01; 95% CI, 1.31-3.10), epileptiform electroencephalogram (EEG) abnormality (HR = 1.95; 95% CI, 1.09-3.49), and >1 seizure monthly before treatment (HR = 2.74; 95% CI, 1.69-4.51) were predictors of seizure recurrence. The best negative predictors of remission were as follows: relapse (HR = 0.13; 95% CI, 0.07-0.23) and epileptiform EEG within 1 year of treatment (HR = 0.61; 95% CI, 0.39-0.97). Delayed treatment after three or more seizures did not significantly increase the risk of recurrence (P = 0.70) or remission (P = 0.31) compared with early treatment after one or two seizures.

CONCLUSIONS

Multiple seizure types, epileptiform EEG abnormality, and >1 seizure monthly before treatment predict seizure recurrence. Relapse and epileptiform EEG within 1 year of treatment predict adverse seizure outcome. Early treatment does not affect relapse or prognosis.

PTTG-binding factor (PBF) is a novel regulator of the thyroid hormone transporter MCT8

Within the basolateral membrane of thyroid follicular epithelial cells, two transporter proteins are central to thyroid hormone (TH) biosynthesis and secretion. The sodium iodide symporter (NIS) delivers iodide from the bloodstream into the thyroid, and after TH biosynthesis, monocarboxylate transporter 8 (MCT8) mediates TH secretion from the thyroid gland. Pituitary tumor-transforming gene-binding factor (PBF; PTTG1IP) is a protooncogene that is up-regulated in thyroid cancer and that binds NIS and modulates its subcellular localization and function. We now show that PBF binds MCT8 in vitro, eliciting a marked shift in MCT8 subcellular localization and resulting in a significant reduction in the amount of MCT8 at the plasma membrane as determined by cell surface biotinylation assays. Colocalization and interaction between PBF and Mct8 was also observed in vivo in a mouse model of thyroid-specific PBF overexpression driven by a bovine thyroglobulin (Tg) promoter (PBF-Tg). Thyroidal Mct8 mRNA and protein expression levels were similar to wild-type mice. Critically, however, PBF-Tg mice demonstrated significantly enhanced thyroidal TH accumulation and reduced TH secretion upon TSH stimulation. Importantly, Mct8-knockout mice share this phenotype. These data show that PBF binds and alters the subcellular localization of MCT8 in vitro, with PBF overexpression leading to an accumulation of TH within the thyroid in vivo. Overall, these studies identify PBF as the first protein to interact with the critical TH transporter MCT8 and modulate its function in vivo. Furthermore, alongside NIS repression, PBF may thus represent a new regulator of TH biosynthesis and secretion.

Patterns of treatment response in newly diagnosed epilepsy

OBJECTIVE

To delineate the temporal patterns of outcome and to determine the probability of seizure freedom with successive antiepileptic drug regimens in newly diagnosed epilepsy.

METHODS

Patients in whom epilepsy was diagnosed and the first antiepileptic drug prescribed between July 1, 1982, and April 1, 2006, were followed up until March 31, 2008. Outcomes were categorized into 4 patterns: (A) early and sustained seizure freedom; (B) delayed but sustained seizure freedom; (C) fluctuation between periods of seizure freedom and relapse; and (D) seizure freedom never attained. Probability of seizure freedom with successive drug regimens was compared. Seizure freedom was defined as no seizures for ≥1 year.

RESULTS

A total of 1,098 patients were included (median age 32 years, range 9-93). At the last clinic visit, 749 (68%) patients were seizure-free, 678 (62%) on monotherapy. Outcome pattern A was observed in 408 (37%), pattern B in 246 (22%), pattern C in 172 (16%), and pattern D in 272 (25%) patients. There was a higher probability of seizure freedom in patients receiving 1 compared to 2 drug regimens, and 2 compared to 3 regimens (p < 0.001). The difference was greater among patients with symptomatic or cryptogenic than with idiopathic epilepsy. Less than 2% of patients became seizure-free on subsequent regimens but a few did so on their sixth or seventh regimen.

CONCLUSIONS

Most patients with newly diagnosed epilepsy had a constant course which could usually be predicted early. The chance of seizure freedom declined with successive drug regimens, most markedly from the first to the third and among patients with localization-related epilepsies.

Association of CD247 with systemic lupus erythematosus in Asian populations

OBJECTIVE

Systemic lupus erythematosus (SLE) is a prototypic autoimmune disease with complex genetic inheritance. CD247 (CD3Z, TCRZ) plays a vital role in antigen recognition and signal transduction in antigen-specific immune responses, and is known to be involved in SLE pathogenesis. Weak disease association was reported for genetic variants in this gene in Caucasian studies for SLE, Crohn's disease and systemic sclerosis, but its role as a genetic risk factor was never firmly established.

METHODS

In this study, using a collection of 612 SLE patients and 2193 controls of Chinese ethnicity living in Hong Kong in a genome-wide study, single nucleotide polymorphisms (SNPs) in and around CD247 were identified as being associated with SLE. The two most significant SNPs in this locus were selected for further replication using TaqMan genotyping assay in 3339 Asian patients from Hong Kong, Mainland China, and Thailand, as well as 4737 ethnically and geographically matched controls.

RESULTS

The association of CD247 with SLE in Asian populations was confirmed (rs704853: odds ratio [OR] = 0. 81, p = 2.47 × 10(-7); rs858543: OR = 1.10, p = 0.0048). Patient-only analysis suggested that rs704853 is also linked to oral ulcers, hematologic disorders and anti-double-stranded DNA (dsDNA) antibody production.

CONCLUSION

A significant association between variants in CD247 and SLE was demonstrated in Asian populations. Understanding the involvement of CD247 in SLE may shed new light on disease mechanisms and development of new treatment paradigms.

A validation study of the Chinese wearing off questionnaire 9-symptom for Parkinson's disease

OBJECTIVE

Development of wearing off (WO) often goes unnoticed for both patients with Parkinson's disease (PD) and physicians due to the complexity of this phenomenon. A brief 9-symptom WO questionnaire (WOQ-9) was recently found to be highly sensitive in its detection. We aimed to validate a Chinese version WOQ-9 (CWOQ-9) among Chinese patients with PD.

METHODS

We recruited 101 literate Chinese PD patients among 4 different neurology or movement disorders clinics in Hong Kong to participate in this study by completing the CWOQ-9. Clinical judgment by the specialists was considered the gold standard for diagnosing WO.

RESULTS

The mean age (±SD) of the patients was 61 (±9) years and 35 (34.7%) of them were female. The disease duration was 7.4 (±5.4) years and 69 (68.3%) of them were diagnosed clinically to have WO by the specialists. The positive and negative predictive values, sensitivity and specificity of CWOQ-9 were 86%, 71%, 87%, and 69% respectively. The area under curve (AUC) was 0.78 (p<0.001).

CONCLUSION

This simple patient questionnaire is a valid tool for the detection of WO among Chinese PD patients.

Association between carbamazepine-induced cutaneous adverse drug reactions and the HLA-B*1502 allele among patients in central China

The aim of this study was to investigate the association between carbamazepine (CBZ)-induced cutaneous adverse drug reactions (cADRs) and the HLA-B*1502 allele among patients from central China. Eight patients with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN), 28 with mild maculopapular eruptions (MPEs), 50 CBZ-tolerant controls, and 71 healthy volunteers were recruited. HLA genotyping was performed using the polymerase chain reaction sequence-based typing (SBT) method. As a result, the HLA-B*1502 allele was observed at the following rates: (1) 100% (8/8) among those with CBZ-induced SJS/TEN, (2) 10.7% (3/28) among those with CBZ-induced MPEs; (3) 8.0% (4/50) among CBZ-tolerant controls; (4) 8.5% (6/71) among healthy volunteers. The eight patients with SJS/TEN positive for the HLA-B*1502 allele had an odds ratio (OR) of 184 compared with CBZ-tolerant controls. There was no significant difference in frequency between patients with MPEs and CBZ-tolerant controls (P>0.05). Thus, CBZ-induced SJS/TEN, but not MPEs, is strongly associated with HLA-B*1502. Testing for HLA-B*1502 should be recommended for patients from central China prior to initial CBZ treatment.

Agreement between initial and final diagnosis of first seizures, epilepsy and non-epileptic events: a prospective study

BACKGROUND

Differentiating between first seizure, epilepsy and a non-epileptic event is a challenging clinical exercise for many physicians as it may lead to different therapeutic implications. This study aims to investigate the agreement between the initial diagnosis at the accident and emergency (A&E) department and the final diagnosis following inpatient neurological evaluation of seizure disorders.

METHOD

A prospective observational study between April 2004 and June 2005 in a regional hospital in Hong Kong recruited 1701 patients from the A&E to neurology/medical wards with initial diagnoses/labels matching any one of 12 predefined keywords which were categorised as either "seizure specific" or "non-specific".

RESULTS

Among the 1170 patients with "non-specific" initial diagnoses/labels, 58 (5%) were finally diagnosed as having had a first seizure or epilepsy. Among 531 patients with "seizure specific" initial diagnoses/labels, 27 (5.1%) were subsequently diagnosed as having had non-epileptic events. The kappa value for agreement between the initial and final diagnosis was 0.88. Of the 154 patients with a final diagnosis of first seizure, 34 (22%) had "non-specific" initial labels. Among these patients, components of the evaluation contributing to revision of diagnosis included retrieval of witness accounts (47%), epileptiform discharges on EEG (47%), short term monitoring in patients suspected of acute symptomatic seizures (28%) and panel discussion of cases (22%).

CONCLUSION

There was generally a high degree of agreement between the initial and final diagnosis, but first seizures were often missed initially. Careful history taking, judicious use of EEG, selective short term monitoring and liaison with specialists are important in reaching an accurate diagnosis.

Finding the missing link between ictal bradyarrhythmia, ictal asystole, and sudden unexpected death in epilepsy

Basic science studies of the human brain have supported the cortical representation of cardiovascular responses, including heart rate variability. Clinical observations of ictal bradyarrhythmia may be mechanistically explained by the influence of the central autonomic network, although the localization and lateralization issues need to be considered in the light of patterns of seizure spread, hand dominance, and presence of lesions. Ictal bradyarrhythmia also offers a mechanistic explanation of sudden unexpected death in epilepsy (SUDEP), though it may explain only some but not all cases of SUDEP. The missing links are (1) clinical evidence of common factors shared by patients with ictal bradyarrhythmia and patients who die from SUDEP, (2) evidence of arrhythmia as a risk factor for SUDEP from epidemiological studies, and, (3) determination of the importance of ictal bradyarrhythmia in SUDEP with respect to other proposed mechanisms including apnea and intrinsic cardiac abnormalities. There remains a need to review the seizure mechanisms in cases of SUDEP and to step up the amount of concurrent ECG/intracranial EEG analysis in both ictal bradyarrhythmia and SUDEP cases.

Advanced colorectal cancer treatment and outcome in the community oncology setting

16040

Background: The treatment of advanced (adv) colorectal cancer (CRC) is currently a moving target due to the availability of new agents and a multitude of clinical trials. It is of interest to see how community oncologists have responded to these changes, and what effect they have had on outcome (survival). We report the chemotherapy treatment (tx) of adv CRC in the community oncology setting. Methods: This is an IRB-approved retrospective study. All available patient (pt) records with adv CRC, treated with chemotherapy, and having expired between 2003 and 2005, or who were still alive at data capture were included. Results: Two hundred and seven pts (60% newly diagnosed; 40% recurred), from 4 clinics (FL, OH, NV, ME) receiving 2444 cycles (3% in 2002; 18% in 03; 40% in 04, 39% in 05) were identified. Fifty percent of pts were male, the mean age was 65 yo, and the ECOG P.S. were 21%-0; 49%-1; 25%-2; 5%-3. Pts received a mean of 12 cycles of tx. A large variation in regimen usage was seen. Forty-three percent of pts received only 1 line of tx including 20+ regimens (top 10: Folfox4; IFL; 5FU/leuc; CapeOx; Folfox6; Xeloda; Folfiri2; Folfox7; CPT-11, Folfiri1), 24% received 2 lines of tx including 18+ regimens 2nd line (top 10: Folfox4; CPT-11; CapeOx; IFL; Xeloda; 5FU/leuc; Folfiri2; Folfox6; Cetuximab; Folfiri1), 15% received 3 lines of tx including 16+ regimens 3rd line (top 10: Folfox4; CapeOx; CPT-11; Xeloda; 5FU/leuc; IFL; Cetuximab; Xeliri; Folfiri1; Bevacizumab). In addition, 9% of pts received 4 lines of tx and 5% received 5 or more lines of tx. Of interest, looking at 1st line tx, IFL decreased and Folfox4 increased over the study period. Biologics were found in 48% of cycles (bevacizumab 35%; cetuximab 13%). Seventy-seven percent of pts had significant toxicity. Toxicity defined as a dose or regimen change, toxic delay or a return visit was seen in 23% of cycles (combined endpoint). Survival was available for 74 pts (81% of deaths were reported in 2004/05). Overall median survival was 17 months (<66 yo - 20.3 mo; >65 yo - 11.5 mo; newly diagnosed - 19.0 mo; recurred - 14.3 mo). Conclusions: Community oncologists utilized a multitude of agents/regimens in the tx of adv CRC. This may be appropriate in light of all the recent changes in disease tx strategy. Although, survival rates are near those published in the literature.

[Table: see text]

Gender differences in suicide risk by socio-demographic factors in Hong Kong

Some peculiarly low male-to-female suicide ratios have been reported in the Far Eastern populations. This article attempts to investigate whether there are gender differences in suicide risk by socio-demographic factors in Hong Kong, and hereby to explain the low male-to-female suicide ratios. The effects of marital status, duration-of-residence, and occupational status on suicide are first studied by periodic suicide rates in 1990-1992, and 2000-2002, then by Poisson regression. Some interesting results are found: Unlike most findings elsewhere, migration in Hong Kong did not induce suicide; occupational status was negatively related to suicide only for men but not for women; the particularly low male-to-female suicide ratio was not due to a larger protection from marriage for men than for women as reported in the literature, but very probably to a very high suicide rate for the non-working population. The authors suggest some plausible explanations of the findings and hence further research to be conducted.

The natural history of epilepsy: an epidemiological view

Better information of the natural history of epilepsy has important implications for understanding the underlying neurobiology, evaluating treatment strategies, and planning healthcare resources. The traditional pessimistic view has been dispelled by results from modern community based prospective studies, showing that over 60% of newly diagnosed patients will enter remission upon treatment. Recent outcome studies suggest that medical intractability may be predicted after failure of two antiepileptic drugs. Poor prognostic factors include a high initial seizure density, symptomatic aetiology, and presence of structural cerebral abnormalities, all of which can be identified early on. Among patients who have entered remission, many will remain seizure-free after antiepileptic drug treatment is withdrawn, suggesting that the underlying seizure generating factor has remitted. Whether some of these patients have entered remission "spontaneously" is contentious because, with effective pharmacotherapy for epilepsy in use for over 100 years, the natural history of untreated epilepsy is largely unknown. Circumstantial evidence, mostly arising from resource poor countries where antiepileptic drug treatment is not readily available, indicates that spontaneous remission may occur in up to 30% of cases. Observations from these complementary sources suggest that, at the population level, prognosis of newly diagnosed epilepsy may be broadly categorised into three groups: remission without treatment, remission with treatment only, and persistent seizures despite treatment. As understanding of the prognostic factors improves, the potential of a "prognostic group specific" management approach should be explored so that effective treatments may be used in a more rational and targeted fashion.

Epilepsy in Hong Kong: a literature review

OBJECTIVE

To review data on the causes, clinical features, and management of patients with epilepsy in Hong Kong.

DATA SOURCES

MEDLINE and Chinese Current Medical Contents were used to search the literature. A manual search of the Hong Kong Medical Journal, Hong Kong Practitioner, and Chinese Medical Journal (1982-2002) was also undertaken.

STUDY SELECTION

Key words for the literature search were 'epilepsy' and 'Hong Kong'.

DATA EXTRACTION

All relevant articles in English or in Chinese language were reviewed.

DATA SYNTHESIS

Overall, disease characteristics and the response to both medical and surgical treatments of epilepsy among local Chinese patients with epilepsy was found to be comparable to that reported for patients in western countries. Knowledge of epilepsy among the general population was more limited than expected from the international literature, and attitudes to epilepsy relatively more negative, adding to the psychosocial burden for people with epilepsy.

CONCLUSION

Further research in Hong Kong on aspects of epileptology is indicated with a view to developing more innovative and effective therapy.

Use of iron oxide-coated sand to remove strontium from simulated Hanford tank wastes

The ability of iron oxide-coated sand (IOCS) to adsorb strontium from synthetic wastes simulating the tank wastes at the Hanford Nuclear Reservation was examined in this study. These wastes have high pH and high ionic strength, containing up to 5.5 M Na+, 3.7 M NO3-, and 1.2 M OH-. The use of IOCS in such applications may be advantageous because it is inexpensive, is nontoxic, and can be prepared from readily available materials. IOCS can selectively remove strontium from solutions, even when they contain overwhelmingly higher concentrations of potentially competing cations such as Ca2+, Al3+, and Cr3+. Sr-EDTA chelates do not adsorb to IOCS. However, the interference caused by EDTA can be substantially overcome by the addition of excess Ca to the solution since Ca displaces Sr from EDTA. The adsorbed Sr can be released, and the IOCS can be regenerated by exposure to dilute acid (pH approximately 3) for short periods. The physical and adsorptive properties of the IOCS remain essentially unaltered over at least several dozens of regeneration cycles, corresponding to treatment of at least 20000 bed volumes of influent. The only byproduct of the regeneration process is a small volume of residual waste containing essentially only strontium and dilute acid.

Effectiveness of first antiepileptic drug

PURPOSE

To investigate the interaction among efficacy, tolerability, and overall effectiveness of the first antiepileptic drug (AED) in patients with newly diagnosed epilepsy.

METHODS

The 470 patients were diagnosed, treated and followed up from January 1984 at a single center. Outcome was classified as seizure freedom for at least the last year or failure of initial treatment because of inadequate seizure control, adverse events, or for other reasons.

RESULTS

Overall, 47% of patients became seizure-free with the first prescribed AED. A higher proportion (p = 0.025) of patients with symptomatic or cryptogenic epilepsy changed treatment because of intolerable side effects (17%), and a lower proportion (p = 0.007) became seizure-free (43.5%) compared with those with idiopathic epilepsy (8.5% and 58%, respectively). Most patients (83%) received carbamazepine (CBZ; n = 212), sodium valproate (VPA; n = 101), or lamotrigine (LTG; n = 78). The majority of seizure-free patients required only a moderate daily AED dose (93.1% with < or =800 mg CBZ, 91.3% with < or =1,500 mg VPA, 93.8% with < or =300 mg LTG), with commonest dose ranges being 400-600 mg for CBZ, 600-1,000 mg for VPA, and 125-200 mg for LTG. Most withdrawals due to poor tolerability also occurred at or below these dose levels (CBZ: 98%; VPA: 100%; LTG: 75%). Patients taking CBZ (27%) had a higher incidence of adverse events necessitating a change of treatment than did those treated with VPA (13%) or LTG (10%), resulting in fewer becoming seizure-free (CBZ vs. VPA, p = 0.02; CBZ vs. LTG, p = 0.002).

CONCLUSIONS

Nearly 50% of newly diagnosed patients became seizure-free on the first-ever AED, with >90% doing so at moderate or even modest dosing. Tolerability was as important as efficacy in determining overall effectiveness.

Hormone profiles in young adults with epilepsy treated with sodium valproate or lamotrigine monotherapy

PURPOSE

Treatment with sodium valproate (VPA) may be associated with polycystic ovarian syndrome (PCOS) in some women with epilepsy. By comparing hormone profiles in young adults taking VPA or lamotrigine (LTG) as monotherapy, this study aimed to explore whether a pharmacologic effect of VPA could be responsible for this observation.

METHODS

Hormone profiles in men and women taking VPA (n = 40) or LTG (n = 36) monotherapy for epilepsy were compared. None of the women were receiving hormonal contraception or replacement. Patients gave details of seizure type and frequency, menstrual cycle, and medical and drug history. Body mass index was calculated, and fasting insulin, glucose, cholesterol, triglycerides (TG), high- and low-density lipoproteins, testosterone, dihydroepiandosterone (DHEA), androstenedione, sex hormone-binding globulin (SHBG), free androgen index (FAI), luteinising hormone (LH), follicle-stimulating hormone (FSH), and antiepileptic drug (AED) concentrations were measured.

RESULTS

There were no differences between treatment groups for both sexes in age and seizure control. Only four obese VPA-treated women were hyperinsulinaemic (p = 0.05); three with abnormal menstrual cycles; one with raised testosterone. Testosterone (p = 0.02), FAI (p = 0.03), and TG (p = 0.02) levels were higher, however, in women taking the drug. Obese patients of both sexes (p = 0.01) and VPA-treated men (p = 0.03) had higher insulin concentrations.

CONCLUSIONS

VPA therapy may be associated with subclinical elevation in fasting insulin levels. Testosterone and TG levels were higher in VPA-treated women compared with the levels in those taking LTG. However, only a minority of obese females exhibited biochemical characteristics suggestive of PCOS. Biochemical screening may allow women at risk of developing PCOS to avoid VPA.

The mechanisms of action of commonly used antiepileptic drugs

In the past decade, nine new drugs have been licensed for the treatment of epilepsy. With limited clinical experience of these agents, the mechanisms of action of antiepileptic drugs may be an important criterion in the selection of the most suitable treatment regimens for individual patients. At the cellular level, three basic mechanisms are recognised: modulation of voltage-dependent ion channels, enhancement of inhibitory neurotransmission, and attenuation of excitatory transmission. In this review, we will attempt to introduce the concepts of ion channel and neurotransmitter modulation and, thereafter, group currently used antiepileptic drugs according to their principal mechanisms of action.

Does the cause of localisation-related epilepsy influence the response to antiepileptic drug treatment?

PURPOSE

We investigated the response to antiepileptic drug (AED) therapy in patients with localisation-related epilepsy associated with different underlying causes.

METHODS

Five hundred and fifty adolescent and adult patients who had partial epilepsy treated with AEDs and who had undergone magnetic resonance imaging of brain were followed up prospectively from 1984 at a single centre. More than 70% were newly diagnosed. None had had epilepsy surgery.

RESULTS

Three hundred and twelve (57%) patients had been seizure free at their last clinic visit for at least a year. Patients with mesial temporal sclerosis (MTS; n = 73, 42% seizure free) were less likely to be controlled (p < 0.01) than were those with arteriovenous malformation (AVM; n = 14, 78%), cerebral infarction (n = 46, 67%), primary tumour (n = 35, 63%), cortical gliosis (n = 81, 57%), cerebral atrophy (n = 49, 55%), and cortical dysplasia (CD; n = 63, 54%). Among the seizure-free patients, those with MTS were more likely to require more than one AED compared with those with other aetiologies (48 vs. 35%; p < 0.05). There was no difference in outcome between patients with symptomatic and cryptogenic epilepsy (n = 361, 58% vs. n = 189, 56% seizure free, respectively). Patients with MTS, CD, and cryptogenic epilepsy were more likely (p = 0.02) to have a family history of epilepsy than were the other groups. MTS patients also had a higher incidence of febrile convulsions (p < 0.001).

CONCLUSIONS

The majority of patients with focal-onset epilepsy became seizure free on AED treatment. MTS-related seizures had the worst prognosis. Although many patients with this pathology may benefit from epilepsy surgery, a considerable number will be controlled with AED therapy.

Neuropsychological effects of epilepsy and antiepileptic drugs

Epilepsy and its treatment can have deleterious cognitive and behavioural consequences. Affected individuals have a higher prevalence of neuropsychological dysfunction than the general population because of complex interactions among several multifaceted and overlapping influences--for example, underlying neuropathologies, ictal and interictal neuronal discharges, a plethora of antiepileptic drugs, and numerous psychosocial issues. Research into the clinical relevance of these factors has been dogged by a range of methodological pitfalls including lack of standardisation of neuropsychological tests, small numbers and multiple testing, and statistical failure to appreciate differential effects of interactive elements in individual patients. Although antiepileptic drugs can impair neuropsychological functioning, their positive effect on seizure control might improve cognition and behaviour. Each person should be assessed individually with respect to factors unique to his or her seizure disorder and its treatment.

The star systems: overview and use in determining antiepileptic drug choice

An explosion in antiepileptic drug (AED) therapy began in the 1990s with the licensing of 9 new chemical entities and more to come. Important differences between AEDs may not be detected by regulatory trials, which are designed to satisfy licensing requirements and often diverge considerably from everyday clinical practice. The Star Systems have been developed as evidence-based yet pragmatic and flexible models for comparing AEDs. Each drug has been judged across a range of criteria, including mechanism of action, pharmacokinetics, ease of use, efficacy, tolerability, safety, interaction profile and a 'comfort factor'. A score has been allocated under each category and systems have been devised for patients with newly diagnosed epilepsy and those with difficult-to-control seizures requiring combination therapy. The choice of treatment should involve assessment of patient-related factors, accurate classification of seizure type and syndrome, married with an understanding of the pharmacology of the AEDs. A staged management plan should be formulated when initiating treatment with the aim of preventing the development of refractory epilepsy. When using combinations of AEDs, the mechanism of action of each agent should be taken into consideration. Such an individualised approach to management will optimise the chance of attaining remission and help many more patients achieve a fulfilling life.

Glutamic acid decarboxylase autoantibodies in controlled and uncontrolled epilepsy: a pilot study

There have been anecdotal reports of raised glutamic acid decarboxylase (GAD) autoantibodies in patients with refractory epilepsy. We measured serum GAD autoantibodies in 105 patients with idiopathic or symptomatic epilepsy. There was no significant difference in the absolute titre of GAD autoantibody between patients with controlled and uncontrolled epilepsy. However, four female patients with uncontrolled epilepsy had levels that were over three times above the highest detected in the seizure-free group, three of whom also tested positive for pancreatic islet cell antibodies. Larger scale studies, perhaps comparing different epilepsy syndromes, are required to determine the exact clinical role of GAD autoantibodies in epilepsy.

Randomized, multicenter comparison of oral granisetron and oral ondansetron for emetogenic chemotherapy

STUDY OBJECTIVES

To compare the antiemetic effectiveness and safety of oral granisetron plus dexamethasone with those of oral ondansetron plus dexamethasone administered before emetogenic chemotherapy.

DESIGN

Randomized, prospective, multicenter, open-label study.

SETTINGS

University-teaching hospital and veterans health care system.

PATIENTS

Sixty-one chemotherapy-naïve patients scheduled to receive emetogenic antineoplastic agents.

INTERVENTION

A single-dose oral granisetron 1 mg and dexamethasone 12 mg or single-dose oral ondansetron 16 mg and dexamethasone 12 mg was administered before chemotherapy.

MEASUREMENTS AND RESULTS

Twenty-four hours after administration patients were contacted to assess nausea, emesis, and adverse events. There were no statistical differences in frequency of nausea or emesis between groups. Seventy-six percent and 82% of patients receiving ondansetron and granisetron, respectively, experienced no emesis 24 hours after chemotherapy. Complete protection from nausea occurred in 58% and 46% of patients receiving the drugs, respectively. Adverse events were similar between groups.

CONCLUSION

Oral granisetron 1 mg and ondansetron 16 mg plus dexamethasone are safe and effective in preventing nausea and vomiting related to emetogenic chemotherapy.

Epilepsy after the first drug fails: substitution or add-on?

When and how a combination of antiepileptic drugs (AEDs) should be used in patients unresponsive to monotherapy is not known. We followed up prospectively 248 patients in whom treatment with the first AED was unsuccessful. When treatment failed due to intolerable adverse events, a second (substituted) drug was prescribed. When failure was due to lack of efficacy, either AED substitution or combination (add-on) was undertaken. Patients were considered to be seizure-free if they had no seizures for at least 1 year. Among patients with inadequate seizure control on the first well tolerated AED, those who received substituted monotherapy (n= 35) and those who received add-on treatment (n= 42) had similar seizure-free rates (substitution vs. add-on: 17% vs. 26%) and incidence of intolerable side effects (substitution vs. add-on: 26% vs. 12%). Based on the drugs' perceived primary mode of action, more patients became seizure-free when the combination involved a sodium channel blocker and a drug with multiple mechanisms of action (36%) compared to other combinations (7 %, P= 0.05). None of the 11 patients who received add-on treatment after a second drug had also failed became seizure-free, compared to 26% in those who received add-on as soon as the first tolerated AED proved to be ineffective (n= 42, P= 0.05). These preliminary observations have generated verifiable hypotheses regarding the early management of epilepsy. A randomized study comparing substitution and combination after the failure of the first AED is underway.

Early identification of refractory epilepsy

BACKGROUND

More than 30 percent of patients with epilepsy have inadequate control of seizures with drug therapy, but why this happens and whether it can be predicted are unknown. We studied the response to antiepileptic drugs in patients with newly diagnosed epilepsy to identify factors associated with subsequent poor control of seizures.

METHODS

We prospectively studied 525 patients (age, 9 to 93 years) who were given a diagnosis, treated, and followed up at a single center between 1984 and 1997. Epilepsy was classified as idiopathic (with a presumed genetic basis), symptomatic (resulting from a structural abnormality), or cryptogenic (resulting from an unknown underlying cause). Patients were considered to be seizure-free if they had not had any seizures for at least one year.

RESULTS

Among the 525 patients, 333 (63 percent) remained seizure-free during antiepileptic-drug treatment or after treatment was stopped. The prevalence of persistent seizures was higher in patients with symptomatic or cryptogenic epilepsy than in those with idiopathic epilepsy (40 percent vs. 26 percent, P=0.004) and in patients who had had more than 20 seizures before starting treatment than in those who had had fewer (51 percent vs. 29 percent, P<0.001). The seizure-free rate was similar in patients who were treated with a single established drug (67 percent) and patients who were treated with a single new drug (69 percent). Among 470 previously untreated patients, 222 (47 percent) became seizure-free during treatment with their first antiepileptic drug and 67 (14 percent) became seizure-free during treatment with a second or third drug. In 12 patients (3 percent) epilepsy was controlled by treatment with two drugs. Among patients who had no response to the first drug, the percentage who subsequently became seizure-free was smaller (11 percent) when treatment failure was due to lack of efficacy than when it was due to intolerable side effects (41 percent) or an idiosyncratic reaction (55 percent).

CONCLUSIONS

Patients who have many seizures before therapy or who have an inadequate response to initial treatment with antiepileptic drugs are likely to have refractory epilepsy.