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Delanty N, Mohanraj R, Shankar R, Wehner T, Stephen LJ, D'Souza W, Cappucci S, McMurray R, Sainz-Fuertes R, Villanueva V. Perampanel for the treatment of epilepsy with genetic aetiology: Real-world evidence from the PERMIT Extension study. Epilepsy Res 2024; 202:107339. [PMID: 38492461 DOI: 10.1016/j.eplepsyres.2024.107339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/14/2024] [Accepted: 02/29/2024] [Indexed: 03/18/2024]
Abstract
Genetic factors contribute to the aetiology of epilepsy in >50% of cases, and information on the use of antiseizure medications in people with specific aetiologies will help guide treatment decisions. The PERMIT Extension study pooled data from two real-world studies (PERMIT and PROVE) to investigate the effectiveness and safety/tolerability of perampanel (PER) when used to treat people with focal and generalised epilepsy in everyday clinical practice. This post-hoc analysis of PERMIT Extension explored the use of PER when used to treat individuals presumed to have epilepsy with a genetic aetiology. Assessments included retention rate (evaluated at 3, 6 and 12 months), effectiveness (responder and seizure freedom rates; evaluated at 3, 6, 12 months and the last visit [last observation carried forward) and tolerability (adverse events [AEs]). Of the 6822 people with epilepsy included in PERMIT Extension, 1012 were presumed to have a genetic aetiology. The most common genetic aetiologies were idiopathic generalised epilepsy (IGE; 58.2%), tuberous sclerosis (1.1%), Dravet syndrome (0.8%) and genetic epilepsy with febrile seizures plus (GEFS+; 0.5%). Retention rates at 3, 6 and 12 months in the total genetic aetiology population were 89.3%, 79.7% and 65.9%, respectively. In the total genetic aetiology population, responder rates at 12 months and the last visit were 74.8% and 68.3%, respectively, and corresponding seizure freedom rates were 48.9% and 46.5%, respectively. For the specific aetiology subgroups, responder rates at 12 months and the last visit were, respectively: 90.4% and 84.4% (IGE), 100% and 57.1% (tuberous sclerosis), 100% and 71.4% (Dravet syndrome), and 33.3% and 20.0% (GEFS+). Corresponding seizure freedom rates were, respectively: 73.1% and 64.6% (IGE), 33.3% and 22.2% (tuberous sclerosis), 20.0% and 28.6% (Dravet syndrome), and 0% and 0% (GEFS+). The incidence of AEs was 46.5% for the total genetic aetiology population, 48.8% for IGE, 27.3% for tuberous sclerosis, 62.5% for Dravet syndrome, and 20% for GEFS+. Tolerability findings were consistent with PER's known safety profile. PER was effective and generally well tolerated when used in individuals with a presumed genetic epilepsy aetiology in clinical practice. PER was effective across a wide range of genetic aetiologies.
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Affiliation(s)
- Norman Delanty
- Department of Neurology, Beaumont Hospital, Dublin, Ireland.
| | - Rajiv Mohanraj
- Greater Manchester Neurosciences Centre, Salford Royal Hospital, UK
| | | | - Tim Wehner
- National Hospital for Neurology and Neurosurgery, UCLH Foundation Trust, and Department of Clinical and Experimental Epilepsy, UCL, London, UK
| | - Linda J Stephen
- Epilepsy Unit, West Glasgow Ambulatory Care Hospital, Glasgow, Scotland, UK
| | - Wendyl D'Souza
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Victoria, Australia
| | | | | | | | - Vicente Villanueva
- Refractory Epilepsy Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Akil Prasath RV, Mohanraj R, Balaramdas KR, Jhony Kumar Tagore A, Raja P, Rajasekaran A. Characterization of carbon fluxes, stock and nutrients in the sacred forest groves and invasive vegetation stands within the human dominated landscapes of a tropical semi-arid region. Sci Rep 2024; 14:4513. [PMID: 38402350 PMCID: PMC10894248 DOI: 10.1038/s41598-024-55294-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/22/2024] [Indexed: 02/26/2024] Open
Abstract
In the semi-arid plains of Southern India, outside the protected area network, sacred groves forests and the barren lands invaded by Prosopis juliflora are reckoned to be the major greenery, but have homogenous and heterogeneous vegetation respectively. This study attempted to compare 50 Sacred Groves Stands (SGS) and 50 monodominant Prosopis juliflora Stands (PJS) for the functional diversity, evenness, floral diversity, carbon stock and dynamics, carbon-fixing traits, dendrochronology of trees, soil nutrient profiles, and soil erosion. Quadrat sample survey was adopted to record stand density, species richness, abundance, basal area and leaf area index; composite soil samples were collected at depths 0-30 cm for nutrient profiling (N, P, K, and OC). Photosynthesis rate (µmole co2 m2/sec), air temperature (°c), leaf intracellular co2 concentration (ppm), ambient photosynthetic active radiation (µmole m2/sec), transpiration rate (m. mole H2O m2/sec) were determined for the 51 tree species existed in SGS and PJS using Plant Photosynthesis system. Structural Equation Model (SEM) was applied to derive the carbon sequestering potential and photosynthetic efficiency of eight dominant tree species using vital input parameters, including eco-physiological, morphological, and biochemical characterization. The Revised Universal Soil Loss Equation (RUSLE) model, in conjunction with ArcGIS Pro and ArcGIS 10.3, was adopted to map soil loss. Carbon source/sink determinations inferred through Net Ecosystem Productivity (NEP) assessments showed that mature SGS potentially acted as a carbon sink (0.06 ± 0.01 g C/m2/day), while matured PJS acted as a carbon source (-0.34 ± 0.12 g C/m2/day). Soil erosion rates were significantly greater (29.5 ± 13.4 ton/ha/year) in SGS compared to PJS (7.52 ± 2.55 ton/ha/year). Of the eight selected tree species, SEM revealed that trees belonging to the family Fabaceae [Wrightia tinctoria (estimated coefficient: 1.28, p = 0.02) > Prosopis juliflora (1.22, p = 0.01) > Acacia nilotica (1.21, p = 0.03) > Albizia lebbeck (0.97, p = 0.01)] showed comparatively high carbon sequestering ability.
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Affiliation(s)
- R V Akil Prasath
- Department of Environmental Science and Management, Bharathidasan University, Tiruchirappalli, 620024, India
| | - R Mohanraj
- Department of Environmental Science and Management, Bharathidasan University, Tiruchirappalli, 620024, India.
| | - K R Balaramdas
- Department of Environmental Science and Management, Bharathidasan University, Tiruchirappalli, 620024, India
| | | | - P Raja
- St. Joseph's College, Tiruchirappalli, India
| | - A Rajasekaran
- Institute of Forest Genetics and Tree Breeding, Coimbatore, 641002, India
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Raghu A, Ganesh A, Muthu MS, Vignesh KC, Mohanraj R, Wadgave U. Development and validation of a questionnaire to assess commonality knowledge of traumatic dental injuries and management of emergencies. Eur Arch Paediatr Dent 2024; 25:39-47. [PMID: 38017351 DOI: 10.1007/s40368-023-00851-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/20/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Dental trauma represents a significant public health problem, causing a burden for both individuals and society. The aim of this study is to systematically develop and validate a questionnaire on 'traumatic dental injuries and management of emergencies' (TIME) for assessing the knowledge, attitude and practice (KAP) for a commonality. METHODS The scale development phases included conceptual framework, systematic development of an item pool, refinement of the item pool by Focus-group discussion (n = 23), validity-testing using Content Validity Index (n = 5), translation and back-translation, Cognitive interviewing (n = 30,45), and reliability testing (n = 40). The conceptual framework was built based on six broad constructs, such as broken teeth, knocked-out (avulsion) teeth, pushed/moved-in and loosened teeth (luxation injuries), soft tissue injuries, follow-up and management, and prevention and protection. RESULTS Reviews of existing questionnaires significantly helped to generate an initial pool of 68 items (refined to 51 items). Lawshe's content validity was 0.92. High test-retest reliability was demonstrated (kappa value = 0.98). The questionnaire showed a high level of reliability (Cronbach's alpha = 0.86) with great internal consistency. CONCLUSION TIME is the first validated scale for recording knowledge, attitude and practices on traumatic dental injuries and management of emergencies for non-dental professionals. The 51-tem tool will allow dentists to evaluate KAP of commonality. KAP measured across the globe would have a significant impact on planning awareness programs by dentists and dental associations.
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Affiliation(s)
- Aksshaya Raghu
- Centre for Early Childhood Caries Research, Department of Pediatric and Preventive Dentistry, Sri Ramachandra Dental College and Hospital, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - A Ganesh
- Department of Public Health Dentistry, Sri Ramachandra Dental College and Hospital, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - M S Muthu
- Centre for Early Childhood Caries Research, Department of Pediatric and Preventive Dentistry, Sri Ramachandra Dental College and Hospital, Sri Ramachandra Institute of Higher Education and Research, Chennai, India.
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Al Jurf, United Arab Emirates.
| | - Krishnapillai Chandrababu Vignesh
- Centre for Early Childhood Caries Research, Department of Pediatric and Preventive Dentistry, Sri Ramachandra Dental College and Hospital, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
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Carey C, Rogers T, Mohanraj R. 162 Use of brain imaging and EEG for prognostication in post-cardiac arrest coma. J Neurol Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn2.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Introduction and AimsAccurate prognostication for comatose patients following out of hospital cardiac arrests (OOHCA) remains challenging. This study aimed to evaluate the use of CT-scans and EEGs for neuro-prognostication in comatose OOHCA patients admitted to ICU in 2 major cardiac centres.MethodsRecords of 71 patients admitted to ICU following OOHCA in 2019 were reviewed. Use of CT-scans and EEGs were compared with the European Resuscitation Council (ERC) guidelines.Results46 (64.8%) patients had withdrawal of life support (WLS) during admission. 60 (84.5%) patients had reported CT-brains, of which 26.7% showed either generalised oedema or a loss of grey-white matter distinction and 73.3% showed other ischaemic changes or normal results. 100% of patients with general- ised oedema or a loss of distinction and 59.1% patients with other ischaemic changes or normal scans had WLS during admission. EEGs were performed in 21 patients (29.6%), 18 (85.7%) of which had WLS. 22 (31.0%) patients had WLS within 72 hours of arrest. 90.9% of these patients had CT-heads and 0% had EEGs performed.ConclusionEEGs were used infrequently for neuro-prognostication and cerebral oedema and a loss of grey-white matter distinction were more often associated with WLS.
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Shakeshaft A, Laiou P, Abela E, Stavropoulos I, Richardson MP, Pal DK, Howell A, Hyde A, McQueen A, Duran A, Gaurav A, Collingwood A, Kitching A, Shakeshaft A, Papathanasiou A, Clough A, Gribbin A, Swain A, Needle A, Hall A, Smith A, Macleod A, Chhibda A, Fonferko-Shadrach B, Camara B, Petrova B, Stuart C, Hamilton C, Peacey C, Campbell C, Cotter C, Edwards C, Picton C, Busby C, Quamina C, Waite C, West C, Ng CC, Giavasi C, Backhouse C, Holliday C, Mewies C, Thow C, Egginton D, Dickerson D, Rice D, Mullan D, Daly D, Mcaleer D, Gardella E, Stephen E, Irvine E, Sacre E, Lin F, Castle G, Mackay G, Salim H, Cock H, Collier H, Cockerill H, Navarra H, Mhandu H, Crudgington H, Hayes I, Stavropoulos I, Daglish J, Smith J, Bartholomew J, Cotta J, Ceballos JP, Natarajan J, Crooks J, Quirk J, Bland J, Sidebottom J, Gesche J, Glenton J, Henry J, Davis J, Ball J, Selmer KK, Rhodes K, Holroyd K, Lim KS, O’Brien K, Thrasyvoulou L, Makawa L, Charles L, Richardson L, Nelson L, Walding L, Woodhead L, Ehiorobo L, Hawkins L, Adams L, Connon M, Home M, Baker M, Mencias M, Richardson MP, Sargent M, Syvertsen M, Milner M, Recto M, Chang M, O'Donoghue M, Young M, Ray M, Panjwani N, Ghaus N, Sudarsan N, Said N, Pickrell O, Easton P, Frattaroli P, McAlinden P, Harrison R, Swingler R, Wane R, Ramsay R, Møller RS, McDowall R, Clegg R, Uka S, White S, Truscott S, Francis S, Tittensor S, Sharman SJ, Chung SK, Patel S, Ellawela S, Begum S, Kempson S, Raj S, Bayley S, Warriner S, Kilroy S, MacFarlane S, Brown T, Samakomva T, Nortcliffe T, Calder V, Collins V, Parker V, Richmond V, Stern W, Haslam Z, Šobíšková Z, Agrawal A, Whiting A, Pratico A, Desurkar A, Saraswatula A, MacDonald B, Fong CY, Beier CP, Andrade D, Pauldhas D, Greenberg DA, Deekollu D, Pal DK, Jayachandran D, Lozsadi D, Galizia E, Scott F, Rubboli G, Angus-Leppan H, Talvik I, Takon I, Zarubova J, Koht J, Aram J, Lanyon K, Irwin K, Hamandi K, Yeung L, Strug LJ, Rees M, Reuber M, Kirkpatrick M, Taylor M, Maguire M, Koutroumanidis M, Khan M, Moran N, Striano P, Bala P, Bharat R, Pandey R, Mohanraj R, Thomas R, Belderbos R, Slaght SJ, Delamont S, Sastry S, Mariguddi S, Kumar S, Kumar S, Majeed T, Jegathasan U, Whitehouse W. Heterogeneity of resting-state EEG features in juvenile myoclonic epilepsy and controls. Brain Commun 2022; 4:fcac180. [PMID: 35873918 PMCID: PMC9301584 DOI: 10.1093/braincomms/fcac180] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/18/2022] [Accepted: 07/07/2022] [Indexed: 11/12/2022] Open
Abstract
Abnormal EEG features are a hallmark of epilepsy, and abnormal frequency and network features are apparent in EEGs from people with idiopathic generalized epilepsy in both ictal and interictal states. Here, we characterize differences in the resting-state EEG of individuals with juvenile myoclonic epilepsy and assess factors influencing the heterogeneity of EEG features. We collected EEG data from 147 participants with juvenile myoclonic epilepsy through the Biology of Juvenile Myoclonic Epilepsy study. Ninety-five control EEGs were acquired from two independent studies [Chowdhury et al. (2014) and EU-AIMS Longitudinal European Autism Project]. We extracted frequency and functional network-based features from 10 to 20 s epochs of resting-state EEG, including relative power spectral density, peak alpha frequency, network topology measures and brain network ictogenicity: a computational measure of the propensity of networks to generate seizure dynamics. We tested for differences between epilepsy and control EEGs using univariate, multivariable and receiver operating curve analysis. In addition, we explored the heterogeneity of EEG features within and between cohorts by testing for associations with potentially influential factors such as age, sex, epoch length and time, as well as testing for associations with clinical phenotypes including anti-seizure medication, and seizure characteristics in the epilepsy cohort. P-values were corrected for multiple comparisons. Univariate analysis showed significant differences in power spectral density in delta (2-5 Hz) (P = 0.0007, hedges' g = 0.55) and low-alpha (6-9 Hz) (P = 2.9 × 10-8, g = 0.80) frequency bands, peak alpha frequency (P = 0.000007, g = 0.66), functional network mean degree (P = 0.0006, g = 0.48) and brain network ictogenicity (P = 0.00006, g = 0.56) between epilepsy and controls. Since age (P = 0.009) and epoch length (P = 1.7 × 10-8) differed between the two groups and were potential confounders, we controlled for these covariates in multivariable analysis where disparities in EEG features between epilepsy and controls remained. Receiver operating curve analysis showed low-alpha power spectral density was optimal at distinguishing epilepsy from controls, with an area under the curve of 0.72. Lower average normalized clustering coefficient and shorter average normalized path length were associated with poorer seizure control in epilepsy patients. To conclude, individuals with juvenile myoclonic epilepsy have increased power of neural oscillatory activity at low-alpha frequencies, and increased brain network ictogenicity compared with controls, supporting evidence from studies in other epilepsies with considerable external validity. In addition, the impact of confounders on different frequency-based and network-based EEG features observed in this study highlights the need for careful consideration and control of these factors in future EEG research in idiopathic generalized epilepsy particularly for their use as biomarkers.
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Affiliation(s)
- Amy Shakeshaft
- Department of Basic & Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,MRC Centre for Neurodevelopmental Disorders, King’s College London, London, UK
| | - Petroula Laiou
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Eugenio Abela
- Department of Basic & Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Mark P Richardson
- Correspondence may also be addressed to: Professor Mark P Richardson Maurice Wohl Clinical Neurosciences Institute Institute of Psychiatry, Psychology & Neuroscience King’s College London, 5 Cutcombe Road, London SE5 9RX, UK E-mail:
| | - Deb K Pal
- Correspondence to: Professor Deb K Pal Maurice Wohl Clinical Neurosciences Institute Institute of Psychiatry, Psychology & Neuroscience King’s College London 5 Cutcombe Road, London SE5 9RX, UK E-mail:
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Matthews R, Ahmed R, Mohanraj R. 043 A case of cerebral air embolism from giant pulmonary bulla during air travel. J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Cerebral air embolism following pulmonary barotrauma during flight in patients with giant pulmonary bullae is rare, with only five reported cases. We aim to highlight and better understand this unusual condition.A 47-year-old male airline passenger with a primary lung bulla experienced an inflight cerebral air embolism resulting in hypoxic brain injury. On landing, he was found unconscious and developed seizures. He was admitted to intensive care, requiring invasive ventilation. CT brain demonstrated diffuse oedema. Sub- sequent MR brain imaging demonstrated bilateral hypoxic injury, characteristic of air embolism. Chest CT revealed a giant pulmonary bulla.Air embolism occurs in patients with pulmonary bullae during flight due to pulmonary barotrauma. Pressure change during ascent causes expansion of bullae, resulting in tears in the pulmonary vasculature, with air leakage and embolisation to the arterial cerebral circulation. No British Thoracic Society air travel guide- lines extend to advice regarding risk of rupture of bulla given the rarity of this presentation.Neurological deficit in cerebral air embolism is variable, and some cases can be reversible. Our patient had modest improvement in clinical status and was discharged to a neurorehabilitation facility. Patients with known giant pulmonary bullae should be counselled on the risks associated with air travel.rachaelmatthews@doctors.org.uk
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Prabhakaran A, Coyle H, Mohanraj R. 136 New valproate guidelines and adherence to the pregnancy prevention programme: experience in a tertiary clinic. J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives: To establish the proportion of women of childbearing age on Sodium Valproate (VPA) for epilepsy who met the requirements of the Pregnancy Prevention Programme (PPP) in accordance with the Medicines and Healthcare products Regulatory Agency (MHRA) guidelines, with a view to identifying rates of compliance and the reasons for non-adherence.Methods128 female participants of childbearing age currently on VPA, who had completed an annual risk assessment from Greater Manchester, were included in the study. Patient data was gathered review of Electronic Patient Records.ResultsThe majority of women (n=86, 67%) did not meet the conditions of the PPP: 59 (69%) were on no contraception, and 27 (31%) were on inadequate contraception such as OCP, Depo injection, and condoms. Non adherence to PPP was due to 11 different reasons, the most common (n=27) being learning disability, followed by, no intention of becoming pregnant (n=7), not sexually active (n=13), and patient choice (n=9)ConclusionsPPP does not appear to be relevant to the majority of women of child bearing age pre- scribed VPA. Further patient education about rates of unplanned pregnancies and risks of VPA might help improve adherence to PPP.asmithaa.prabhakaran@student.manchester.ac.uk
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Ahmed R, Pegg E, Taylor J, Mohanraj R. 005 Automated classification of inter-ictal EEG in the diagnosis of epilepsy. J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundDiagnosis of epilepsy is based on descriptions of attacks, supported by finding epileptiform activity on EEG. Routine EEG can detect inter-ictal epileptiform discharges (IEDs) in approximately 50% of patients with epilepsy, and approximately 1% of the general population can have IEDs without ever developing epilepsy. The lack of a reliable biomarker is a factor in the high misdiagnosis rate of epilepsy. The EEG carries a wealth of information on brain activity, which cannot be discerned by visual analysis. Advanced EEG analysis with machine learning approaches hold promise in unlocking additional useful information contained in the EEG signal.Methods20 patients with idiopathic generalised epilepsy and 20 age-matched controls underwent a 64-channel EEG. After pre-processing, a 20 second epoch of resting state, eyes closed EEG free from IEDs and artefact was used for analysis. Band-pass filtered EEG was used to construct functional connectivity matrices by calculating phase locking value (PLV) between electrode pairs. Connectivity matrices were analysed by a machine learning algorithm to classify patients into epilepsy and controls.ResultsThe ML classifier achieved a classification accuracy of 60% between patients with epilepsy and normal controls.ConclusionsAutomated machine learning analysis has the potential to improve the diagnostic utility of EEG in epilepsy. Alternatives to functional connectivity matrices will be explored in future studies with the objective of improving classifier performance.rohanahmed92@gmail.com
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Glasse H, Hotchkies A, Bailey M, Mohanraj R, Cahill V, Cooper P. 149 Mesial temporal lobe epilepsy with amygdala enlargement: a phenotype of autoimmune epilepsy? J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundMesial temporal lobe epilepsy with amygdala enlargement (MTLE-AE) is a relatively newly described subtype of focal epilepsy. The aetiology of MTLE-AE remains unclear. We investigated the prevalence of antibodies to neuronal antigens in a cohort of adult patients with MTLE-AEMethodsPatients with MTLE-AE presenting to a tertiary epilepsy clinic were identified. Demographic and characteristic data were collected by review of records. The antibody prevalence in epilepsy (APE2) score was calculated for all patients.Results25 cases of TLE-AE who had undergone antibody testing were identified. 5 cases had positive antibodies (2 VGKC+LGI-1, 1 VGKC alone, 2 GAD). Mean age of epilepsy onset was 46.2 and 35.4 years for antibody positive and negative groups respectively. The antibody positive group had a higher mean APE2 score (6) than the negative group (3.8), partially due to a higher incidence of neuropsychiatric features and prodromal illness. All VGKC positive patients achieved seizure freedom with immunotherapy.DiscussionMTLE-AE may be related to autoimmune processes in a proportion of cases. This potentially treatable cause may be missed in patients with epilepsy, if antibody testing is not undertaken.hannah.glasse@doctors.org.uk
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Aslanyan A, Boardman J, Glasse H, Lilleker J, Mohanraj R. 084 Is there a positive correlation between single breath count and forced vital capacity? J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
IntroductionMonitoring respiratory function is a critical part of the management of patients with acute neuromuscular disease. Single breath count (SBC) testing is often performed as a surrogate for the Forced Vital Capacity (FVC), especially in resource poor environments. However, equivalence of these two tests has not been formally evaluated.MethodsWe will compare the SBC and FVC in 50 healthy adults. Correlation will be evaluated using linear regression and factors influencing the SBC and FVC will be investigated.ResultsTo date 10 participants have been recruited (4 male, 6 female, mean age 30 years). Provisional analysis has shown a mean best SBC and FVC was 71 (SD 19) and 4.8 Litres (SD 1.3) respectively. In this small sample a significant correlation between SBC and FVC was demonstrated (p=0.03, R-squared=0.47). Recruitment is on schedule to complete by March 2020 and full results will be available for presentation at the conference.DiscussionTo our knowledge no study has directly compared SBC and FVC in healthy adult population. Our study will provide useful data to help understand the appropriateness of interchanging these tests in clinical practice.aram.aslanyan@srft.nhs.uk
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Prabhakar P, Das G, Mohapatra D, Seth R, Setlur K, Mandal P, Mohanraj R, Meena J, Kumar Gupta A. Teleconsultation: An importatnt tool leading to a paradigm shift in the management of maintenance phase chemotherapy of acute lymphoblastic leukemia. Pediatric Hematology Oncology Journal 2022. [DOI: 10.1016/j.phoj.2022.10.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Prabhakar P, Das G, Mohapatra D, Seth R, Setlur K, Mandal P, Mohanraj R, Meena J, Gupta AK. Teleconsultation: An importatnt tool leading to a paradigm shift in the management of maintenance phase chemotherapy of acute lymphoblastic leukemia. Pediatric Hematology Oncology Journal 2022. [DOI: 10.1016/j.phoj.2022.10.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Marson AG, Burnside G, Appleton R, Smith D, Leach JP, Sills G, Tudur-Smith C, Plumpton CO, Hughes DA, Williamson PR, Baker G, Balabanova S, Taylor C, Brown R, Hindley D, Howell S, Maguire M, Mohanraj R, Smith PE. Lamotrigine versus levetiracetam or zonisamide for focal epilepsy and valproate versus levetiracetam for generalised and unclassified epilepsy: two SANAD II non-inferiority RCTs. Health Technol Assess 2021; 25:1-134. [PMID: 34931602 DOI: 10.3310/hta25750] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Levetiracetam (Keppra®, UCB Pharma Ltd, Slough, UK) and zonisamide (Zonegran®, Eisai Co. Ltd, Tokyo, Japan) are licensed as monotherapy for focal epilepsy, and levetiracetam is increasingly used as a first-line treatment for generalised epilepsy, particularly for women of childbearing age. However, there is uncertainty as to whether or not they should be recommended as first-line treatments owing to a lack of evidence of clinical effectiveness and cost-effectiveness. OBJECTIVES To compare the clinical effectiveness and cost-effectiveness of lamotrigine (Lamictal®, GlaxoSmithKline plc, Brentford, UK) (standard treatment) with levetiracetam and zonisamide (new treatments) for focal epilepsy, and to compare valproate (Epilim®, Sanofi SA, Paris, France) (standard treatment) with levetiracetam (new treatment) for generalised and unclassified epilepsy. DESIGN Two pragmatic randomised unblinded non-inferiority trials run in parallel. SETTING Outpatient services in NHS hospitals throughout the UK. PARTICIPANTS Those aged ≥ 5 years with two or more spontaneous seizures that require anti-seizure medication. INTERVENTIONS Participants with focal epilepsy were randomised to receive lamotrigine, levetiracetam or zonisamide. Participants with generalised or unclassifiable epilepsy were randomised to receive valproate or levetiracetam. The randomisation method was minimisation using a web-based program. MAIN OUTCOME MEASURES The primary outcome was time to 12-month remission from seizures. For this outcome, and all other time-to-event outcomes, we report hazard ratios for the standard treatment compared with the new treatment. For the focal epilepsy trial, the non-inferiority limit (lamotrigine vs. new treatments) was 1.329. For the generalised and unclassified epilepsy trial, the non-inferiority limit (valproate vs. new treatments) was 1.314. Secondary outcomes included time to treatment failure, time to first seizure, time to 24-month remission, adverse reactions, quality of life and cost-effectiveness. RESULTS Focal epilepsy. A total of 990 participants were recruited, of whom 330 were randomised to receive lamotrigine, 332 were randomised to receive levetiracetam and 328 were randomised to receive zonisamide. Levetiracetam did not meet the criteria for non-inferiority (hazard ratio 1.329) in the primary intention-to-treat analysis of time to 12-month remission (hazard ratio vs. lamotrigine 1.18, 97.5% confidence interval 0.95 to 1.47), but zonisamide did meet the criteria (hazard ratio vs. lamotrigine 1.03, 97.5% confidence interval 0.83 to 1.28). In the per-protocol analysis, lamotrigine was superior to both levetiracetam (hazard ratio 1.32, 95% confidence interval 1.05 to 1.66) and zonisamide (hazard ratio 1.37, 95% confidence interval 1.08 to 1.73). For time to treatment failure, lamotrigine was superior to levetiracetam (hazard ratio 0.60, 95% confidence interval 0.46 to 0.77) and zonisamide (hazard ratio 0.46, 95% confidence interval 0.36 to 0.60). Adverse reactions were reported by 33% of participants starting lamotrigine, 44% starting levetiracetam and 45% starting zonisamide. In the economic analysis, both levetiracetam and zonisamide were more costly and less effective than lamotrigine and were therefore dominated. Generalised and unclassifiable epilepsy. Of 520 patients recruited, 260 were randomised to receive valproate and 260 were randomised to receive to levetiracetam. A total of 397 patients had generalised epilepsy and 123 had unclassified epilepsy. Levetiracetam did not meet the criteria for non-inferiority in the primary intention-to-treat analysis of time to 12-month remission (hazard ratio 1.19, 95% confidence interval 0.96 to 1.47; non-inferiority margin 1.314). In the per-protocol analysis of time to 12-month remission, valproate was superior to levetiracetam (hazard ratio 1.68, 95% confidence interval 1.30 to 2.15). Valproate was superior to levetiracetam for time to treatment failure (hazard ratio 0.65, 95% confidence interval 0.50 to 0.83). Adverse reactions were reported by 37.4% of participants receiving valproate and 41.5% of those receiving levetiracetam. Levetiracetam was both more costly (incremental cost of £104, 95% central range -£587 to £1234) and less effective (incremental quality-adjusted life-year of -0.035, 95% central range -0.137 to 0.032) than valproate, and was therefore dominated. At a cost-effectiveness threshold of £20,000 per quality-adjusted life-year, levetiracetam was associated with a probability of 0.17 of being cost-effective. LIMITATIONS The SANAD II trial was unblinded, which could have biased results by influencing decisions about dosing, treatment failure and the attribution of adverse reactions. FUTURE WORK SANAD II data could now be included in an individual participant meta-analysis of similar trials, and future similar trials are required to assess the clinical effectiveness and cost-effectiveness of other new treatments, including lacosamide and perampanel. CONCLUSIONS Focal epilepsy - The SANAD II findings do not support the use of levetiracetam or zonisamide as first-line treatments in focal epilepsy. Generalised and unclassifiable epilepsy - The SANAD II findings do not support the use of levetiracetam as a first-line treatment for newly diagnosed generalised epilepsy. For women of childbearing potential, these results inform discussions about the benefit (lower teratogenicity) and harm (worse seizure outcomes and higher treatment failure rate) of levetiracetam compared with valproate. TRIAL REGISTRATION Current Controlled Trials ISRCTN30294119 and EudraCT 2012-001884-64. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 75. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Anthony G Marson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Girvan Burnside
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Richard Appleton
- The Roald Dahl EEG Unit, Alder Hey Children's Health Park, Liverpool, UK
| | - Dave Smith
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Graeme Sills
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Catrin Tudur-Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Catrin O Plumpton
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Paula R Williamson
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Gus Baker
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Silviya Balabanova
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Claire Taylor
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Richard Brown
- Addenbrooke's Hospital NHS Foundation Trust, Cambridge, UK
| | - Dan Hindley
- Bolton NHS Foundation Trust, Royal Bolton Hospital, Bolton, UK
| | - Stephen Howell
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | - Philip Em Smith
- The Alan Richens Epilepsy Unit, University Hospital of Wales, Cardiff, UK
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14
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Chen Y, Fallon N, Kreilkamp BAK, Denby C, Bracewell M, Das K, Pegg E, Mohanraj R, Marson AG, Keller SS. Probabilistic mapping of thalamic nuclei and thalamocortical functional connectivity in idiopathic generalised epilepsy. Hum Brain Mapp 2021; 42:5648-5664. [PMID: 34432348 PMCID: PMC8559489 DOI: 10.1002/hbm.25644] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 08/04/2021] [Accepted: 08/16/2021] [Indexed: 02/06/2023] Open
Abstract
It is well established that abnormal thalamocortical systems play an important role in the generation and maintenance of primary generalised seizures. However, it is currently unknown which thalamic nuclei and how nuclear‐specific thalamocortical functional connectivity are differentially impacted in patients with medically refractory and non‐refractory idiopathic generalised epilepsy (IGE). In the present study, we performed structural and resting‐state functional magnetic resonance imaging (MRI) in patients with refractory and non‐refractory IGE, segmented the thalamus into constituent nuclear regions using a probabilistic MRI segmentation method and determined thalamocortical functional connectivity using seed‐to‐voxel connectivity analyses. We report significant volume reduction of the left and right anterior thalamic nuclei only in patients with refractory IGE. Compared to healthy controls, patients with refractory and non‐refractory IGE had significant alterations of functional connectivity between the centromedian nucleus and cortex, but only patients with refractory IGE had altered cortical connectivity with the ventral lateral nuclear group. Patients with refractory IGE had significantly increased functional connectivity between the left and right ventral lateral posterior nuclei and cortical regions compared to patients with non‐refractory IGE. Cortical effects were predominantly located in the frontal lobe. Atrophy of the anterior thalamic nuclei and resting‐state functional hyperconnectivity between ventral lateral nuclei and cerebral cortex may be imaging markers of pharmacoresistance in patients with IGE. These structural and functional abnormalities fit well with the known importance of thalamocortical systems in the generation and maintenance of primary generalised seizures, and the increasing recognition of the importance of limbic pathways in IGE.
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Affiliation(s)
- Yachin Chen
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Nicholas Fallon
- Department of Psychology, University of Liverpool, Liverpool, UK
| | - Barbara A K Kreilkamp
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | | | - Martyn Bracewell
- The Walton Centre NHS Foundation Trust, Liverpool, UK.,Schools of Medical Sciences and Psychology, Bangor University, Bangor, UK
| | - Kumar Das
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Emily Pegg
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Rajiv Mohanraj
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Simon S Keller
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,The Walton Centre NHS Foundation Trust, Liverpool, UK
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15
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Pegg EJ, McKavanagh A, Bracewell RM, Chen Y, Das K, Denby C, Kreilkamp BAK, Laiou P, Marson A, Mohanraj R, Taylor JR, Keller SS. Functional network topology in drug resistant and well-controlled idiopathic generalized epilepsy: a resting state functional MRI study. Brain Commun 2021; 3:fcab196. [PMID: 34514400 PMCID: PMC8417840 DOI: 10.1093/braincomms/fcab196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 11/23/2022] Open
Abstract
Despite an increasing number of drug treatment options for people with idiopathic generalized epilepsy (IGE), drug resistance remains a significant issue and the mechanisms underlying it remain poorly understood. Previous studies have largely focused on potential cellular or genetic explanations for drug resistance. However, epilepsy is understood to be a network disorder and there is a growing body of literature suggesting altered topology of large-scale resting networks in people with epilepsy compared with controls. We hypothesize that network alterations may also play a role in seizure control. The aim of this study was to compare resting state functional network structure between well-controlled IGE (WC-IGE), drug resistant IGE (DR-IGE) and healthy controls. Thirty-three participants with IGE (10 with WC-IGE and 23 with DR-IGE) and 34 controls were included. Resting state functional MRI networks were constructed using the Functional Connectivity Toolbox (CONN). Global graph theoretic network measures of average node strength (an equivalent measure to mean degree in a network that is fully connected), node strength distribution variance, characteristic path length, average clustering coefficient, small-world index and average betweenness centrality were computed. Graphs were constructed separately for positively weighted connections and for absolute values. Individual nodal values of strength and betweenness centrality were also measured and ‘hub nodes’ were compared between groups. Outcome measures were assessed across the three groups and between both groups with IGE and controls. The IGE group as a whole had a higher average node strength, characteristic path length and average betweenness centrality. There were no clear differences between groups according to seizure control. Outcome metrics were sensitive to whether negatively correlated connections were included in network construction. There were no clear differences in the location of ‘hub nodes’ between groups. The results suggest that, irrespective of seizure control, IGE interictal network topology is more regular and has a higher global connectivity compared to controls, with no alteration in hub node locations. These alterations may produce a resting state network that is more vulnerable to transitioning to the seizure state. It is possible that the lack of apparent influence of seizure control on network topology is limited by challenges in classifying drug response. It is also demonstrated that network topological features are influenced by the sign of connectivity weights and therefore future methodological work is warranted to account for anticorrelations in graph theoretic studies.
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Affiliation(s)
- Emily J Pegg
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Andrea McKavanagh
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | | | - Yachin Chen
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Kumar Das
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Barbara A K Kreilkamp
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Petroula Laiou
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anthony Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Rajiv Mohanraj
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jason R Taylor
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Simon S Keller
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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16
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Bowen R, Hashmi A, Lewis J, Hassani A, Mohanraj R, Mott J, Pearson R. PO-1398 SRS for brain metastases from renal cell carcinoma; UK tertiary referral centre 5-year experience. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)07849-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Hutchcroft C, Jones M, Lavin T, Lilleker J, Molloy J, McKee D, Richardson A, Mohanraj R. The Last Act of Love. Pract Neurol 2021; 21:459. [PMID: 34155125 DOI: 10.1136/practneurol-2021-003018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 11/03/2022]
Affiliation(s)
| | - Matthew Jones
- Department of Neurology, Greater Manchester Neuroscience Centre, Salford, UK
| | - Tim Lavin
- Department of Neurology, Greater Manchester Neuroscience Centre, Salford, UK
| | - James Lilleker
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Greater Manchester Neuroscience Centre, Salford, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jane Molloy
- Department of Neurology, Greater Manchester Neuroscience Centre, Salford, UK
| | - David McKee
- Department of Neurology, Greater Manchester Neuroscience Centre, Salford, UK
| | - Anna Richardson
- Department of Neurology, Greater Manchester Neuroscience Centre, Salford, UK
| | - Rajiv Mohanraj
- Department of Neurology, Greater Manchester Neuroscience Centre, Salford, UK .,Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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18
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Marson A, Burnside G, Appleton R, Smith D, Leach JP, Sills G, Tudur-Smith C, Plumpton C, Hughes DA, Williamson P, Baker GA, Balabanova S, Taylor C, Brown R, Hindley D, Howell S, Maguire M, Mohanraj R, Smith PE. The SANAD II study of the effectiveness and cost-effectiveness of levetiracetam, zonisamide, or lamotrigine for newly diagnosed focal epilepsy: an open-label, non-inferiority, multicentre, phase 4, randomised controlled trial. Lancet 2021; 397:1363-1374. [PMID: 33838757 PMCID: PMC8047799 DOI: 10.1016/s0140-6736(21)00247-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/22/2020] [Accepted: 01/20/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Levetiracetam and zonisamide are licensed as monotherapy for patients with focal epilepsy, but there is uncertainty as to whether they should be recommended as first-line treatments because of insufficient evidence of clinical effectiveness and cost-effectiveness. We aimed to assess the long-term clinical effectiveness and cost-effectiveness of levetiracetam and zonisamide compared with lamotrigine in people with newly diagnosed focal epilepsy. METHODS This randomised, open-label, controlled trial compared levetiracetam and zonisamide with lamotrigine as first-line treatment for patients with newly diagnosed focal epilepsy. Adult and paediatric neurology services across the UK recruited participants aged 5 years or older (with no upper age limit) with two or more unprovoked focal seizures. Participants were randomly allocated (1:1:1) using a minimisation programme with a random element utilising factor to receive lamotrigine, levetiracetam, or zonisamide. Participants and investigators were not masked and were aware of treatment allocation. SANAD II was designed to assess non-inferiority of both levetiracetam and zonisamide to lamotrigine for the primary outcome of time to 12-month remission. Anti-seizure medications were taken orally and for participants aged 12 years or older the initial advised maintenance doses were lamotrigine 50 mg (morning) and 100 mg (evening), levetiracetam 500 mg twice per day, and zonisamide 100 mg twice per day. For children aged between 5 and 12 years the initial daily maintenance doses advised were lamotrigine 1·5 mg/kg twice per day, levetiracetam 20 mg/kg twice per day, and zonisamide 2·5 mg/kg twice per day. All participants were included in the intention-to-treat (ITT) analysis. The per-protocol (PP) analysis excluded participants with major protocol deviations and those who were subsequently diagnosed as not having epilepsy. Safety analysis included all participants who received one dose of any study drug. The non-inferiority limit was a hazard ratio (HR) of 1·329, which equates to an absolute difference of 10%. A HR greater than 1 indicated that an event was more likely on lamotrigine. The trial is registered with the ISRCTN registry, 30294119 (EudraCt number: 2012-001884-64). FINDINGS 990 participants were recruited between May 2, 2013, and June 20, 2017, and followed up for a further 2 years. Patients were randomly assigned to receive lamotrigine (n=330), levetiracetam (n=332), or zonisamide (n=328). The ITT analysis included all participants and the PP analysis included 324 participants randomly assigned to lamotrigine, 320 participants randomly assigned to levetiracetam, and 315 participants randomly assigned to zonisamide. Levetiracetam did not meet the criteria for non-inferiority in the ITT analysis of time to 12-month remission versus lamotrigine (HR 1·18; 97·5% CI 0·95-1·47) but zonisamide did meet the criteria for non-inferiority in the ITT analysis versus lamotrigine (1·03; 0·83-1·28). The PP analysis showed that 12-month remission was superior with lamotrigine than both levetiracetam (HR 1·32 [97·5% CI 1·05 to 1·66]) and zonisamide (HR 1·37 [1·08-1·73]). There were 37 deaths during the trial. Adverse reactions were reported by 108 (33%) participants who started lamotrigine, 144 (44%) participants who started levetiracetam, and 146 (45%) participants who started zonisamide. Lamotrigine was superior in the cost-utility analysis, with a higher net health benefit of 1·403 QALYs (97·5% central range 1·319-1·458) compared with 1·222 (1·110-1·283) for levetiracetam and 1·232 (1·112, 1·307) for zonisamide at a cost-effectiveness threshold of £20 000 per QALY. Cost-effectiveness was based on differences between treatment groups in costs and QALYs. INTERPRETATION These findings do not support the use of levetiracetam or zonisamide as first-line treatments for patients with focal epilepsy. Lamotrigine should remain a first-line treatment for patients with focal epilepsy and should be the standard treatment in future trials. FUNDING National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Anthony Marson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.
| | - Girvan Burnside
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Richard Appleton
- The Roald Dahl EEG Unit, Alder Hey Children's Health Park, Liverpool, UK
| | - Dave Smith
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Graeme Sills
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Catrin Tudur-Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Catrin Plumpton
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Wales, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Wales, UK
| | - Paula Williamson
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Gus A Baker
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Silviya Balabanova
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Claire Taylor
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Richard Brown
- Addenbrooke's Hospital NHS Foundation Trust, Cambridge, UK
| | - Dan Hindley
- Bolton NHS Foundation Trust, Royal Bolton Hospital, Lancashire, UK
| | - Stephen Howell
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | - Philip E Smith
- The Alan Richens Epilepsy Unit, University Hospital of Wales, Cardiff, Wales, UK
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19
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Marson A, Burnside G, Appleton R, Smith D, Leach JP, Sills G, Tudur-Smith C, Plumpton C, Hughes DA, Williamson P, Baker GA, Balabanova S, Taylor C, Brown R, Hindley D, Howell S, Maguire M, Mohanraj R, Smith PE. The SANAD II study of the effectiveness and cost-effectiveness of valproate versus levetiracetam for newly diagnosed generalised and unclassifiable epilepsy: an open-label, non-inferiority, multicentre, phase 4, randomised controlled trial. Lancet 2021; 397:1375-1386. [PMID: 33838758 PMCID: PMC8047813 DOI: 10.1016/s0140-6736(21)00246-4] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/22/2020] [Accepted: 01/20/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Valproate is a first-line treatment for patients with newly diagnosed idiopathic generalised or difficult to classify epilepsy, but not for women of child-bearing potential because of teratogenicity. Levetiracetam is increasingly prescribed for these patient populations despite scarcity of evidence of clinical effectiveness or cost-effectiveness. We aimed to compare the long-term clinical effectiveness and cost-effectiveness of levetiracetam compared with valproate in participants with newly diagnosed generalised or unclassifiable epilepsy. METHODS We did an open-label, randomised controlled trial to compare levetiracetam with valproate as first-line treatment for patients with generalised or unclassified epilepsy. Adult and paediatric neurology services (69 centres overall) across the UK recruited participants aged 5 years or older (with no upper age limit) with two or more unprovoked generalised or unclassifiable seizures. Participants were randomly allocated (1:1) to receive either levetiracetam or valproate, using a minimisation programme with a random element utilising factors. Participants and investigators were aware of treatment allocation. For participants aged 12 years or older, the initial advised maintenance doses were 500 mg twice per day for levetiracetam and valproate, and for children aged 5-12 years, the initial daily maintenance doses advised were 25 mg/kg for valproate and 40 mg/kg for levetiracetam. All drugs were administered orally. SANAD II was designed to assess the non-inferiority of levetiracetam compared with valproate for the primary outcome time to 12-month remission. The non-inferiority limit was a hazard ratio (HR) of 1·314, which equates to an absolute difference of 10%. A HR greater than 1 indicated that an event was more likely on valproate. All participants were included in the intention-to-treat (ITT) analysis. Per-protocol (PP) analyses excluded participants with major protocol deviations and those who were subsequently diagnosed as not having epilepsy. Safety analyses included all participants who received one dose of any study drug. This trial is registered with the ISRCTN registry, 30294119 (EudraCt number: 2012-001884-64). FINDINGS 520 participants were recruited between April 30, 2013, and Aug 2, 2016, and followed up for a further 2 years. 260 participants were randomly allocated to receive levetiracetam and 260 participants to receive valproate. The ITT analysis included all participants and the PP analysis included 255 participants randomly allocated to valproate and 254 randomly allocated to levetiracetam. Median age of participants was 13·9 years (range 5·0-94·4), 65% were male and 35% were female, 397 participants had generalised epilepsy, and 123 unclassified epilepsy. Levetiracetam did not meet the criteria for non-inferiority in the ITT analysis of time to 12-month remission (HR 1·19 [95% CI 0·96-1·47]); non-inferiority margin 1·314. The PP analysis showed that the 12-month remission was superior with valproate than with levetiracetam. There were two deaths, one in each group, that were unrelated to trial treatments. Adverse reactions were reported by 96 (37%) participants randomly assigned to valproate and 107 (42%) participants randomly assigned to levetiracetam. Levetiracetam was dominated by valproate in the cost-utility analysis, with a negative incremental net health benefit of -0·040 (95% central range -0·175 to 0·037) and a probability of 0·17 of being cost-effectiveness at a threshold of £20 000 per quality-adjusted life-year. Cost-effectiveness was based on differences between treatment groups in costs and quality-adjusted life-years. INTERPRETATION Compared with valproate, levetiracetam was found to be neither clinically effective nor cost-effective. For girls and women of child-bearing potential, these results inform discussions about benefit and harm of avoiding valproate. FUNDING National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Anthony Marson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.
| | - Girvan Burnside
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Richard Appleton
- The Roald Dahl EEG Unit, Alder Hey Children's Health Park, Liverpool, UK
| | - Dave Smith
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Graeme Sills
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Catrin Tudur-Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Catrin Plumpton
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Wales, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Wales, UK
| | - Paula Williamson
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Gus A Baker
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Silviya Balabanova
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Claire Taylor
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Richard Brown
- Addenbrooke's Hospital NHS Foundation Trust, Cambridge, UK
| | - Dan Hindley
- Bolton NHS Foundation Trust, Royal Bolton Hospital, Lancashire, UK
| | - Stephen Howell
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | - Philip E Smith
- The Alan Richens Epilepsy Unit, University Hospital of Wales, Cardiff, Wales, UK
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20
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Pegg EJ, Taylor JR, Laiou P, Richardson M, Mohanraj R. Interictal electroencephalographic functional network topology in drug-resistant and well-controlled idiopathic generalized epilepsy. Epilepsia 2021; 62:492-503. [PMID: 33501642 DOI: 10.1111/epi.16811] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/20/2020] [Accepted: 12/22/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The study aim was to compare interictal encephalographic (EEG) functional network topology between people with well-controlled idiopathic generalized epilepsy (WC-IGE) and drug-resistant IGE (DR-IGE). METHODS Nineteen participants with WC-IGE, 18 with DR-IGE, and 20 controls underwent a resting state, 64-channel EEG. An artifact-free epoch was bandpass filtered into the frequency range of high and low extended alpha. Weighted functional connectivity matrices were calculated. Mean degree, degree distribution variance, characteristic path length (L), clustering coefficient, small world index (SWI), and betweenness centrality were measured. A Kruskal-Wallis H-test assessed effects across groups. Where significant differences were found, Bonferroni-corrected Mann-Whitney pairwise comparisons were calculated. RESULTS In the low alpha band (6-9 Hz), there was a significant difference in L at the three-group level (p < .0001). This was lower in controls than both WC-IGE and DR-IGE (p < .0001 for both), with no difference in L between WC-IGE and DR-IGE. Mean degree (p = .031), degree distribution variance (p = .032), and SWI (p = .023) differed across the three groups in the high alpha band (10-12 Hz). Mean degree and degree distribution variance were lower in WC-IGE than controls (p = .029 for both), and SWI was higher in WC-IGE compared with controls (p = .038), with no differences in other pairwise comparisons. SIGNIFICANCE IGE network topology is more regular in the low alpha frequency band, potentially reflecting a more vulnerable structure. WC-IGE network topology is different from controls in the high alpha band. This may reflect drug-induced network changes that have stabilized the WC-IGE network by rendering it less likely to synchronize. These results are of potential importance in advancing the understanding of mechanisms of epilepsy drug resistance and as a possible basis for a biomarker of DR-IGE.
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Affiliation(s)
- Emily J Pegg
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Salford, UK.,Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine, and Health, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Jason R Taylor
- Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine, and Health, School of Biological Sciences, University of Manchester, Manchester, UK.,Manchester Academic Health Sciences Centre, Manchester, UK
| | - Petroula Laiou
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Mark Richardson
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Rajiv Mohanraj
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Salford, UK.,Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine, and Health, School of Biological Sciences, University of Manchester, Manchester, UK
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21
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Fry AE, Marra C, Derrick AV, Pickrell WO, Higgins AT, Te Water Naude J, McClatchey MA, Davies SJ, Metcalfe KA, Tan HJ, Mohanraj R, Avula S, Williams D, Brady LI, Mesterman R, Tarnopolsky MA, Zhang Y, Yang Y, Wang X, Rees MI, Goldfarb M, Chung SK. Missense variants in the N-terminal domain of the A isoform of FHF2/FGF13 cause an X-linked developmental and epileptic encephalopathy. Am J Hum Genet 2021; 108:176-185. [PMID: 33245860 PMCID: PMC7820623 DOI: 10.1016/j.ajhg.2020.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/30/2020] [Indexed: 01/22/2023] Open
Abstract
Fibroblast growth factor homologous factors (FHFs) are intracellular proteins which regulate voltage-gated sodium (Nav) channels in the brain and other tissues. FHF dysfunction has been linked to neurological disorders including epilepsy. Here, we describe two sibling pairs and three unrelated males who presented in infancy with intractable focal seizures and severe developmental delay. Whole-exome sequencing identified hemi- and heterozygous variants in the N-terminal domain of the A isoform of FHF2 (FHF2A). The X-linked FHF2 gene (also known as FGF13) has alternative first exons which produce multiple protein isoforms that differ in their N-terminal sequence. The variants were located at highly conserved residues in the FHF2A inactivation particle that competes with the intrinsic fast inactivation mechanism of Nav channels. Functional characterization of mutant FHF2A co-expressed with wild-type Nav1.6 (SCN8A) revealed that mutant FHF2A proteins lost the ability to induce rapid-onset, long-term blockade of the channel while retaining pro-excitatory properties. These gain-of-function effects are likely to increase neuronal excitability consistent with the epileptic potential of FHF2 variants. Our findings demonstrate that FHF2 variants are a cause of infantile-onset developmental and epileptic encephalopathy and underline the critical role of the FHF2A isoform in regulating Nav channel function.
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Affiliation(s)
- Andrew E Fry
- Institute of Medical Genetics, University Hospital of Wales, Cardiff CF14 4XW, UK; Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff CF14 4XN, UK.
| | - Christopher Marra
- Department of Biological Sciences, Hunter College of City University, 695 Park Avenue, New York, NY 10065, USA; Program in Biology, Graduate Center of City University, 365 Fifth Avenue, New York, NY 10016, USA
| | - Anna V Derrick
- Neurology and Molecular Neuroscience Research, Institute of Life Science, Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK
| | - William O Pickrell
- Neurology and Molecular Neuroscience Research, Institute of Life Science, Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK; Neurology department, Morriston Hospital, Swansea Bay University Hospital Health Board, Swansea SA6 6NL, UK
| | - Adam T Higgins
- Neurology and Molecular Neuroscience Research, Institute of Life Science, Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK
| | - Johann Te Water Naude
- Paediatric Neurology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK
| | - Martin A McClatchey
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff CF14 4XN, UK
| | - Sally J Davies
- Institute of Medical Genetics, University Hospital of Wales, Cardiff CF14 4XW, UK
| | - Kay A Metcalfe
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust and Institute of Human Development, University of Manchester, Manchester M13 9WL, UK
| | - Hui Jeen Tan
- Department of Paediatric Neurology, Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK
| | - Rajiv Mohanraj
- Department of Neurology, Salford Royal Hospital NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK
| | - Denise Williams
- West Midlands Regional Genetics Service, Clinical Genetics Unit, Birmingham Women's Hospital, Birmingham B15 2TG, UK
| | - Lauren I Brady
- Department of Paediatrics, McMaster University, 1200 Main St. W., Hamilton, ON L8N 3Z5, Canada
| | - Ronit Mesterman
- Department of Paediatrics, McMaster University, 1200 Main St. W., Hamilton, ON L8N 3Z5, Canada
| | - Mark A Tarnopolsky
- Department of Paediatrics, McMaster University, 1200 Main St. W., Hamilton, ON L8N 3Z5, Canada
| | - Yuehua Zhang
- Department of Pediatrics, Peking University First Hospital, Xicheng District, Beijing 100034, China
| | - Ying Yang
- Department of Pediatrics, Peking University First Hospital, Xicheng District, Beijing 100034, China
| | | | - Mark I Rees
- Neurology and Molecular Neuroscience Research, Institute of Life Science, Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK; Faculty of Medicine and Health, Camperdown, University of Sydney, NSW 2006, Australia
| | - Mitchell Goldfarb
- Department of Biological Sciences, Hunter College of City University, 695 Park Avenue, New York, NY 10065, USA; Program in Biology, Graduate Center of City University, 365 Fifth Avenue, New York, NY 10016, USA
| | - Seo-Kyung Chung
- Neurology and Molecular Neuroscience Research, Institute of Life Science, Swansea University Medical School, Swansea University, Swansea SA2 8PP, UK; Kids Neuroscience Centre, Kids Research, Children Hospital at Westmead, Sydney, NSW 2145, Australia; Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, NSW 2050, Australia
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22
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Matthews R, Mirza F, Siripurapu R, Ramdass R, Varma AR, Mohanraj R. Dysarthria and ptosis. Pract Neurol 2020; 21:practneurol-2020-002647. [PMID: 33249405 DOI: 10.1136/practneurol-2020-002647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Rachael Matthews
- Department of Neurology, Salford Royal Hospitals NHS Trust, Salford, UK
| | - Farhat Mirza
- Department of Neurology, Salford Royal Hospitals NHS Trust, Salford, UK
| | - Rekha Siripurapu
- Department of Neuroradiology, Salford Royal Hospitals NHS Trust, Salford, UK
| | - Ranjit Ramdass
- Department of Neurophysiology, Salford Royal Hospitals NHS Trust, Salford, UK
| | - Anoop Ranjan Varma
- Department of Neurology, Salford Royal Hospitals NHS Trust, Salford, UK
- Division of Neuroscience and Experimental Psychology , The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - Rajiv Mohanraj
- Department of Neurology, Salford Royal Hospitals NHS Trust, Salford, UK
- Division of Neuroscience and Experimental Psychology , The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
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23
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Pegg EJ, Taylor JR, Mohanraj R. Spectral power of interictal EEG in the diagnosis and prognosis of idiopathic generalized epilepsies. Epilepsy Behav 2020; 112:107427. [PMID: 32949965 DOI: 10.1016/j.yebeh.2020.107427] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/09/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Idiopathic generalized epilepsies (IGE) are characterized by generalized interictal epileptiform discharges (IEDs) on a normal background electroencephalography (EEG). However, the yield of IEDs can be low. Approximately 20% of patients with IGE fail to achieve seizure control with antiepileptic drug (AED) treatment. Currently, there are no reliable prognostic markers for early identification of drug-resistant epilepsy (DRE). We examined spectral power of the interictal EEG in patients with IGE and healthy controls, to identify potential diagnostic and prognostic biomarkers of IGE. METHODS A 64-channel EEG was recorded under standard conditions in patients with well-controlled IGE (WC-IGE, n = 19), drug-resistant IGE (DR-IGE, n = 18), and age-matched controls (n = 20). After preprocessing, fast Fourier transform was performed to obtain 1D frequency spectra for each EEG channel. The 1D spectra (averaged over channels) and 2D topographic maps (averaged over canonical frequency bands) were computed for each participant. Power spectra in the 3 cohorts were compared using one-way analysis of variance (ANOVA), and power spectra images were compared using T-contrast tests. A post hoc analysis compared peak alpha power between the groups. RESULTS Compared with controls, participants with IGE had higher interictal EEG spectral power in the delta band in the midline central region, in the theta band in the midline, in the beta band over the left hemisphere, and in the gamma band over right hemisphere and left central regions. There were no differences in spectral power between cohorts with WC-IGE and DR-IGE. Peak alpha power was lower in WC-IGE and DR-IGE than controls. CONCLUSIONS Electroencephalography spectral power analysis could form part of a clinically useful diagnostic biomarker for IGE; however, it did not correlate with response to AED in this study.
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Affiliation(s)
- Emily J Pegg
- Department of Neurology, Manchester Centre for Clinical Neurosciences, United Kingdom; Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Jason R Taylor
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom; Manchester Academic Health Sciences Centre, United Kingdom
| | - Rajiv Mohanraj
- Department of Neurology, Manchester Centre for Clinical Neurosciences, United Kingdom; Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom.
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24
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Adewusi J, Burness C, Ellawela S, Emsley H, Hughes R, Lawthom C, Maguire M, McLean B, Mohanraj R, Oto M, Singhal S, Reuber M. Brivaracetam efficacy and tolerability in clinical practice: A UK-based retrospective multicenter service evaluation. Epilepsy Behav 2020; 106:106967. [PMID: 32179501 DOI: 10.1016/j.yebeh.2020.106967] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/14/2020] [Accepted: 02/01/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE This multicenter service evaluation explores the efficacy and tolerability of brivaracetam (BRV) in an unselected, consecutive population in 'real-life' clinical settings. METHOD We retrospectively collected data from patient records at 11 UK hospitals and epilepsy centers. Consecutive patients prescribed BRV with at least 3 months of follow-up (FU) were included. Apart from reporting effectiveness and tolerability of BRV across the whole cohort, we compared treatment outcomes depending on previous levetiracetam use (LEV+ versus LEV-), comorbid learning disability (LD+ versus LD-), and epilepsy syndrome (focal versus generalized epilepsy). RESULTS Two hundred and ninety patients (46% male, median age: 38 years, range: 15 to 77) with ≥3 months of FU were included. The median duration of BRV exposure was 12 months (range: 1 day to 72 months). Overall BRV retention was 71.1%. While 56.1% of patients improved in terms of seizure frequency category (daily, weekly, monthly, yearly seizures), 23.1% did not improve on this measure and 20.8% deteriorated. In terms of seizure frequency, 21% of patients experienced a ≥50% reduction, with 7.0% of all patients becoming seizure-free. Treatment-emergent adverse events (AEs) were reported by 107 (36.9%) patients, but there were no serious AEs. The commonest AEs were sedation/fatigue (18.3%), mood changes (9.0%), and irritability/aggression (4.8%). There were no significant differences in drug retention, seizure frequency outcomes, or AEs between the LEV+ and LEV- subgroups, or between patients with generalized or focal epilepsies. Although 15.5% of patients in the LD+ group achieved a ≥50% reduction, this rate was lower than in the LD- group. CONCLUSIONS This 'real-life' evaluation suggests that reductions in seizure frequency can be achieved with BRV in patients with highly refractory epilepsy. Brivaracetam may be a useful treatment option in patients who have previously failed to respond to or tolerate LEV, those with LD, or (off-label) those with generalized epilepsies.
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Affiliation(s)
- J Adewusi
- Academic Neurology Unit, University of Sheffield, UK.
| | - C Burness
- The Walton Centre, NHS Foundation Trust, Liverpool, UK.
| | - S Ellawela
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK.
| | - H Emsley
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.
| | - R Hughes
- Manchester University NHS Foundation Trust, UK.
| | | | - M Maguire
- Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK.
| | - B McLean
- Royal Cornwall Hospital NHS Trust, Truro, UK.
| | - R Mohanraj
- Salford Royal NHS Foundation Trust, Manchester, UK.
| | - M Oto
- William Quarriers Epilepsy Centre, Glasgow, UK
| | - S Singhal
- Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - M Reuber
- Academic Neurology Unit, University of Sheffield, UK.
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25
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Pegg EJ, Taylor JR, Keller SS, Mohanraj R. Interictal structural and functional connectivity in idiopathic generalized epilepsy: A systematic review of graph theoretical studies. Epilepsy Behav 2020; 106:107013. [PMID: 32193094 DOI: 10.1016/j.yebeh.2020.107013] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/22/2020] [Accepted: 02/28/2020] [Indexed: 12/18/2022]
Abstract
The evaluation of the role of anomalous neuronal networks in epilepsy using a graph theoretical approach is of growing research interest. There is currently no consensus on optimal methods for performing network analysis, and it is possible that variations in study methodology account for diverging findings. This review focuses on global functional and structural interictal network characteristics in people with idiopathic generalized epilepsy (IGE) with the aim of appraising the methodological approaches used and assessing for meaningful consensus. Thirteen studies were included in the review. Data were heterogenous and not suitable for meta-analysis. Overall, there is a suggestion that the cerebral neuronal networks of people with IGE have different global structural and functional characteristics to people without epilepsy. However, the nature of the aberrations is inconsistent with some studies demonstrating a more regular network configuration in IGE, and some, a more random topology. There is greater consistency when different data modalities and connectivity subtypes are compared separately, with a tendency towards increased small-worldness of networks in functional electroencephalography/magnetoencephalography (EEG/MEG) studies and decreased small-worldness of networks in structural studies. Prominent variation in study design at all stages is likely to have contributed to differences in study outcomes. Despite increasing literature surrounding neuronal network analysis, systematic methodological studies are lacking. Absence of consensus in this area significantly limits comparison of results from different studies, and the ability to draw firm conclusions about network characteristics in IGE.
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Affiliation(s)
- Emily J Pegg
- Department of Neurology, Manchester Centre for Clinical Neurosciences, United Kingdom; Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom.
| | - Jason R Taylor
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom; Manchester Academic Health Sciences Centre, United Kingdom
| | - Simon S Keller
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, United Kingdom; The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Rajiv Mohanraj
- Department of Neurology, Manchester Centre for Clinical Neurosciences, United Kingdom; Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
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26
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Mohanraj R, Vimala R. ECG Signal Denoising with Field-Programmable Gate Array Implementation of Fast Digital Finite Impulse Response and Infinite Impulse Response Filters. j med imaging hlth inform 2020. [DOI: 10.1166/jmihi.2020.2842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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27
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de Bézenac C, Garcia-Finana M, Baker G, Moore P, Leek N, Mohanraj R, Bonilha L, Richardson M, Marson AG, Keller S. Investigating imaging network markers of cognitive dysfunction and pharmacoresistance in newly diagnosed epilepsy: a protocol for an observational cohort study in the UK. BMJ Open 2019; 9:e034347. [PMID: 31619436 PMCID: PMC6797398 DOI: 10.1136/bmjopen-2019-034347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Epilepsy is one of the most common serious brain disorders, characterised by seizures that severely affect a person's quality of life and, frequently, their cognitive and mental health. Although most existing work has examined chronic epilepsy, newly diagnosed patients present a unique opportunity to understand the underlying biology of epilepsy and predict effective treatment pathways. The objective of this prospective cohort study is to examine whether cognitive dysfunction is associated with measurable brain architectural and connectivity impairments at diagnosis and whether the outcome of antiepileptic drug treatment can be predicted using these measures. METHODS AND ANALYSIS 107 patients with newly diagnosed focal epilepsy from two National Health Service Trusts and 48 healthy controls (aged 16-65 years) will be recruited over a period of 30 months. Baseline assessments will include neuropsychological evaluation, structural and functional Magnetic Resonance Imaging (MRI), Electroencephalography (EEG), and a blood and saliva sample. Patients will be followed up every 6 months for a 24-month period to assess treatment outcomes. Connectivity- and network-based analyses of EEG and MRI data will be carried out and examined in relation to neuropsychological evaluation and patient treatment outcomes. Patient outcomes will also be investigated with respect to analysis of molecular isoforms of high mobility group box-1 from blood and saliva samples. ETHICS AND DISSEMINATION This study was approved by the North West, Liverpool East Research Ethics Committee (19/NW/0384) through the Integrated Research Application System (Project ID 260623). Health Research Authority (HRA) approval was provided on 22 August 2019. The project is sponsored by the UoL (UoL001449) and funded by a UK Medical Research Council (MRC) research grant (MR/S00355X/1). Findings will be presented at national and international meetings and conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER IRAS Project ID 260623.
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Affiliation(s)
- Christophe de Bézenac
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Gus Baker
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Perry Moore
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Nicola Leek
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Rajiv Mohanraj
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Leonardo Bonilha
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mark Richardson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anthony Guy Marson
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Simon Keller
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
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28
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Chauhan V, Niepel G, Richardson A, Mohanraj R. PO008 Extreme delta brush on eeg – secondary to ketamine use? J Neurol Neurosurg Psychiatry 2017. [DOI: 10.1136/jnnp-2017-abn.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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29
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Matthews R, Mirza F, Ramdass R, Mohanraj R. PO231 A case of superficial siderosis mimicking myasthenia gravis. J Neurol Neurosurg Psychiatry 2017. [DOI: 10.1136/jnnp-2017-abn.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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30
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Magudapathi C, Nithya J, Mohanraj R, Sivanesan B, Radha A. Krukenberg Tumor in Pregnancy. Indian J Gynecol Oncolog 2017. [DOI: 10.1007/s40944-017-0161-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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31
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Mirza N, Appleton R, Burn S, du Plessis D, Duncan R, Farah JO, Feenstra B, Hviid A, Josan V, Mohanraj R, Shukralla A, Sills GJ, Marson AG, Pirmohamed M. Genetic regulation of gene expression in the epileptic human hippocampus. Hum Mol Genet 2017; 26:1759-1769. [PMID: 28334860 PMCID: PMC5411756 DOI: 10.1093/hmg/ddx061] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/12/2016] [Accepted: 02/16/2017] [Indexed: 01/21/2023] Open
Abstract
Epilepsy is a serious and common neurological disorder. Expression quantitative loci (eQTL) analysis is a vital aid for the identification and interpretation of disease-risk loci. Many eQTLs operate in a tissue- and condition-specific manner. We have performed the first genome-wide cis-eQTL analysis of human hippocampal tissue to include not only normal (n = 22) but also epileptic (n = 22) samples. We demonstrate that disease-associated variants from an epilepsy GWAS meta-analysis and a febrile seizures (FS) GWAS are significantly more enriched with epilepsy-eQTLs than with normal hippocampal eQTLs from two larger independent published studies. In contrast, GWAS meta-analyses of two other brain diseases associated with hippocampal pathology (Alzheimer's disease and schizophrenia) are more enriched with normal hippocampal eQTLs than with epilepsy-eQTLs. These observations suggest that an eQTL analysis that includes disease-affected brain tissue is advantageous for detecting additional risk SNPs for the afflicting and closely related disorders, but not for distinct diseases affecting the same brain regions. We also show that epilepsy eQTLs are enriched within epilepsy-causing genes: an epilepsy cis-gene is significantly more likely to be a causal gene for a Mendelian epilepsy syndrome than to be a causal gene for another Mendelian disorder. Epilepsy cis-genes, compared to normal hippocampal cis-genes, are more enriched within epilepsy-causing genes. Hence, we utilize the epilepsy eQTL data for the functional interpretation of epilepsy disease-risk variants and, thereby, highlight novel potential causal genes for sporadic epilepsy. In conclusion, an epilepsy-eQTL analysis is superior to normal hippocampal tissue eQTL analyses for identifying the variants and genes underlying epilepsy.
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Affiliation(s)
- Nasir Mirza
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool L69 3GL, UK
| | - Richard Appleton
- The Roald Dahl EEG Unit, Paediatric Neurosciences Foundation, Alder Hey Children's NHS Foundation Trust, Liverpool L12 2AP, UK
| | - Sasha Burn
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool L12 2AP, UK
| | - Daniel du Plessis
- Department of Cellular Pathology, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Roderick Duncan
- Department of Neurology, Christchurch Hospital, Christchurch 8140, New Zealand
| | - Jibril Osman Farah
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - Bjarke Feenstra
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Anders Hviid
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Vivek Josan
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Rajiv Mohanraj
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Arif Shukralla
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Graeme J. Sills
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool L69 3GL, UK
| | - Anthony G. Marson
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool L69 3GL, UK
| | - Munir Pirmohamed
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool L69 3GL, UK
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Agushi E, Mohanraj R. P10.01 Epilepsy following low grade glioma surgery. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox036.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bartlam R, Mohanraj R. Ictal bradyarrhythmias and asystole requiring pacemaker implantation: Combined EEG-ECG analysis of 5 cases. Epilepsy Behav 2016; 64:212-215. [PMID: 27750160 DOI: 10.1016/j.yebeh.2016.06.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 06/23/2016] [Accepted: 06/24/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Seizures can lead to cardiac arrhythmias by a number of mechanisms including activation/inhibition of cortical autonomic centers, increase in vagal tone through activation of brainstem reflex centers, and respiratory failure. Ictal asystole (IA) is a potential mechanism underlying sudden unexpected death in epilepsy (SUDEP). We analyzed the clinical features of 5 patients who developed IA requiring pacemaker implantation. METHODS Patients with ictal arrhythmias were identified from the video-telemetry and ambulatory EEG database at Greater Manchester Neurosciences Centre, as well as an independent epilepsy residential care facility. Only those who had IA requiring pacemaker implantation were included in the analysis. A total of 5 patients were identified. RESULTS Of the 5 patients with IA, 4 were female. All 5 patients had focal epilepsy, and four had temporal lobe epilepsy. Ictal asystole occurred with focal seizures with impairment of awareness. Seizure onset was left-sided in 2 patients, right-sided in one, left-sided onset with switch of lateralization in one, and nonlateralized in one patient. Three patients had hippocampal sclerosis, one of whom had undergone epilepsy surgery, one had traumatic encephalomalacia of the temporal lobe, and one patient had no lesions detected on MRI. Interictal epileptiform activity was more pronounced during sleep in all patients. Asystole occurred in association with sleep-related seizures in 4 of 5 patients. CONCLUSIONS Ictal asystole (IA) occurred in association with sleep-related seizures in 4 out of 5 cases, predominantly in patients with temporal lobe epilepsy. These findings may be of relevance to SUDEP.
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Affiliation(s)
| | - Rajiv Mohanraj
- University of Manchester, Manchester, UK; Department of Neurology, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK.
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Lilleker JB, Yeo T, van Sonderen A, Jones MS, Mohanraj R, Chai JY, Tan K, Schreurs MW, de Bruijn MA, Sillevis Smitt PA, Titulaer MJ. The relevance of VGKC positivity in the absence of LGI1 and Caspr2 antibodiesAuthor Response. Neurology 2016; 87:1848-1849. [DOI: 10.1212/wnl.0000000000003300] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Mirza N, Vasieva O, Appleton R, Burn S, Carr D, Crooks D, du Plessis D, Duncan R, Farah JO, Josan V, Miyajima F, Mohanraj R, Shukralla A, Sills GJ, Marson AG, Pirmohamed M. An integrative in silico system for predicting dysregulated genes in the human epileptic focus: Application to SLC transporters. Epilepsia 2016; 57:1467-74. [PMID: 27421837 DOI: 10.1111/epi.13473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Many different gene families are currently being investigated for their potential role in epilepsy and in the response to antiepileptic drugs. A common research challenge is identifying the members of a gene family that are most significantly dysregulated within the human epileptic focus, before taking them forward for resource-intensive functional studies. Published data about transcriptomic changes within the human epileptic focus remains incomplete. A need exists for an accurate in silico system for the prediction of dysregulated genes within the epileptic focus. We present such a bioinformatic system. We demonstrate the validity of our approach by applying it to the solute carrier (SLC) gene family. There are >400 known SLCs. SLCs have never been systematically studied in epilepsy. METHODS Using our in silico system, we predicted the SLCs likely to be dysregulated in the epileptic focus. We validated our in silico predictions by identifying ex vivo the SLCs dysregulated in epileptic foci, and determining the overlap between our in silico and ex vivo results. For the ex vivo analysis, we used a custom oligonucleotide microarray containing exon probes for all known SLCs to analyze 24 hippocampal samples obtained from surgery for pharmacoresistant mesial temporal lobe epilepsy and 24 hippocampal samples from normal postmortem controls. RESULTS There was a highly significant (p < 9.99 × 10(-7) ) overlap between the genes identified by our in silico and ex vivo strategies. The SLCs identified were either metal ion exchangers or neurotransmitter transporters, which are likely to play a part in epilepsy by influencing neuronal excitability. SIGNIFICANCE The identified SLCs are most likely to mediate pharmacoresistance in epilepsy by enhancing the intrinsic severity of epilepsy, but further functional work will be needed to fully evaluate their role. Our successful in silico strategy can be adapted in order to prioritize genes relevant to epilepsy from other gene families.
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Affiliation(s)
- Nasir Mirza
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Olga Vasieva
- Institute of Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Richard Appleton
- The Roald Dahl EEG Unit, Paediatric Neurosciences Foundation, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Sasha Burn
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Daniel Carr
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Daniel Crooks
- Department of Neuropathology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Daniel du Plessis
- Department of Cellular Pathology, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Roderick Duncan
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Jibril Osman Farah
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Vivek Josan
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Fabio Miyajima
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Rajiv Mohanraj
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Arif Shukralla
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Graeme J Sills
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Anthony G Marson
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Munir Pirmohamed
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
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Agushi E, Lekka E, Mohanraj R, Gkolemis C, Karabatsou K. QOL-02EPILEPSY FOLLOWING LOW GRADE GLIOMA SURGERY: SINGLE CENTRE EXPERIENCE. Neuro Oncol 2015. [DOI: 10.1093/neuonc/nov230.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Arivoli A, Mohanraj R, Seenivasan R. Application of vertical flow constructed wetland in treatment of heavy metals from pulp and paper industry wastewater. Environ Sci Pollut Res Int 2015; 22:13336-13343. [PMID: 25940487 DOI: 10.1007/s11356-015-4594-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 04/23/2015] [Indexed: 06/04/2023]
Abstract
The paper production is material intensive and generates enormous quantity of wastewater containing organic pollutants and heavy metals. Present study demonstrates the feasibility of constructed wetlands (CWs) to treat the heavy metals from pulp and paper industry effluent by using vertical flow constructed wetlands planted with commonly available macrophytes such as Typha angustifolia, Erianthus arundinaceus, and Phragmites australis. Results indicate that the removal efficiencies of the planted CWs for iron, copper, manganese, zinc, nickel, and cadmium were 74, 80, 60, 70, 71, and 70 %, respectively. On the other hand, the removal efficiency of the unplanted system was significantly lower ranging between 31 and 55 %. Among the macrophytes, T. angustifolia and E. arundinaceus exhibited comparatively higher bioconcentration factor (10(2) to 10(3)) than P. australis.
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Affiliation(s)
- A Arivoli
- Department of Environmental Management, Bharathidasan University, Tiruchirappalli, 620024, Tamil Nadu, India
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Abstract
Purpose
– The purpose of this paper is to apply a framework for value stream mapping (VSM) integrated with fuzzy quality function deployment (QFD) for enabling scientific prioritization of improvement proposals to improve leanness.
Design/methodology/approach
– The literature was reviewed from the perspectives of VSM, QFD and fuzzy logic applications. The current state map was developed for the case component; fuzzy QFD was used for prioritizing improvement proposals and prioritized proposals were incorporated in the future state map.
Findings
– The approach enabled the scientific mapping of wastes with improvement proposals and thereby enabling systematic implementation of improvement proposals. The conducted pilot study resulted in 4 percent reduction in cycle time. As the lean implementation is a continuous process, furthermore improvements are expected in near future.
Research limitations/implications
– The study was conducted in an Indian camshaft manufacturing organization. The improvements in terms of leanness parameters were quantified.
Practical implications
– The findings determined from the study has practical relevance. Besides, managerial implications were also discussed.
Originality/value
– The study presented in this paper was conducted in a real time manufacturing environment. Hence the contributions of study are found to be valuable among academic and practicing communities.
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Seenivasan R, Prasath V, Mohanraj R. Restoration of sodic soils involving chemical and biological amendments and phytoremediation by Eucalyptus camaldulensis in a semiarid region. Environ Geochem Health 2015; 37:575-586. [PMID: 25547478 DOI: 10.1007/s10653-014-9674-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 12/23/2014] [Indexed: 06/04/2023]
Abstract
Salt-affected soils in semiarid regions impede the agricultural productivity and degrade the ecosystem health. In South India, several hectares of land are salt-affected, where the evapotranspiration exceeds the annual precipitation. This study is an attempt to ameliorate sodic soils, by an experiment involving chemical treatment (addition of gypsum), organic amendments (decomposed bagasse pith and green manuring with Sesbania rostrata) and phytoremediation by plantation of Eucalyptus camaldulensis. The prime focus is to minimize the use of gypsum and improve the soil health in terms of nutrients, microbial population and enzyme activity in addition to sodicity reclamation. At the end of the third year, a reduction of 10 % in soil pH, 33 % in electrical conductivity and 20 % in exchangeable sodium percentage was achieved compared to the initial values. Three- to fourfold increases in organic carbon content were observed. Significant improvement in the available major and micronutrients of soil, microbial growth and enzyme activity was observed, suggesting phytoremediation by E. camaldulensis as a sustainable option for restoration of similar kind of degraded lands.
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Affiliation(s)
- R Seenivasan
- Department of Environmental Management, Bharathidasan University, Tiruchirappalli, 620024, India
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Mirza N, Appleton R, Burn S, Carr D, Crooks D, du Plessis D, Duncan R, Farah JO, Josan V, Miyajima F, Mohanraj R, Shukralla A, Sills GJ, Marson AG, Pirmohamed M. Identifying the biological pathways underlying human focal epilepsy: from complexity to coherence to centrality. Hum Mol Genet 2015; 24:4306-16. [DOI: 10.1093/hmg/ddv163] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 04/30/2015] [Indexed: 12/31/2022] Open
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41
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Manjula M, Mohanraj R, Devi MP. Biomonitoring of heavy metals in feathers of eleven common bird species in urban and rural environments of Tiruchirappalli, India. Environ Monit Assess 2015; 187:267. [PMID: 25893764 DOI: 10.1007/s10661-015-4502-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 04/01/2015] [Indexed: 06/04/2023]
Abstract
Heavy metals continue to remain as a major environmental concern in spite of emission control measures. In this study, we analyzed the concentrations of heavy metals (Fe, Cr, Mn, Ni, Cu, Zn, and Cd) in the feathers of 11 species of birds collected from urban and rural areas of Tiruchirappalli, Southern India. Metal concentrations followed the order: Fe > Cu > Zn > Cr > Mn > Ni > Cd. Irrespective of sample locations, heavy metals such as Fe, Cr, Ni, Zn, and Cu were detected in high concentrations, while Cd and Mn were observed in lower concentrations. In contrary to our assumption, there were no statistically significant intraspecific and urban-rural differences in the metal concentrations except for Zn. Pairwise comparisons among species irrespective of metal type showed significant interspecific differences between Acridotheres tristis and Centropus phasianinus, A. tristis and Milvus migrans, C. phasianinus and M. migrans, M. migrans and Eudynamys scolopaceus, and Psittacula krameri and E. scolopaceus. Principal component analysis carried out for urban data extracted Ni, Mn, Zn, Fe, and Cu accounting for 48% variance implying dietary intake and external contamination as important sources for metals. In the rural, association of Zn, Cd, Ni, and Cr suggests the impact of metal fabrication industries and leather tanning operations.
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Affiliation(s)
- Menon Manjula
- Department of Environmental Management, School of Environmental Sciences, Bharathidasan University, Tiruchirappalli, 620 024, Tamil Nadu, India
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Dhanakumar S, Solaraj G, Mohanraj R. Heavy metal partitioning in sediments and bioaccumulation in commercial fish species of three major reservoirs of river Cauvery delta region, India. Ecotoxicol Environ Saf 2015; 113:145-51. [PMID: 25497770 DOI: 10.1016/j.ecoenv.2014.11.032] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 10/29/2014] [Accepted: 11/26/2014] [Indexed: 05/16/2023]
Abstract
Chemical partitioning of heavy metals (Fe, Mn, Cu, Cr, Pb, Zn, Ni) were determined in surface sediments of three reservoirs at the Delta region of Cauvery River, India. The abundance of metals in sediments varied in the following descending order: Fe, Mn, Cr, Zn, Cu, Ni, and Pb. Higher concentrations of Zn, Pb, Fe, Mn and Cu in exchangeable and carbonate fraction indicated toxicity risk to the biota. Therefore, to understand the extent of bioaccumulation, six commercial fish species were collected from the same sites and analyzed for heavy metals distribution in different organs. Among the metals found in fish samples, iron was observed in the highest concentration, followed by Zn, Pb, Cr, Mn, Cu, and Ni. Concentrations of Pb, Cr and Zn in many fish samples exceeded the permissible limits of Food and Agriculture Organization. The concentrations of Pb (17.7-31.7%), Cr (6.2-15.1%), Cu (15.2-30.5%) and Zn (30-40%) associated with exchangeable and carbonate fractions had significant positive correlation with the respective metal concentrations in fish. Among the fish species, Catla catla and Etroplus suratensis showed the highest accumulation of metals suggesting risk for human consumption.
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Affiliation(s)
- S Dhanakumar
- Department of Environmental Management, Bharathidasan University, Tiruchirappalli 620024, Tamil Nadu, India
| | - G Solaraj
- Department of Environmental Management, Bharathidasan University, Tiruchirappalli 620024, Tamil Nadu, India
| | - R Mohanraj
- Department of Environmental Management, Bharathidasan University, Tiruchirappalli 620024, Tamil Nadu, India.
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Coyle H, Clough P, Cooper P, Mohanraj R. Clinical experience with perampanel: focus on psychiatric adverse effects. Epilepsy Behav 2014; 41:193-6. [PMID: 25461214 DOI: 10.1016/j.yebeh.2014.09.072] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 09/23/2014] [Accepted: 09/26/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Perampanel (PER) is a novel antiepileptic drug that inhibits the AMPA class of glutamate receptors. It has been available in the UK since September 2012. We undertook a retrospective analysis of efficacy and tolerability of PER in 47 patients with drug-refractory epilepsy attending a regional epilepsy service in the UK. METHODS Demographic and clinical data of patients with refractory epilepsy prescribed PER were collected by review of records. Efficacy, as measured by responder rates (>50% reduction in seizure frequency), retention rates, and adverse effects, was analyzed. RESULTS Of the 47 patients prescribed PER, 39 (87%) had focal epilepsy, four (9%) had idiopathic generalized epilepsy, 3 (6%) had symptomatic generalized epilepsy, and 1 had unclassified epilepsy. Patients were taking a median of 2 AEDs (range: 1-5) when starting on PER. The median dose of PER was 8 mg (range: 2-12 mg). Thirteen (28%) patients were classed as responders, but no patients experienced sustained seizure freedom. Twenty-one (45%) patients had withdrawn from PER during the study period, with 16 (76%) of them withdrawing due to intolerable adverse effects, 4 due to inadequate seizure control, and 1 due to the combination of both. The most frequent adverse effects requiring withdrawal from PER were behavioral reactions including suicidal ideation (n = 2), aggressive behavior (n = 2), and both (n = 1). CONCLUSION In our experience, PER had a retention rate of 55% and a responder rate of 28%. Psychiatric adverse effects, including suicidal ideation, were the most common reasons for withdrawal.
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Affiliation(s)
- Helen Coyle
- Greater Manchester Neurosciences Centre, Salford Royal Hospital, UK
| | - Peter Clough
- Greater Manchester Neurosciences Centre, Salford Royal Hospital, UK
| | - Paul Cooper
- Greater Manchester Neurosciences Centre, Salford Royal Hospital, UK; University of Manchester, Manchester, UK
| | - Rajiv Mohanraj
- Greater Manchester Neurosciences Centre, Salford Royal Hospital, UK; University of Manchester, Manchester, UK.
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Neelakantan P, Cheng CQ, Mohanraj R, Sriraman P, Subbarao C, Sharma S. Antibiofilm activity of three irrigation protocols activated by ultrasonic, diode laser or Er:YAG laser in vitro. Int Endod J 2014; 48:602-10. [PMID: 25080240 DOI: 10.1111/iej.12354] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 07/29/2014] [Indexed: 11/30/2022]
Abstract
AIM To investigate the impact of three irrigation protocols, activated by three different methods, on mature biofilms of Enterococcus faecalis in vitro. METHODOLOGY Root canals in 280 single-rooted teeth were instrumented using a rotary Ni-Ti system. Biofilms of E. faecalis were generated based on a previously established protocol. Samples were randomly divided into three experimental (n = 80) and one control (n = 40) group based on the irrigation protocol employed: group 1 (NaOCl + Etidronic acid), 1 : 1 mixture of 6% NaOCl and 18% etidronic acid; group 2 (NaOCl-EDTA), 3% NaOCl followed by 17% EDTA; group 3 (NaOCl-EDTA-NaOCl), 3% NaOCl followed by 17% EDTA and a final flush of 3% NaOCl. Saline served as the control. Samples were further divided into four subgroups (n = 20) based on the activation method: subgroup A, no activation; subgroup B, ultrasonic activation; group C, diode laser; group D, Er:YAG laser. Confocal laser scanning microscopy was used to assess bacterial viability in situ. Root dentine powder was obtained for determining the colony-forming units (CFU mL(-1) ). Data were analysed by appropriate statistical analyses with P = 0.05. RESULTS All experimental irrigation protocols caused complete destruction of the biofilm in the root canal lumen. Within the dentinal tubules, all groups had a significantly higher percentage of dead bacteria than the saline control (P < 0.05). There was no significant difference between NaOCl + etidronic acid and NaOCl-EDTA-NaOCl (P > 0.05), whereas both groups brought about more bacterial reduction than NaOCl-EDTA (P < 0.05). There was no significant difference between diode laser and Er:YAG laser in any of the groups (P > 0.05). Both diode and Er:YAG laser were more effective than ultrasonic activation and conventional syringe irrigation in reducing E. fecalis biofilms (P < 0.05). CONCLUSIONS The use of NaOCl after or in combination with a chelator caused the greatest reduction of E. faecalis. Diode laser and Er:YAG laser activation were superior to ultrasonics in dentinal tubule disinfection.
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Affiliation(s)
- P Neelakantan
- Biofilm Research Cluster, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha University, Chennai, India
| | - C Q Cheng
- Biofilm Research Cluster, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha University, Chennai, India
| | - R Mohanraj
- Biofilm Research Cluster, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha University, Chennai, India
| | - P Sriraman
- Biofilm Research Cluster, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha University, Chennai, India
| | - C Subbarao
- Biofilm Research Cluster, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha University, Chennai, India
| | - S Sharma
- Biofilm Research Cluster, Department of Conservative Dentistry and Endodontics, Saveetha Dental College and Hospitals, Saveetha University, Chennai, India
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Lilleker JB, Biswas V, Mohanraj R. Glutamic acid decarboxylase (GAD) antibodies in epilepsy: diagnostic yield and therapeutic implications. Seizure 2014; 23:598-602. [PMID: 24836709 DOI: 10.1016/j.seizure.2014.04.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 04/05/2014] [Accepted: 04/19/2014] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The aetiology of adult onset epilepsy remains unascertained in a significant proportion of patients. Antibodies directed against neuronal antigens have been suggested to have a potential pathogenic role in some cases of epilepsy. We describe a series of patients with adult onset epilepsy in whom antibodies to glutamic acid decarboxylase (GAD Abs) have been identified. METHODS All patients attending a regional epilepsy service with unexplained adult onset epilepsy' were tested for the presence of GAD Abs. Those with high serum titres underwent CSF analysis, and were offered additional treatment with immunotherapy. Those who underwent immunotherapy were monitored by monthly review. Clinical details and response to treatment was collated by review of notes. RESULTS Of 112 patients tested, high serum titres were found in 6 (5.4%) patients. These patients had clinical and electroencephalographic evidence of focal epilepsy. CSF analysis revealed oligoclonal bands and intrathecal GAD Abs in all patients. Five patients received immunotherapy. No improvement in seizures was observed in any. One patient with equivocal MRI evidence of hippocampal sclerosis and concordant video EEG and PET scan, achieved 12 months seizure freedom following temporal lobectomy. CONCLUSIONS The relevance of GAD Abs to epilepsy remains uncertain. Our experience does not support the routine use of immunotherapy in patients with epilepsy and GAD Abs. Larger studies enrolling greater numbers of patients are required to identify sufficient numbers of patients for controlled treatment trials.
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Affiliation(s)
| | | | - Rajiv Mohanraj
- Greater Manchester Neurosciences Centre, United Kingdom; University of Manchester, United Kingdom.
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Hurford R, Mohanraj R. BONE DISEASE IN EPILEPSY: THE FORGOTTEN SIDE EFFECT. J Neurol Psychiatry 2013. [DOI: 10.1136/jnnp-2013-306573.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Aspinall M, Pal P, Mohanraj R. CEREBRAL WHITE MATTER DISEASE IN PATIENTS WITH MALIGNANCY: PML VERSUS TOXIC LEUCOENCEPHALOPATHY DUE TO CHEMOTHERAPY. J Neurol Neurosurg Psychiatry 2013. [DOI: 10.1136/jnnp-2013-306573.218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Whitehorn S, Mohanraj R, Jones M. SUPERFICIAL SIDEROSIS OF THE CENTRAL NERVOUS SYSTEM: A CLINICAL SERVICE REVIEW. J Neurol Psychiatry 2013. [DOI: 10.1136/jnnp-2013-306573.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lilleker JB, Jones MS, Mohanraj R. VGKC complex antibodies in epilepsy: Diagnostic yield and therapeutic implications. Seizure 2013; 22:776-9. [DOI: 10.1016/j.seizure.2013.06.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 06/10/2013] [Accepted: 06/11/2013] [Indexed: 01/17/2023] Open
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Sundaram T, Nagarajan M, Nagarajan V, Supe SS, Mohanraj R, Balaji T, Jayakumar S, Balasubramaniam M, Govindarajan KN. Forward versus inverse planning in oropharyngeal cancer: A comparative study using physical and biological indices. J Cancer Res Ther 2013; 9:422-9. [PMID: 24125977 DOI: 10.4103/0973-1482.119326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
CONTEXT Possible benefits of inverse planning. AIMS To analyze possible benefits of inverse planning intensity modulated radiation therapy (IMRT) over field-in-field 3D conformal radiation therapy (FIF-3DCRT) and to evaluate the differences if any, between low (6 Million Volts) and high energy (15 Million Volts) IMRT plans. MATERIALS AND METHODS Ten patients with squamous cell carcinoma of oropharynx, previously treated with 6 MV step and shoot IMRT were studied. V100, V33, V66 , mean dose and normal tissue complication probabilities (NTCP) were evaluated for parotid glands. Maximum dose and NTCP were the parameters for spinal cord. STATISTICAL ANALYSIS USED A two-tailed t-test was applied to analyze statistical significance between the different techniques. RESULTS For combined parotid gland, a reduction of 4.374 Gy, 9.343 Gy and 7.883 Gy were achieved for D100, D66 and D33, respectively in 6 MV-IMRT when compared with FIF-3DCRT. Spinal cord sparing was better in 6 MV-IMRT (40.963 ± 2.650), with an average reduction of maximum spinal cord dose by 7.355 Gy from that using the FIF-3DCRT technique. The uncomplicated tumor control probabilities values were higher in IMRT plans thus leading to a possibility of dose escalation. CONCLUSIONS Though low-energy IMRT is the preferred choice for treatment of oropharyngeal cancers, FIF-3DCRT must be given due consideration as a second choice for its well established advantages over traditional conventioan technique.
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Affiliation(s)
- T Sundaram
- Department of Radiation Oncology, Valavadi Narayanaswamy Cancer Centre, G. Kuppuswamy Naidu Memorial Hospital, Coimbatore, India
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