Classic ketogenic diet versus further antiseizure medicine in infants with drug-resistant epilepsy (KIWE): a UK, multicentre, open-label, randomised clinical trial

BACKGROUND

Many infancy-onset epilepsies have poor prognosis for seizure control and neurodevelopmental outcome. Ketogenic diets can improve seizures in children older than 2 years and adults who are unresponsive to antiseizure medicines. We aimed to establish the efficacy of a classic ketogenic diet at reducing seizure frequency compared with further antiseizure medicine in infants with drug-resistant epilepsy.

METHODS

In this phase 4, open-label, multicentre, randomised clinical trial, infants aged 1-24 months with drug-resistant epilepsy (defined as four or more seizures per week and two or more previous antiseizure medications) were recruited from 19 hospitals in the UK. Following a 1-week or 2-week observation period, participants were randomly assigned using a computer-generated schedule, without stratification, to either a classic ketogenic diet or a further antiseizure medication for 8 weeks. Treatment allocation was masked from research nurses involved in patient care, but not from participants. The primary outcome was the median number of seizures per day, recorded during weeks 6-8. All analyses were by modified intention to treat, which included all participants with available data. Participants were followed for up to 12 months. All serious adverse events were recorded. The trial is registered with the European Union Drug Regulating Authorities Clinical Trials Database (2013-002195-40). The trial was terminated early before all participants had reached 12 months of follow-up because of slow recruitment and end of funding.

FINDINGS

Between Jan 1, 2015, and Sept 30, 2021, 155 infants were assessed for eligibility, of whom 136 met inclusion criteria and were randomly assigned; 75 (55%) were male and 61 (45%) were female. 78 infants were assigned to a ketogenic diet and 58 to antiseizure medication, of whom 61 and 47, respectively, had available data and were included in the modifified intention-to-treat analysis at week 8. The median number of seizures per day during weeks 6-8, accounting for baseline rate and randomised group, was similar between the ketogenic diet group (5 [IQR 1-16]) and antiseizure medication group (3 [IQR 2-11]; IRR 1·33, 95% CI 0·84-2·11). A similar number of infants with at least one serious adverse event was reported in both groups (40 [51%] of 78 participants in the ketogenic diet group and 26 [45%] of 58 participants in the antiseizure medication group). The most common serious adverse events were seizures in both groups. Three infants died during the trial, all of whom were randomly assigned a ketogenic diet: one child (who also had dystonic cerebral palsy) was found not breathing at home; one child died suddenly and unexpectedly at home; and one child went into cardiac arrest during routine surgery under anaesthetic. The deaths were judged unrelated to treatment by local principal investigators and confirmed by the data safety monitoring committee.

INTERPRETATION

In this phase 4 trial, a ketogenic diet did not differ in efficacy and tolerability to a further antiseizure medication, and it appears to be safe to use in infants with drug-resistant epilepsy. A ketogenic diet could be a treatment option in infants whose seizures continue despite previously trying two antiseizure medications.

FUNDING

National Institute for Health and Care Research.

Text integration processes in children with Childhood Epilepsy with Centro-Temporal Spikes

Although Childhood Epilepsy with Centro-Temporal Spikes (CECTS) is considered a 'benign' form of epilepsy, word reading, listening comprehension, and reading comprehension difficulties have been reported. We examined two core skills for text comprehension, coherence monitoring and inference generation, in children with CECTS and compared performance with typically developing controls. Children with CECTS (n = 23; 9 females; mean age 9 y 0 m) and the comparison group (n = 38; 14 females; mean age 9 y 1 m) completed two tasks. For coherence monitoring they heard 24 narrative texts, 16 containing two inconsistent sentences, and responded to a yes/no question to assess identification of the inconsistency after each text; for inference making they heard 16 texts designed to elicit a target inference by integrating information in two sentences and responded to a yes/no question to assess generation of the inference. In both tasks there was a near condition, in which critical sentences were adjacent, and a far condition in which these sentences were separated by filler sentences. Accuracy to the question and the processing time for critical sentences in the text were measured. We used listening comprehension tasks to control for variation in word reading ability. Mixed effects analyses for each task revealed that children with CECTS show comparable levels of accuracy to age-matched peers in these tasks tapping two core text integration skills: detection of inconsistencies and generation of inferences. However, they take longer to process texts indicating a likely source of their listening and reading comprehension difficulties.

A homozygous GRIN1 null variant causes a more severe phenotype of early infantile epileptic encephalopathy

Pathogenic variants in glutamate receptor, ionotropic, NMDA-1 (GRIN1) cause an autosomal dominant or recessive neurodevelopmental disorder with global developmental delay, with or without seizures (AD or AR GRIN1-NDD). Here, we describe a novel homozygous canonical splice site variant in GRIN1 in a 12-month-old boy with early infantile epileptic encephalopathy and severe global developmental delay. This represents only the second family with a homozygous predicted-null variant in GRIN1 reported to date. We review the published literature on AR GRIN1-NDD and find that the phenotype in our patient is much more severe than those seen with homozygous missense variants. A similarly severe phenotype of intractable epilepsy and infantile death has only been reported in one other family with a homozygous nonsense variant in GRIN1. We, therefore, propose that biallelic predicted-null variants in GRIN1 can cause a markedly more severe clinical phenotype than AR GRIN1-NDD caused by missense variants.

Hepatic toxicological responses of SiO2 nanoparticle on Oreochromis mossambicus

The present study was carried out to investigate the impact of various concentrations of SiO₂ nanoparticles (SiO₂ NP) on the commonly available freshwater fish Oreochromis mossambicus. The 96 h median lethal concentration (LC₅₀) of SiO₂ NP was found to be between 270-280 ppm. This novel study has demonstrated histological alterations in the hepatic tissues and a dose-dependent depletion of tissue protein content and an elevated transaminases activity in the treated fish, which has facilitated understanding of the impact of SiO₂ NP in O. mossambicus.

Haemato-immunological studies in ZnO and TiO2 nanoparticles exposed euryhaline fish, Oreochromis mossambicus

The present study was aimed to analyze the effect of ZnO and TiO₂ nanoparticles (NPs) on Haemato-immunological parameters in adult Tilapia, Oreochromis mossambicus. The nanoparticles size found as 47 nm and 30 nm for ZnO and TiO₂ respectively. The acute toxicity (96 h) of ZnO (LC50: 100-110 ppm) and TiO₂ (LC50: 80-90 ppm) NPs were identified by using probit analysis. RBC, Hb and HCT levels decreased in nanoparticles exposed groups resulted in decreased oxygen carrying capacity of RBC and other erythrocyte indices (MCH, MCV, MCHC). Increased WBC, neutrophils & monocytes and decreased lymphocyte levels were observed as increased concentration of the nanoparticles. The results were found as statistically significant (p < 0.05). In conclusion, the present study depicts that ZnO NPs exhibits more toxicity than TiO₂ NPs. Nanoparticles presence even in low concentration (ppm) cause damage to the connective tissues of fish, so the existing permissible levels of these nanoparticles in water are need to be revised.

Toxicological effect of Al2O3 nanoparticles on histoarchitecture of the freshwater fish Oreochromis mossambicus

In the present study, freshwater fish Oreochromis mossambicus were exposed to sub lethal concentrations (120, 150 and 180 ppm) of Aluminium oxide nanoparticles (Al₂O₃ NPs) for 96 h. Histological abnormalities were not observed in the organs of control fishes whereas severe damages and extensive architectural loss was found in the brain, gill, intestine, kidney and muscle tissues of treated fishes with more pronounced effects in 180 ppm. The results showed that the acute exposure to Al₂O₃NPs altered the histoarchitecture in various fish tissues.

Reading comprehension difficulties in children with rolandic epilepsy

AIM

Difficulties in reading comprehension can arise from either word reading or listening comprehension difficulties, or a combination of the two. We sought to determine whether children with rolandic epilepsy had poor reading comprehension relative to typically developing comparison children, and whether such difficulties were associated with word reading and/or general language comprehension difficulties.

METHOD

In this cross-sectional study, children with rolandic epilepsy (n=25; 16 males, 9 females; mean age 9y 1mo, SD 1y 7mo) and a comparison group (n=39; 25 males, 14 females; mean age 9y 1mo, SD 1y 3mo) completed assessments of reading comprehension, listening comprehension, word/non-word reading, speech articulation, and Non-verbal IQ.

RESULTS

Reading comprehension and word reading were worse in children with rolandic epilepsy (F_1,61 =6.89, p=0.011, ηp2=0.10 and F_1,61 =6.84, p=0.011, ηp2=0.10 respectively), with listening comprehension being marginal (F_1,61 =3.81, p=0.055, ηp2=0.06). Word reading and listening comprehension made large and independent contributions to reading comprehension, explaining 70% of the variance.

INTERPRETATION

Children with rolandic epilepsy may be at risk of reading comprehension difficulties. Thorough assessment of individual children is required to ascertain whether the difficulties lie with decoding text, or with general comprehension skills, or both.

WHAT THIS PAPER ADDS

Children with rolandic epilepsy may be at risk of poor reading comprehension. This was related to poor word reading, poor listening comprehension, or both. Reading comprehension interventions should be tailored to the profile of difficulties.

Histological alterations in the hepatic tissues of Al2O3 nanoparticles exposed freshwater fish Oreochromis mossambicus

Adverse effects of nanoparticles on aquatic environment and organisms have drawn much special attention to many researches. Aluminium oxide nanoparticles (Al₂O₃-NPs) have potential uses in varied fields and are seen entering into the ecosystem. Their potential toxicity to the freshwater fish is not much studied. Hence this study was framed to investigate the effect Al₂O₃ NPs on freshwater fish Oreochromis mossambicus in terms of sub lethal toxicity, histological changes and hepato somatic index (HSI) under laboratory conditions. Fishes were exposed to varying concentrations of Al₂O₃ NPs for 96hr. LC₅₀ value was found to be in between 235 and 245ppm. The findings of the present work showed that the NPs were accumulated in the fish liver and caused major histological anomalies such as structural alterations in the portal vein, necrotic hepatocytes, vacuolation, aggregation of blood cells and melanomacrophages. Significant histological alterations were observed in the highest concentration. Our results evidenced that the Al₂O₃ NPs in the aquatic environment affects the health condition of the fishes.

Ammonium molybdate phosphate functionalized silicon dioxide impregnated in calcium alginate for highly efficient removal of 137Cs from aquatic bodies

Development of new hybrid material (SiO₂-AMP–Ca-Alg beads) for cesium uptake without disturbing the water quality parameters.

Social cognition in children with epilepsy in mainstream education

AIM

To establish whether deficits in social cognition are present in children with generalized or focal epilepsy in mainstream education, and whether any relation exists between social cognition, communication, and behaviour measures.

METHOD

In a cross-sectional study, children with an epilepsy-only diagnoses in mainstream education (n=20 with generalized epilepsy; eight males, 12 females; mean age 11y 6mo, SD 2y 6mo; and n=27 with focal epilepsy; 12 males, 15 females; mean age 11y 8mo, SD 2y 2mo) and comparison participants (n=57; 28 males, 29 females; mean age 11y 2mo, SD 2y 4mo) were administered the Strange Stories task and the Mind in the Eyes task, as well as an IQ assessment. Parents completed the Children's Communication Checklist-2 and the Child Behavior Checklist (CBCL).

RESULTS

Both groups of children with epilepsy performed more poorly than control children on the Mental Stories component of the Strange Stories task, F(2,101)=3.2, p<0.001. Performance on Mental Stories was related to pragmatic communication, but only in the generalized epilepsy group (r=0.51, p=0.03, 95% CI=0.2-0.8). There were no differences between epilepsy groups or control participants in the Mind in the Eyes task, F(2,101)=0.4, p=0.4.

INTERPRETATION

Children with 'epilepsy only' are at risk of deficits in social cognition and may require appropriate support.

Optical trapping in an absorbing medium: from optical tweezing to thermal tweezing

We report on optical trapping in a weakly absorbing medium, hemin, an iron-containing porphyrin that is an important component of hemoglobin. By altering the hemin concentration we are able to control the amount of optical energy that is absorbed; changing the hemin concentration from <12 mg/ml to >45 mg/ml enables the onset of thermal trapping to be observed. By estimating the trap strength using two different methods we are readily able to differentiate between the optical trapping and thermal trapping regimes. We also deduce the rise in temperature that occurs within the laser focal volume: temperature changes of 5-24 K are observed for laser power values of 10-90 mW for hemin concentrations of 0-50 mg/ml.

Optical-tweezer-induced microbubbles as scavengers of carbon nanotubes

A modified optical tweezers set-up has been used to generate microbubbles in flowing, biologically relevant fluids and human whole blood that contains carbon nanotubes (CNTs) using low power (< or =5 mW), infrared (1064 nm wavelength), continuous wave laser light. Temperature driven effects at the tweezers' focal point help to optically trap these microbubbles. It is observed that proximate CNTs are driven towards the focal spot where, on encountering the microbubble, they adhere to it. Such CNT-loaded microbubbles can be transported both along and against the flow of surrounding fluid, and can also be exploded to cause fragmentation of the bundles. Thus, microbubbles may be used for scavenging, transporting and dispersal of potentially toxic CNTs in biologically relevant environments.

Clinical and radiological features of childhood cerebral infarction following varicella zoster virus infection

The aim of the study was to describe the clinical and radiological features of childhood post-varicella cerebral infarction (PVCI). A retrospective review was undertaken of children with arterial ischaemic stroke (AIS) who had experienced varicella zoster virus (VZV) infection within the preceding year. Twenty-four children (15 males, nine females; age range at time of VZV infection 2mo-6y) were identified, with a median of 4 months between VZV and AIS (range 1wk-12mo). All had infarction in the middle cerebral artery (MCA) territory and abnormalities of the M1 segment; arteriopathy affected other arteries in 10 children. After a median of 27 months, six patients had recurrent transient ischaemic attacks (TIA), with new infarcts in two of 22 children on re-imaging. Arterial disease improved in 11 children, was stable in four, and progressed in seven (of whom four had recurrent TIA and two had re-infarction). PVCI affects young, previously healthy children within a few months of VZV infection and is characterized by MCA territory infarction and proximal MCA disease. One quarter of patients have recurrence, usually, but not inevitably, associated with progressive arteriopathy. Treatable co-existing AIS risk factors should always be excluded. A more comprehensive diagnostic evaluation should be considered in children with AIS who do not fit the clinical and radiological profile outlined, even where there is a history of recent VZV infection.

Effects of the polyamine analogues BE-4-4-4-4, BE-3-7-3, and BE-3-3-3 on the proliferation of three prostate cancer cell lines

PURPOSE

Polyamines are biologic cations necessary for normal cell growth. Polyamine analogues have been shown to be effective inhibitors of tumor growth. We tested the effect of the polyamine analogues 1,1 9-bis(ethylamino)-5,10,15-triazanonadecane (BE-4-4-4-4), N1,N11-bis(ethyl)norspermine (BE-3-3-3) and 1,15-bis(ethylamino)-4,12-diazapentadecane (BE-3-7-3) on the growth of the prostate cancer cell lines DU145, LNCaP and PC-3 in vitro. We also tested the effect of BE-4-4-4-4 on androgen-independent DU145 cells in vivo via a nude mouse xenograft model.

METHODS

In vitro, cell proliferation was measured using a DNA assay or a colony-formation assay. In vivo, mice were given saline or BE-4-4-4-4 3 mg/kg or 5 mg/kg intraperitoneally twice daily on days 7-10 and 14-17 (cycle 1), days 49-52 and 56-59 (cycle 2) and days 91-94 and 98-101 (cycle 3).

RESULTS

The proliferation of DU145, LNCaP and PC-3 prostate cancer cell lines was inhibited in a dose-dependent manner by BE-4-4-4-4. Intracellular putrescine, spermidine and spermine levels in all three cell lines declined after only 24 h exposure to BE-4-4-4-4 in vitro. Animals receiving BE-4-4-4-4 showed inhibition of tumor growth which continued throughout the experiment with 74% (3 mg/kg) and 81% (5 mg/kg) growth inhibition seen on day 101. No overt toxic reactions besides weight loss were observed in BE-4-4-4-4-treated animals. Tumor tissue from animals treated with BE-4-4-4-4 showed a dose-dependent decrease in spermidine and spermine levels but no decline in putrescine levels as compared with control. BE-4-4-4-4 levels were highest in tumors on day 63 with levels reaching 0.33 and 1.45 nmol/mg protein from animals treated at the 3 mg/kg and 5 mg/kg doses, respectively.

CONCLUSION

These results show the polyamine analogues BE-4-4-4-4, BE-3-3-3 and BE-3-7-3 to be effective inhibitors of prostate cancer cell growth in vitro and BE-4-4-4-4 to be an effective inhibitor of DU145 cells in vivo with minimal toxicity.

Two new photoaffinity polyamines appear to alter the helical twist of DNA in nucleosome core particles

Two new photoaffinity derivatives of polyamines have been synthesized by the reaction of spermine or spermidine with methyl 4-azidobenzimidate. The new compounds were purified chromatographically and characterized by several methods including proton magnetic resonance spectroscopy. The spermine derivative is N1-ABA-spermine [(azidobenzamidino)spermine], and the spermidine derivative is a mixture of N1- and N8-ABA-spermidine. ABA-spermine stabilizes nucleosome core particles in thermal denaturation experiments, with similar but not identical effects when compared with the parent polyamine, spermine. In circular dichroism experiments, ABA-spermine was capable of producing a B----Z transition in poly(dG-m5dC) at a concentration of 30 microM, compared with 5 microM required to produce the same effect with spermine. On the other hand, ANB-spermine [(azidonitrobenzoyl)spermine; Morgan, J. E., Calkins, C. C., & Matthews, H. R. (1989) Biochemistry 28, 5095-5106] stabilized the B form of poly(dG-br5dC). ABA-spermine is a potent inhibitor of ornithine decarboxylase from Escherichia coli, giving 50% inhibition at 0.12 mM, while ANB-spermine is a modest inhibitor, comparable to spermine or spermidine. Under conditions of nitrogen-limited growth, yeast take up ABA-spermine and ABA-spermidine at approximately one-third to half the rate of spermidine or spermine. In contrast, ANB-spermine was not significantly taken up. The photoaffinity polyamines were used to photoaffinity label the DNA in nucleosome core particles, and the sites of labeling were determined by exonuclease protection. All photoaffinity reagents showed both nonspecific labeling and specific sites of higher occupancy. However, the positions of the sites varied: the ANB-spermine sites confirmed those previously reported (Morgan et al., 1989); the ABA-spermine and ABA-spermidine sites were spaced at 9.8 bp intervals from the 3' end of each DNA strand. This observation, together with the effect of spermine on the circular dichroism of DNA in nucleosome core particles, implies that polyamines alter the helical twist of DNA in nucleosome core particles. The ABA-polyamines are offered as general-purpose photoaffinity polyamine reagents.

Phosphonolipids. XXV. Synthesis of -octadecyl- -hexadecanoyl-L- -glyceryl-(2-aminoethyl)phosphonate, a homologue of an -monoether-phosphonocephalin occurring in Tetrahymena pyriformis

The α-monoether-phosphonocephalin isolated by Thompson and Woo from Tetrahymena pyriformis was shown to possess the L-configuration. A homologue of the natural compound, vis. α-octadecyl-β-hexadecanoyl-L-α-glyceryl-(2-aminoethyl)phosphonate, has been synthesized. It was obtained via the following series of intermediate compounds: L-acetone glycerol → D-octadecylglycerol → α-trityl-D-octadecylglycerol → α-trityl-β-hexadecanoyl-D-octadecylglycerol → β-hexadecanoyl-D-octadecylglycerol → α-octadecyl-β-hexadecanoyl-L-α-glyceryl-(2-phthalimidoethyl)phosphonate.

Synthesis of alpha-phosphotidic acids

A procedure permitting the synthesis of both optical isomers as well as the racemic form of saturated or unsaturated phosphotidic acids is reported. The phosphotidic acids are obtainable by treating the pyridinium salts of L-, D-, or DL-dihydroxypropylphosphonic acid for 24 h at 80° with a mixture of the anhydride and the tetraethylammonium salt of the fatty acid to be introduced, and separating the reaction products by column chromatography on silicic acid. The preparation of the dipalmitoyl and distearoyl L-dihydroxypropylphosphonic acids is described.

Phosphonic acid analogues of carbohydrate metabolites. I. Synthesis of L-and D-dihydroxypropylphosphonic acid

A synthesis of the phosphonic acid analogues of L-α- and D-α-glycerophosphoric acid, viz. L- and D-dihydroxypropylphosphonic acid, is described. The L-dihydroxypropylphosphonic acid was obtained by treating acetone α-iodo-L-propylene glycol with triethyl phosphite at 120–125° for 24 h, hydrolyzing the condensation product acetone L-dihydroxypropylphosphonic acid diethyl ester with 2 N sulfuric acid at 100° for 48 h, and isolating the L-dihydroxypropylphosphonic acid as barium salt. The D-dihydroxypropylphosphonic acid was prepared in the same manner from acetone α-iodo-D-propylene glycol. The barium salts are readily soluble in cold water, much less soluble in hot water, and insoluble in the more common organic solvents. Dihydroxypropylphosphonic acid and α-glycerophosphoric acid can be distinguished from each other by their different behaviors towards hot mineral acids, and by the infrared spectra, n.m.r. spectra, and optical rotations of their barium salts.

Phosphonic acid analogues of carbohydrate metabolites. Dihydroxypropylphosphonic acid. II. Substrate specificity of L-glycerol-3-phosphate: NAD oxidoreductase

The specificity of L-glycerol-3-phosphate : NAD oxidoreductase with regard to the phosphate ester bond of L-α-glycerophosphoric acid was investigated by means of L- and DL-dihydroxypropylphosphonic acid. The phosphate ester bond was found to be an essential structural requirement for enzyme activity. Neither L- nor DL-dihydroxypropylphosphonic acid has an inhibitory effect on the oxidation of L-α-glycerophosphoric acid by L-glycerol-3-phosphate : NAD oxidoreductase.

Phosphonolipids. 18. Synthesis of ethylene glycolphosphonic acid analobues of cephalins

The synthesis of ethylene glycolphosphonic acid analogues of cephalins is reported. Two methods for the preparation of several typical members of the new type of phosphonolipids, viz. myristoyl, palmitoyl, and stearoyl ethylene glycol-(2-aminoethyl)phosphonate are described in detail The compounds were obtained by phosphonylation of monoacyl ethylene glycols in the presence of triethylamine with either (2-phthalimidoethyl)phosphonic acid monochloride or (2-N,N-dibenzylaminoethyl)phosphonic acid monochloride (hydrochloride), and freeing the reaction products from their protective groups by hydrazinolysis or hydrogenolysis, respectively. The glycolphosphonocephalins with long-chain fatty acid substituents, in contrast to the corresponding glycolphosphonolecithins, are water-insoluble, show no hemolytic activity, and are not hydrolyzed by lecithinase C to any significant degree. They are hydrolyzed, however, by lecithinase C in the presence of sphingomyelin.

Phosphonolipids. XVI. An alternative method for the synthesis of phosphonic acid analogues of L-alpha-cephalins

The preparation of phosphonic acid analogues of α-cephalins by phosphonylation of D-α,β-diglycerides with (2-N,N-dibenzylaminoethyl)phosphonic acid monochloride instead of (2-phthalimidoethyl)-phosphonic acid monochloride, and removal of the protective benzyl groups of the diacyl α-glyceryl-(2-N,N-dibenzylaminoethyl)phosphonates by catalytic hydrogenolysis is described. A simplified procedure for the preparation of 2-bromoethylphosphonic acid is reported.