Personalized medicine: Vinpocetine to reverse effects of GABRB3 mutation

Objective

To screen a library of potential therapeutic compounds for a woman with Lennox‐Gastaut syndrome due to a Y302C GABRB3 (c.905A>G) mutation.

Methods

We compared the electrophysiological properties of cells with wild‐type or the pathogenic GABRB3 mutation.

Results

Among 1320 compounds, multiple candidates enhanced GABRB3 channel conductance in cell models. Vinpocetine, an alkaloid derived from the periwinkle plant with anti‐inflammatory properties and the ability to modulate sodium and channel channels, was the lead candidate based on efficacy and safety profile. Vinpocetine was administered as a dietary supplement over 6 months, reaching a dosage of 20 mg three times per day, and resulted in a sustained, dose‐dependent reduction in spike‐wave discharge frequency on electroencephalograms. Improved language and behavior were reported by family, and improvements in global impression of change surveys were observed by therapists blinded to intervention.

Significance

Vinpocetine has potential efficacy in treating patients with this mutation and possibly other GABRB3 mutations or other forms of epilepsy. Additional studies on pharmacokinetics, potential drug interactions, and safety are needed.

Why we urgently need improved epilepsy therapies for adult patients

PURPOSE

Up to a third of patients with epilepsy suffer from recurrent seizures despite therapeutic advances.

RESULTS

Current epilepsy treatments are limited by experiential data from treating different types of epilepsy. For example, we lack evidence-based approaches to efficacious multi-drug therapies or identifying potentially serious or disabling adverse events before medications are initiated. Despite advances in neuroscience and genetics, our understanding of epilepsy pathogenesis and mechanisms of treatment-resistance remains limited. For most patients with epilepsy, precision medicine for improved seizure control and reduced toxicity remains a future goal.

CONCLUSION

A third of epilepsy patients suffer from ongoing seizures and even more suffer from adverse effects of treatment. There is a critical need for more effective and safer therapies for epilepsy patients with frequent comorbitidies, including depression, anxiety, migraine, and cognitive impairments, as well as special populations (e.g., women, elderly). Advances from genomic sequencing techniques may identify new genes and regulatory elements that influence both the depth of the epilepsies' roots within brain circuitry as well as ASD resistance. Improved understanding of epilepsy mechanisms, identification of potential new therapeutic targets, and their assessment in randomized controlled trials are needed to reduce the burden of refractory epilepsy. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.

Sleep-disordered breathing, neuroendocrine function, and clinical SUDEP risk in patients with epilepsy

INTRODUCTION

Sudden unexpected death in epilepsy (SUDEP) is a major contributor to epilepsy-related mortality. It is associated with nocturnal seizures and centrally mediated postictal cardiorespiratory dysfunction (CRD), but mechanisms and contributors remain poorly understood.

METHODS

We performed a prospective, cross-sectional, observational pilot study in the Columbia University Medical Center (CUMC) adult epilepsy monitoring unit (EMU) to explore relationships between periictal CRD, sleep-disordered breathing (SDB), neuroendocrine function, and clinical SUDEP risk. Thirty patients (twenty women, ten men) underwent video-electroencephalogram (EEG) with electrocardiogram (EKG) and digital pulse oximetry, inpatient or outpatient polysomnography (PSG), and comprehensive laboratory evaluation of sex steroid hormones. Sudden unexpected death in epilepsy risk was defined as Low (0-2) or High (≥3) using the revised SUDEP-7 Inventory. Sleep-disordered breathing was defined using standard criteria. Neuroendocrine dysfunction was defined as ≥1 laboratory abnormality.

RESULTS

Cardiorespiratory dysfunction occurred more frequently in high-risk patients (60% vs. 27%, p = 0.018). Endocrine dysfunction was seen in 35% of patients, more in men (p = 0.018). Sleep-disordered breathing was found in 88% of fully scoreable PSGs.

CONCLUSIONS

There was no significant relationship between CRD, SDB, and neuroendocrine status, though all PSGs in those with high SUDEP risk or neuroendocrine dysfunction revealed SDB. Larger studies are needed to further elucidate relationships between CRD, SDB, neuroendocrine factors, and SUDEP.

Addition of a hospital bedside sitter during intracranial stereotactic EEG monitoring improves safety and seizure responses in an adult epilepsy monitoring unit

Expert consensus statements recommend continuous observation for patients undergoing intracranial electroencephalography (EEG), but this practice is neither universal nor specific regarding the type of observation. We compared outcomes for patients who underwent intracranial stereotactic EEG (SEEG) before and after the adoption of continuous monitoring by a staff bedside sitter. We retrospectively studied 26 consecutive adult patients who underwent SEEG placement at our center over a three-year period. Thirteen patients were monitored with usual protocol (no-sitter group), and 13 patients had a full-time hospital-employed sitter at bedside (sitter group). We analyzed nursing responses for all electroclinical seizures and characterized seizure-related adverse events. More seizures went unrecognized without a sitter (33.3% versus 15.0% of all seizures; p = 0.03). Two unrecognized focal to bilateral tonic-clonic seizures occurred only in the no-sitter group. Nursing response was significantly faster in the sitter group in relation to both electrographic seizure onset (12.0 s, p = 0.04) and clinical seizure onset (13.5 s, p = 0.02). Two patients in the no-sitter group pulled their electrodes out periictally while none did so in the sitter group. The addition of a full-time staff bedside sitter improved nursing response times and lowered the rate of unrecognized seizures in patients with SEEG monitoring. Sitters also helped to eliminate inadvertent major electrode displacement.

Standard median nerve ultrasound in carpal tunnel syndrome: A retrospective review of 1,021 cases

•

This retrospective cohort study with 1,021 cases of carpal tunnel syndrome (CTS), is one of the largest studies to examine the role of ultrasonography (US) in the diagnosis of CTS.

•

Previously published median nerve values for CTS screening (CSA >9 mm², WFR >1.4), established by prospective trial, were effective in a real world population.

•

This study data suggests that US may have use as a screening tool prior to performing EDx testing for CTS.

Objective

Carpal tunnel syndrome (CTS) is diagnosed with electrodiagnostic (EDx) studies. Investigations have examined US cross sectional-area (CSA) and wrist to forearm ratio (WFR) cut-offs for screening EDx abnormalities in patients with suspected CTS. The objective of this study is to determine if these US parameters are effective in a real world population.

Methods

This is a retrospective review of patients presenting to the Duke Electromyography (EMG) Laboratory during 2013–2014 with a final diagnosis of CTS. US diagnosis of CTS was based upon median nerve cross-sectional area of >9 mm² and/or wrist-to-forearm ratio of >1.4. EDx studies were the gold standard for diagnosis.

Results

A total of 670 patients and 1,021 extremities were studied. US was positive in 97.6% of EDx confirmed CTS.

Conclusion

Median nerve US is nearly as sensitive as the gold standard for EDx testing for the diagnosis of CTS.

Significance

The data here suggest that US may have use as a screening tool prior to performing EDx testing for CTS.

Postictal Magnetic Resonance Imaging Changes Masquerading as Brain Tumor Progression: A Case Series

Seizures are common among patients with brain tumors. Transient, postictal magnetic resonance imaging abnormalities are a long recognized phenomenon. However, these radiographic changes are not as well studied in the brain tumor population. Moreover, reversible neuroimaging abnormalities following seizure activity may be misinterpreted for tumor progression and could consequently result in unnecessary tumor-directed treatment. Here, we describe two cases of patients with brain tumors who developed peri-ictal pseudoprogression and review the relevant literature.

Ultrasound in EMG-Guided Biopsies: A Prospective, Randomized Pilot Trial

INTRODUCTION

At our institution, core muscle biopsies are performed on muscles selected using electromyography (EMG). Ultrasound (US) guidance is not used routinely. The aim of this study was to determine if US guidance of EMG selected muscles would increase the diagnostic yield of the biopsy as compared to the current practice standards.

METHODS

Two trained physicians performed 40 randomized biopsies (US guided or traditional approach). The amount of tissue obtained in each biopsy was recorded (volume and mass), along with the final pathologic diagnosis in each case and incidence of complications.

RESULTS

Forty patients were studied. Sixteen muscle biopsies were done with US guidance; 50% had a definitive diagnosis, and 38% did not. In the non-US guidance group, 58% had a definitive diagnosis, and 33% did not.

CONCLUSIONS

US did not provide any additive advantage when used to guide biopsy in a muscle previously selected for biopsy with EMG. Muscle Nerve 54: 786-788, 2016.