Does adherence to epilepsy quality measures correlate with reduced epilepsy-related adverse hospitalizations? A retrospective experience

In 2011, the American Academy of Neurology (AAN) established eight epilepsy quality measures (EQMs) for chronic epilepsy treatment to address deficits in quality of care. This study assesses the relationship between adherence to these EQMs and epilepsy-related adverse hospitalizations (ERAHs). A retrospective chart review of 475 new epilepsy clinic patients with an ICD-9 code 345.1-9 between 2010 and 2012 was conducted. Patient demographics, adherence to AAN guidelines, and annual number of ERAHs were assessed. Fisher's exact test was used to assess the relationship between adherence to guidelines (as well as socioeconomic variables) and the presence of one or more ERAH per year. Of the eight measures, only documentation of seizure frequency, but not seizure type, correlated with ERAH (relative risk [RR] 0.343, 95% confidence interval [CI] 0.176-0.673, p = 0.010). Among patients in the intellectually disabled population (n = 70), only review/request of neuroimaging correlated with ERAH (RR 0.128, 95% CI 0.016-1.009, p = 0.004). ERAHs were more likely in African American patients (RR 2.451, 95% CI 1.377-4.348, p = 0.008), Hispanic/Latino patients (RR 4.016, 95% CI 1.721-9.346, p = 0.016), Medicaid patients (RR 2.217, 95% CI 1.258-3.712, p = 0.009), and uninsured patients (RR 2.667, 95% CI 1.332-5.348, p = 0.013). In this retrospective series, adherence to the eight AAN quality measures did not strongly correlate with annual ERAH.

The epilepsy phenome/genome project

BACKGROUND

Epilepsy is a common neurological disorder that affects approximately 50 million people worldwide. Both risk of epilepsy and response to treatment partly depend on genetic factors, and gene identification is a promising approach to target new prediction, treatment, and prevention strategies. However, despite significant progress in the identification of genes causing epilepsy in families with a Mendelian inheritance pattern, there is relatively little known about the genetic factors responsible for common forms of epilepsy and so-called epileptic encephalopathies. Study design The Epilepsy Phenome/Genome Project (EPGP) is a multi-institutional, retrospective phenotype-genotype study designed to gather and analyze detailed phenotypic information and DNA samples on 5250 participants, including probands with specific forms of epilepsy and, in a subset, parents of probands who do not have epilepsy.

RESULTS

EPGP is being executed in four phases: study initiation, pilot, study expansion/establishment, and close-out. This article discusses a number of key challenges and solutions encountered during the first three phases of the project, including those related to (1) study initiation and management, (2) recruitment and phenotyping, and (3) data validation. The study has now enrolled 4223 participants.

CONCLUSIONS

EPGP has demonstrated the value of organizing a large network into cores with specific roles, managed by a strong Administrative Core that utilizes frequent communication and a collaborative model with tools such as study timelines and performance-payment models. The study also highlights the critical importance of an effective informatics system, highly structured recruitment methods, and expert data review.

Analysis of EEG patterns and genotypes in patients with Angelman syndrome

We prospectively analyzed EEGs from participants in the ongoing NIH Rare Diseases Clinical Research Network Angelman Syndrome Natural History Study. Of the one-hundred-sixty enrolled patients (2006-2010), 115 had complete data (58 boys, median age 3.6 years). Distinct EEG findings were intermittent rhythmic delta waves (83.5%), interictal epileptiform discharges (74.2%), intermittent rhythmic theta waves (43.5%), and posterior rhythm slowing (43.5%). Centro-occipital and centro-temporal delta waves decreased with age (p=0.01, p=0.03). There were no specific correlations between EEG patterns and genotypes. A classification tree allowed the prediction of deletions class-1 (5.9 Mb) in patients with intermittent theta waves in <50% of EEG and interictal epileptiform abnormalities; UPD, UBE3A mutation or imprinting defects in patients with intermittent theta in <50% of EEG without interictal epileptiform abnormalities; deletions class-2 (5.0 Mb) in patients with >50% theta and normal posterior rhythm; atypical deletions in patients with >50% theta but abnormal posterior rhythm. EEG patterns are important biomarkers in Angelman syndrome and may suggest the underlying genetic etiology.

Chondro/osteoblastic and cardiovascular gene modulation in human artery smooth muscle cells that calcify in the presence of phosphate and calcitriol or paricalcitol

Vitamin D sterol administration, a traditional treatment for secondary hyperparathyroidism, may increase serum calcium and phosphorus, and has been associated with increased vascular calcification (VC). In vitro studies suggest that in the presence of uremic concentrations of phosphorus, vitamin D sterols regulate gene expression associated with trans-differentiation of smooth muscle cells (SMCs) to a chondro/osteoblastic cell type. This study examined effects of vitamin D sterols on gene expression profiles associated with phosphate-enhanced human coronary artery SMC (CASMC) calcification. Cultured CASMCs were exposed to phosphate-containing differentiation medium (DM) with and without calcitriol, paricalcitol, or the calcimimetic R-568 (10(-11)-10(-7) M) for 7 days. Calcification of CASMCs, determined using colorimetry following acid extraction, was dose dependently increased (1.6- to 1.9-fold) by vitamin D sterols + DM. In contrast, R-568 did not increase calcification. Microarray analysis demonstrated that, compared with DM, calcitriol (10(-8) M) + DM or paricalcitol (10(-8) M) + DM similarly and significantly (P < 0.05) regulated genes of various pathways including: metabolism, CYP24A1; mineralization, ENPP1; apoptosis, GIP3; osteo/chondrogenesis, OPG, TGFB2, Dkk1, BMP4, BMP6; cardiovascular, HGF, DSP1, TNC; cell cycle, MAPK13; and ion channels, SLC22A3 KCNK3. R-568 had no effect on CASMC gene expression. Thus, SMC calcification observed in response to vitamin D sterol + DM may be partially mediated through targeting mineralization, apoptotic, osteo/chondrocytic, and cardiovascular pathway genes, although some gene changes may protect against calcification. Further studies to determine precise roles of these genes in development of, or protection against VC and cardiovascular disease are required.

[Photodynamic therapy with verteporfin combined with intravitreal injection of bevacizumab for occult and classic CNV in AMD]

PURPOSE

The aim of this study is to discuss the effect and outcome of a combined photodynamic therapy and intravitreal injection of bevacizumab (1.25 mg) in occult and classic choroidal neovascularisation (CNV) due to AMD. Especially cases of occult CNV with pigment epithelium detachment (PED) are not likely to respond positively to standard photodynamic therapy, often ending up in PED enlargement or tearing of the RPE.

METHODS

In a pilot study involving 23 patients, intravitreal injections of bevacizumab were administered within 12 to 24 hours after standard PDT to reduce the post-PDT increase of proangiogenic and inflammatory factors. Before and at 1, 3 and 6 month after treatment visual acuity and OCT examinations (retinal thickness) were performed.

RESULTS

Mean visual acuity was significantly improved compared to baseline. (VA baseline 20/125, after 1 month 20/80, after 3 months 20/80, and 20/80 after 6 months) and an enlargement of the PED in occult CNV was prevented. We found no RPE rip. OCT findings in patients with occult and classic choroidal neovascularisation 1, 3 and 6 months after combination therapy showed a reduced retinal thickness compared to baseline.

CONCLUSIONS

Photodynamic therapy combined with injection of intravitreal bevacizumab tends to be more effective compared to PDT monotherapy by reducing the post-PDT increase of vascular growth and inflammatory factors. Our short-term results are very promising. Further studies are necessary to show the long-term effect of PDT and anti-VEGF combination therapy.

Calcification inhibitors and Wnt signaling proteins are implicated in bovine artery smooth muscle cell calcification in the presence of phosphate and vitamin D sterols

Administration of active vitamin D sterols to treat secondary hyperparathyroidism in patients with chronic kidney disease receiving dialysis has been associated with elevated serum calcium and phosphorus levels, which may lead to increased risk of vascular calcification. However, calcimimetics, by binding to the parathyroid gland calcium-sensing receptors, reduce serum parathyroid hormone, calcium, phosphorus, and the calcium-phosphorus product. Using cultured bovine aorta vascular smooth muscle cells (BASMCs), an in vitro model of vascular calcification, we compared calcification levels and gene expression profiles after exposure to the phosphate source ss-glycerolphosphate (BGP), the active vitamin D sterols calcitriol and paricalcitol, the calcimimetic R-568, or BGP with the active vitamin D sterols or R-568. Cells exposed to BGP (10 mM) alone or with calcitriol or paricalcitol showed dose-dependent BASMC calcification. No change in calcification was observed in cultures exposed to BGP with R-568, consistent with the observed lack of calcium-sensing receptor expression. Microarray analysis using total cellular RNA from cultures exposed to vehicle or BGP in the absence and presence of 10(-8) M calcitriol or paricalcitol for 7 days showed that cells exposed to BGP with calcitriol or BGP with paricalcitol had virtually identical gene expression profiles, which differed from those of cells treated with BGP or vehicle alone. Several osteoblast- and chondrocyte-associated genes were modulated by BGP and vitamin D exposure. In this study, exposure of BASMCs to phosphate and active vitamin D sterols induced calcification and changes in expression of genes associated with mineralized tissue.

Composite structure of the crystalline epicuticular wax layer of the slippery zone in the pitchers of the carnivorous plant Nepenthes alata and its effect on insect attachment

The slippery zone situated below the peristome inside pitchers of most carnivorous plants from the genus Nepenthes is covered with a thick layer of epicuticular wax. This slippery zone is reported to play a crucial role in animal trapping and prey retention. In N. alata, the wax coverage consists of two clearly distinguished layers. These layers differ in their structure, chemical composition and mechanical properties, and they reduce the insect attachment in different ways. The lower layer resembles foam, composed of interconnected membraneous platelets protruding from the surface at acute angles. The upper layer consists of densely placed separate irregular platelets, located perpendicular to the subjacent layer. Crystals of the upper layer bear small stalks, directed downwards and providing connections to the lower layer. These morphological distinctions correlate with differences in the chemical composition of waxes. The compound classes of alkanes, aldehydes, primary alcohols, free fatty acids, esters and triterpenoids occurred in extracts from both wax layers, but in different proportions. Chain length distributions in aliphatics were different in extracts from the lower and the upper wax layers. Waxes of the upper and lower layers exhibited different mechanical properties: wax of the lower layer is harder and stiffer than that of the upper layer. Moreover, crystals of the upper layer are brittle and may be easily exfoliated or broken to tiny pieces. Laboratory experiments using tethered insects showed that both wax layers reduce the attachment force of insects. It is assumed that a decrease in insect attachment on the two distinct wax layers is provided by the two different mechanisms: (1) crystals of the upper wax layer contaminate insects' adhesive pads; (2) the lower wax layer leads to a reduction of the real contact area of insects' feet with the plant surface.

Self-reported effectiveness of double-fine zones as a speed control measure

This study evaluated the effectiveness of signs alerting drivers to double traffic fines in highway work zones, school zones and safety corridors. The evaluation was based on a driver survey that investigated the decision to exceed speed limits across a range of driving contexts and risk categories. The findings indicated that personal assessments of risk change from one hypothetical situation to another, suggesting that people make a more or less calculated decision to violate the speed limit, based on those risks. The findings also suggested that people perceive a higher relative risk associated with traffic fines if the situation is one in which a doubling of traffic fines may apply. Finally, the results showed that interview subjects who reported being aware of double-fine zones tended to have somewhat higher assessments of the risk associated with traffic citations, traffic fines and higher insurance rates.

Use of the mannan receptor to selectively target vaccine antigens for processing and antigen presentation through the MHC class I and class II pathways

Extensive studies have shown that synthetic and recombinant vaccines developed against hemoparasites have not been as effective as whole parasites or crude membrane fractions in eliciting protective immunity. A possible reason is that synthetic vaccines are not being presented in a form that induces the appropriate immune response. We have developed a bovine model system to evaluate the ability of adjuvant compounds to induce an immune response to peptide antigens dominated by a cytokine profile with a Type 1 (cell-mediated) or Type 2 (humoral) bias. In the initial testing of this system, we found that mRNA expression of certain cytokines (interleukin [IL]-1beta, IL-6, IL-12, IL-15, GM-CSF, iNOS, and tumor necrosis factor [TNF]-alpha) is enhanced when monocyte-derived macrophages are stimulated with peptide antigen conjugated with mannan under oxidizing conditions compared to peptide conjugated with reduced mannan. The data suggest this model will be useful in identifying adjuvant systems that selectively modulate the cytokine profile of antigen presenting cells at the time of antigen presentation and the consequent downstream maturation of naive T cells to effector cells with Type 1 or Type 2 cytokine bias.

Species-specific isotope-ratio measurements of volatile tin and antimony compounds using capillary GC-ICP-time-of-flight MS

The analytical performance of an axial inductively-coupled-plasma time-of-flight mass spectrometer (ICP-TOFMS) as a detector for fast transient chromatographic signals resulting from the coupling to capillary gas chromatography (CGC) was investigated. A cryotrapping GC-ICP-TOFMS method for the determination of volatile metal(loid) compounds (VOMs) in gases was used and the suitability of the TOF mass analyzer for multielemental speciation analysis and multi-isotope ratio determinations was studied in terms of accuracy and precision. Isotope ratios 118Sn/120Sn and 121Sb/123Sb have been determined in in-house gas standard atmospheres in Tedlar bags at two different levels (100 pg and 1 ng) for different elemental species (SnH4, MeSnH3, Me2SnH2, Me3SnH, BuSnH3, SbH3, and MeSbH2). A limitation arising from counting statistics in both detection modes could be shown. A solution containing rhodium (10 ng mL(-1)) and cadmium (40 ng mL(-1)) was introduced simultaneously to the GC outlet. Rhodium acts as a continuous internal standard and Cd is used for mass-bias correction (by measuring the 111Cd/113Cd ratio). The detection system in both pulse counting and analog mode was examined. The best attainable precision was established for Me2SnH2 (analog mode, 12 replicates, 1 ng, RSD 0.34%, accuracy 0.31%) whereas most other species ranged between 0.4 and 0.5% RSD if higher concentrations were used. The limitations of the pulse counting system are clearly seen, with peak heights of more than 2000 counts reaching saturation (for an integration time of 100 ms), which reduces the accuracy of isotope ratio determinations. A dozen VOM could be detected in an aged landfill gas sample; several unidentified Sn compounds were present. Although their isotope ratios are within the confidence value of the standards, it is not yet clear if the acquired precision is good enough to identify isotopic fractionation of metal(loid)s through biovolatilization processes. With the precision achieved, the combination of cryotrapping GC and ICP-TOFMS is a powerful tool for monitoring volatile multi-element species in multi-tracer experiments and isotope dilution methodology.

How much does a regional immunization registry increase documented immunization rates at primary care sites in rural colorado?

OBJECTIVE

To determine increases in immunization up-to-date (UTD) rates at a rural pediatric practice with the sequential addition of records from other sites in a 2-county region.

DESIGN/METHODS

UTD rates for children aged 3 months to 35 months (n = 876) were determined for the index practice and then recalculated after sequential addition of records from 1) the other private practice in the region, 2) 7 public primary care sites, and 3) 2 public health clinics in the region.

RESULTS

Adding records from all sites increased documented UTD rates in the index practice from 49% to 64% at 3 months (N = 33, P = 0.025), 50% to 68% at 5 months (N = 38, P = 0.008), 28% to 45% at 7 months (N = 113, P <.01), 29% to 54% at 12 months (N = 200, P <.001), 11% to 35% at 19 months (N = 124, P <.001), and 10% to 33% at 24 months (N = 368, P <.001).

CONCLUSIONS

Regional registries will be valuable tools for immunization delivery if there is an ongoing commitment to effective collection of current and historical immunization data.

The scaffold protein, Homer1b/c, regulates axon pathfinding in the central nervous system in vivo

Homer proteins are a family of multidomain cytosolic proteins that have been postulated to serve as scaffold proteins that affect responses to extracellular signals by regulating protein-protein interactions. We tested whether Homer proteins are involved in axon pathfinding in vivo, by expressing both wild-type and mutant isoforms of Homer in Xenopus optic tectal neurons. Time-lapse imaging demonstrated that interfering with the ability of endogenous Homer to form protein-protein interactions resulted in axon pathfinding errors at stereotypical choice points. These data demonstrate a function for scaffold proteins such as Homer in axon guidance. Homer may facilitate signal transduction from cell-surface receptors to intracellular proteins that govern the establishment of axon trajectories.

Single-cell electroporation for gene transfer in vivo

We report an electroporation technique for targeting gene transfer to individual cells in intact tissue. Electrical stimulation through a micropipette filled with DNA or other macromolecules electroporates a single cell at the tip of the micropipette. Electroporation of a plasmid encoding enhanced green fluorescent protein (GFP) into the brain of intact Xenopus tadpoles or rat hippocampal slices resulted in GFP expression in single neurons and glia. In vivo imaging showed morphologies, dendritic arbor dynamics, and growth rates characteristic of healthy cells. Coelectroporation of two plasmids resulted in expression of both proteins, while electroporation of fluorescent dextrans allowed direct visualization of transfer of molecules into cells. This technique will allow unprecedented spatial and temporal control over gene delivery and protein expression.

Postsynaptic CPG15 promotes synaptic maturation and presynaptic axon arbor elaboration in vivo

The formation of CNS circuits is characterized by the coordinated development of neuronal structure and synaptic function. The activity-regulated candidate plasticity gene 15 (cpg15) encodes a glycosylphosphatidylinositol (GPI)-linked protein whose in vivo expression increases the dendritic arbor growth rate of Xenopus optic tectal cells. We now demonstrate that tectal cell expression of CPG15 significantly increases the elaboration of presynaptic retinal axons by decreasing rates of branch retractions. Whole-cell recordings from optic tectal neurons indicate that CPG15 expression promotes retinotectal synapse maturation by recruiting functional AMPA receptors to synapses. Expression of truncated CPG15, lacking its GPI anchor, does not promote axon arbor growth and blocks synaptic maturation. These results suggest that CPG15 coordinately increases the growth of pre- and postsynaptic structures and the number and strength of their synaptic contacts.