Antiepileptogenesis and disease modification: Progress, challenges, and the path forward-Report of the Preclinical Working Group of the 2018 NINDS-sponsored antiepileptogenesis and disease modification workshop

Epilepsy is one of the most common chronic brain diseases and is often associated with cognitive, behavioral, or other medical conditions. The need for therapies that would prevent, ameliorate, or cure epilepsy and the attendant comorbidities is a priority for both epilepsy research and public health. In 2018, the National Institute of Neurological Disease and Stroke (NINDS) convened a workshop titled “Accelerating the Development of Therapies for Antiepileptogenesis and Disease Modification” that brought together preclinical and clinical investigators and industry and regulatory bodies’ representatives to discuss and propose a roadmap to accelerate the development of antiepileptogenic (AEG) and disease‐modifying (DM) new therapies. This report provides a summary of the discussions and proposals of the Preclinical Science working group. Highlights of the progress of collaborative preclinical research projects on AEG/DM of ongoing research initiatives aiming to improve infrastructure and translation to clinical trials are presented. Opportunities and challenges of preclinical epilepsy research, vis‐à‐vis clinical research, were extensively discussed, as they pertain to modeling of specific epilepsy types across etiologies and ages, the utilization of preclinical models in AG/DM studies, and the strategies and study designs, as well as on matters pertaining to transparency, data sharing, and reporting research findings. A set of suggestions on research initiatives, infrastructure, workshops, advocacy, and opportunities for expanding the borders of epilepsy research were discussed and proposed as useful initiatives that could help create a roadmap to accelerate and optimize preclinical translational AEG/DM epilepsy research.

A team science approach to discover novel targets for infantile spasms (IS)

Infantile spasms (IS) is a devastating epilepsy syndrome that typically begins in the first year of life. Symptoms consist of stereotypical spasms, developmental delay, and electroencephalogram (EEG) that may demonstrate Hypsarhythmia. Current therapeutic approaches are not always effective, and there is no reliable way to predict which patient will respond to therapy. Given this disorder's complexity and the potential impact of a disease-modifying approach, Citizens United for Research in Epilepsy (CURE) employed a "team science" approach to advance the understanding of IS pathology and explore therapeutic modalities that might lead to the development of new ways to potentially prevent spasms and Hypsarhythmia. This approach was a first-of-its-kind collaborative initiative in epilepsy. The IS initiative funded 8 investigative teams over the course of 1-3 years. Projects included the following: discovery on the basic biology of IS, discovery of novel therapeutic targets, cross-validation of targets, discovery of biomarkers, and prognosis and treatment of IS. The combined efforts of a strong investigative team led to numerous advances in understanding the neural pathways underlying IS, testing of small molecules in preclinical models of IS and generated preliminary data on potential biomarkers. Thus far, the initiative has resulted in over 19 publications and subsequent funding for several investigators. Investigators reported that the IS initiative generally affected their research positively due to its collaborative and iterative nature. It also provided a unique opportunity to mentor junior investigators with an interest in translational research. Learnings included the need for a dedicated project manager and more transparent and real-time communication with investigators. The CURE IS initiative represents a unique approach to fund scientific discoveries on epilepsy. It brought together an interdisciplinary group of investigators-who otherwise would not have collaborated-to find transformative therapies for IS. Learnings from this initiative are being utilized for subsequent initiatives at CURE.

Common data elements for epilepsy mobile health systems

OBJECTIVE

Common data elements (CDEs) are currently unavailable for mobile health (mHealth) in epilepsy devices and related applications. As a result, despite expansive growth of new digital services for people with epilepsy, information collected is often not interoperable or directly comparable. We aim to correct this problem through development of industry-wide standards for mHealth epilepsy data.

METHODS

Using a group of stakeholders from industry, academia, and patient advocacy organizations, we offer a consensus statement for the elements that may facilitate communication among different systems.

RESULTS

A consensus statement is presented for epilepsy mHealth CDEs.

SIGNIFICANCE

Although it is not exclusive, we believe that the use of a minimal common information denominator, specifically these CDEs, will promote innovation, accelerate scientific discovery, and enhance clinical usage across applications and devices in the epilepsy mHealth space. As a consequence, people with epilepsy will have greater flexibility and ultimately more powerful tools to improve their lives.

Silencing Myostatin Using Cholesterol-conjugated siRNAs Induces Muscle Growth

Short interfering RNAs (siRNAs) are a valuable tool for gene silencing with applications in both target validation and therapeutics. Many advances have recently been made to improve potency and specificity, and reduce toxicity and immunostimulation. However, siRNA delivery to a variety of tissues remains an obstacle for this technology. To date, siRNA delivery to muscle has only been achieved by local administration or by methods with limited potential use in the clinic. We report systemic delivery of a highly chemically modified cholesterol-conjugated siRNA targeting muscle-specific gene myostatin (Mstn) to a full range of muscles in mice. Following a single intravenous injection, we observe 85–95% knockdown of Mstn mRNA in skeletal muscle and >65% reduction in circulating Mstn protein sustained for >21 days. This level of Mstn knockdown is also accompanied by a functional effect on skeletal muscle, with animals showing an increase in muscle mass, size, and strength. The cholesterol-conjugated siRNA platform described here could have major implications for treatment of a variety of muscle disorders, including muscular atrophic diseases, muscular dystrophy, and type II diabetes.

Abstract 595: Proof-of-concept Studies for Sirna-mediated Gene Silencing for Coagulation Factors in Rat and Rabbit

Multiple coagulation factors in the intrinsic cascade are emerging targets for new anticoagulant therapies. Rat and rabbit are two commonly utilized preclinical species for studying thrombosis and hemostasis. The present study aimed at establishing feasibility of delivering short interfering RNA (siRNA) to target coagulation factors in rat and rabbit. Plasma kallikrein was selected for rat studies as plasma kallikrein knockout mouse had been described before in thrombosis and hemostasis models. Factor X (FX) was selected for rabbit studies as a rich dataset of FXa inhibitors in rabbits exists in literature. siRNAs that produced over 90% knockdown of rat plasma prekallikrein mRNA and rabbit FX mRNA in vitro were identified from cellular screens. An ionizable amino lipid based lipid nanoparticle (LNP) formulation for siRNA in vivo delivery was characterized as tolerable and exerting no appreciable effect on coagulability at day seven post dosing in both species. Both prekallikrein siRNA and FX siRNA resulted in dose-dependent and selective knockdown of target gene mRNA in the liver of respective species with maximum reduction of over 90% on day 7 following a single dose of the siRNA-LNP. Plasma prekallikrein siRNA at the highest dose (0.5 mg/kg) produced 92% knockdown on the circulating zymogen in the rats, associated with modest (~45%) clot weight reduction in the arteriovenous shunt thrombosis model and no increase in the cuticle bleeding time. These observations are consistent with the modest antithrombotic phenotype and absence of bleeding diathesis reported for the knockout mouse. FX siRNA at the highest dose (1.0 mg/kg) produced 98% knockdown on the circulating zymogen in the rabbits, accompanied with significant prolongation in ex vivo aPTT (103%) and PT (202%) measurements, consistent with the literature findings on pharmacodynamic effects of FXa inhibitors in rabbit. Results thus fit the expectations with both targets and demonstrate for the first time, the feasibility of targeting coagulation factors in rat and rabbit, via systemic delivery of siRNA. The titratable knockdown platform will not only strengthen target validation in thrombosis research but also facilitate studies on hemophilia diseases and hemostatic agents thereof.

High and low responders to novelty and mesolimbic noradrenaline: effects of noradrenergic agents on radial-maze performance

The authors used high and low responders to novelty (HRs and LRs, respectively) to examine the effects of noradrenergic injections into the nucleus accumbens using a special radial-maze task. During the 5 successive test days, solvent-treated HRs acquired this task faster than LRs. Isoproterenol (beta-agonist) combined with phenylephrine (alpha-agonist) improved acquisition in LRs but not in HRs; this effect was counteracted by propranolol (beta-antagonist) and phentolamine (alpha-antagonist). Propranolol combined with phentolamine, as well as phentolamine alone, disrupted acquisition in HRs but not in LRs. Data show that the effects of noradrenergic agents in HRs and LRs are due to differences in acquisition directed by type-specific differences in functional mesolimbic noradrenaline.

High and low responders to novelty and mesolimbic noradrenaline: effects of noradrenergic agents on radial-maze performance

The authors used high and low responders to novelty (HRs and LRs, respectively) to examine the effects of noradrenergic injections into the nucleus accumbens using a special radial-maze task. During the 5 successive test days, solvent-treated HRs acquired this task faster than LRs. Isoproterenol (beta-agonist) combined with phenylephrine (alpha-agonist) improved acquisition in LRs but not in HRs; this effect was counteracted by propranolol (beta-antagonist) and phentolamine (alpha-antagonist). Propranolol combined with phentolamine, as well as phentolamine alone, disrupted acquisition in HRs but not in LRs. Data show that the effects of noradrenergic agents in HRs and LRs are due to differences in acquisition directed by type-specific differences in functional mesolimbic noradrenaline.

SKF 83959 is an antagonist of dopamine D1-like receptors in the prefrontal cortex and nucleus accumbens: a key to its antiparkinsonian effect in animals?

SKF 83959 that has a unique antiparkinson profile in animal models of Parkinson's disease is an in vitro dopamine D1 antagonist of receptors coupled to adenylyl cyclase. We hypothesized that SKF 83959, among others, interacts with dopamine D1 receptors coupled to adenylyl cyclase in the nucleus accumbens and the prefrontal cortex. Effects of intra-accumbal injections of SKF 83959 on locomotor activity were compared to effects of the dopamine D1 agonist SKF 81297 and the dopamine D1 antagonist SCH 39166. Similarly to SCH 39166, SKF 83959 did not affect locomotor activity, but counteracted SKF 81297-induced locomotor activity. Effects of unilateral intra-prefrontal injections of SKF 83959 on rotational behaviour were compared to the effects of the dopamine D1 agonist SKF 81297 and the dopamine D1 antagonists SCH 23390 and SCH 39166 in rats selected on basis of their high locomotor response to novelty and pretreated with a subcutaneous injection of 0.75 mg/kg dexamphetamine. Like SCH 39166 and SCH 23390, SKF 83959 induced a bias for contralateral rotating and blocked the SKF 81297-induced bias for ipsilateral rotating. In conclusion, SKF 83959 is an in vivo antagonist of dopamine D1 receptors that are coupled to adenylyl cyclase in the nucleus accumbens and the prefrontal cortex. The role of these receptors in the antiparkinson profile of SKF 83959 is discussed.

Variation in hippocampal dynorphin b-immunoreactive mossy fiber terminal fields of apomorphine-(un)susceptible rats

The size of distinct hippocampal sub-fields were measured in the apomorphine-susceptible and apomorphine-unsusceptible rat lines. Mossy fiber terminal fields were delineated using dynorphin B immunoreactivity and area measurements were taken from (1) the supra-pyramidal mossy fiber terminal field; (2) the intra- and infra-pyramidal mossy fiber terminal field; (3) the hilus of the fascia dentata (4) the non dynorphin B immunoreactive area of the regio inferior and fascia dentata and (5) the total area of regio inferior and fascia dentata. The data indicate that statistically significant differences in the morphometry of the hippocampal subfields of the apomorphine susceptible and unsusceptible rats are confined to the intra- and infra terminal field: the relative size of the left and right intra- and infra terminal field of apomorphine unsusceptible rats are significantly larger than those of the apomorphine susceptible rats. These data explain at least in part the differential response of these rats to novelty.

The predictive validity of the drug-naive bilaterally MPTP-treated monkey as a model of Parkinson's disease: effects of L-DOPA and the D1 agonist SKF 82958

The aim of this study was twofold: (1) to study the predictive validity of the drug-naive, bilaterally MPTP-treated monkey as an animal model of Parkinson's disease (PD), and (2) to investigate the therapeutic and undesired effects of the D1 agonist SKF 82958 as compared to L-DOPA treatment, in drug-naive and L-DOPA pretreated monkeys. A detailed ethogram was used, allowing the separation of therapeutic and undesired effects. Eight weeks after bilateral intracarotid MPTP administration, SKF 82958 (1 mg/kg, n = 4, SKF 82958, naive group) or methyl-L-DOPA + carbi-dopa (10 + 2.5 mg/kg, n = 4, L-DOPA group) was administered intramuscularly for 22 days. After a drug-free period of eight weeks, the L-DOPA group was treated with SKF 82958 for 22 days (SKF 82959, 1 mg/kg, n=4, pretreated). All drug treatments increased the parameters used classically to evaluate dopaminergic drugs, namely body displacement, dyskinesia and dystonia. However, the new detailed analysis revealed that L-DOPA, but not SKF 82958, had therapeutic effects, reflected by an increase in goal-directed fore-limb use. SKF 82958, but not L-DOPA, induced additional undesired effects; including epileptoid behaviours in both drug-naive and drug-pretreated monkeys. In one L-DOPA-unresponsive monkey, SKF 82958 did induce minor therapeutic effects, as well as undesired effects. Although the effects of SKF 82958 on fore-limb movements, rotational behaviours and body displacement were comparable in the naive and pretreated group, SKF 82958 re-initiated undesired effects in the L-DOPA pretreated group from day one. It is concluded that the bilaterally MPTP-treated monkey is an animal model with predictive validity for PD: it adequately predicts the therapeutic effects and undesired effects of L-DOPA. Furthermore, it is concluded that SKF 82958 is less effective than L-DOPA in the treatment of PD, because it did not induce therapeutic effects, but instead elicited several undesired effects.

Madelung deformity in skeletally immature patients: morphologic assessment using radiography, CT, and MRI

PURPOSE

The purpose of this study was to define the pathoanatomy of the distal radius and surrounding soft tissues, identify the factors that may contribute to diminished forearm rotation, and relate these findings to alterations in wrist motion in skeletally immature patients with the Madelung deformity.

METHOD

Four skeletally immature female patients with bilateral Madelung deformities (eight wrists) underwent evaluation of each wrist with radiography, CT, and MRI to assess the morphology of the deformity. Two patients (four wrists) had isolated idiopathic Madelung deformities, and two patients (four wrists) had Madelung deformities secondary to dyschondrosteosis.

RESULTS

Radiographically, all wrists demonstrated dorsal bowing of the radius, marked ulnar tilting of the radius and radial tilting of the ulna, volar tilting of the distal articular surface of the radius, and triangulation of the epiphysis. On CT, patients with the idiopathic deformity demonstrated dorsal ulnar subluxation and relative supination of the carpus with respect to the distal radius. Patients with dyschondrosteosis demonstrated no ulnar subluxation and relative pronation of the carpus. All wrists demonstrated a fixed pronated deformity of the distal radius. On MRI, a physeal bar that bridged the distal metaphysis of the radius to the epiphysis was identified in all eight wrists, located on the volar aspect of the radius at the lunate facet. An anomalous volar ligament, a volar radiotriquetral ligament, and the short radiolunate ligament were hypertrophied in seven wrists.

CONCLUSION

Based on its location, it is likely that a physeal bar impedes the normal development of the distal radius ulnarly. Hypertrophy of the short radiolunate ligament may be an important contributing factor to carpal pyramidalization owing to tethering on the volar pole of the lunate. Diminished forearm rotation is likely related to carpal malalignment, a fixed pronated deformity of the distal radius, and dorsal bowing of the radius.

Use of high and low responders to novelty in rat studies on the role of the ventral striatum in radial maze performance: effects of intra-accumbens injections of sulpiride

High and low responders to novelty (Wistar rats) were selected with the help of an open-field test and then equipped with intra-accumbens cannulae. They were then tested in a simple four-arm radial maze during 5 successive days, three trials per day, following intra-accumbens injections of distilled water or the dopaminergic D2 antagonist (+/-)-sulpiride. The injections were given 15 min before the first trial on each day. Both types of drug-naive rats reached the same level of performance on day 5. However, high responders made more visits, more revisits, and needed less time to make the first visit than low responders. Moreover, high responders showed their greatest increase in learning 2 days earlier than low responders. It is discussed that these differences between high and low responders are not due simply to differences in locomotor activity, but are due to a subtle, but important, difference in the mode of learning between both types. Sulpiride significantly attenuated the learning in both rat types; however, its effect in high responders was much less than that in low responders. It is suggested that the effects of sulpiride are not due to changes in locomotor activity, motivation, or perception, but are due to a learning deficit. The data are discussed in view of the genetic variation in the neurochemical and neurobiological makeup of the nucleus accumbens in both types.

Anomalous origin of the left coronary artery from the pulmonary artery: repair by aortic reimplantation

From 1980 to 1990, 12 patients (mean age 2.5 years, range 5 months to 9 years) with anomalous origin of the left coronary artery from the pulmonary artery were treated surgically. Five infants were operated upon in the first year of life because of persistent symptoms of congestive heart failure. In all cases, a two-coronary system was constructed by direct aortic reimplantation of the anomalous vessel with no deaths early or late over a follow-up period of up to 10 years. The technique of reimplantation was facilitated by transection of the main pulmonary artery. One patient with severe mitral regurgitation underwent, in addition, a mitral annuloplasty. A pulmonary valvotomy was performed in another patient with associated pulmonary stenosis. Three patients are receiving medication. The reimplanted anomalous left coronary artery was patent in each reevaluated patient (10/12). Left ventricular function improved considerably in all cases. Patients with symptoms should undergo repair soon after diagnosis. Direct aortic reimplantation should be technically feasible in even the smallest infant. Operative mortality is related to preoperative conditions and severity of ischemic damage of the myocardium.

Interfascicular nerve repair

The technique of nerve repair that results in the greatest percentage of regeneration of axons into their original end organs will result in the greatest functional return and the best result. Of prime importance is the motor-to-motor and sensory-to-sensory axonal orientation. Anatomic and physiologic data, as well as technical expertise, must be utilized for precise nerve approximation. To this end, fascicular repair under high-power magnification is an attempt to achieve the best alignment and coaptation of the neural elements.