The effect of 20-minute mindful breathing exercise on psychological well-being in epilepsy: A pilot randomized controlled trial

INTRODUCTION

Depression and anxiety are prevalent in epilepsy patients, but psychiatric or psychological services may not be accessible to all patients. This study aimed to determine the effectiveness of the 20-minute mindful breathing on the psychological well-being of PWE using an instructional video.

METHOD

This was a pilot, assessor-blinded, randomized controlled trial. The intervention group received a guided video and was briefed to perform the exercise twice a week for two weeks while the waitlist control group only received the video upon completion of the study. The subjects were assessed at three-time points (T0: Baseline, T1: 2 weeks after the intervention, T2: 4 weeks after intervention), using the Neurological Disorders Depression Index (NDDI-E), General Anxiety Disorder (GAD-7), Quality of Life in Epilepsy Inventory (QOLIE-31) and Mindfulness Attention Awareness Scale (MAAS).

RESULTS

Twenty patients were recruited, with 10 in the intervention and waitlist-control groups. Compared with the waitlist-control group, participants in the intervention group showed significant improvement in NDDI-E at T1 (p = 0.022) but not at T2 (p = 0.056) and greater improvement in GAD-7 at T1 and T2 but not statistically significant. The QOLIE-31 overall score in the intervention group has significantly improved at T1 (p = 0.036) and T2 (p = 0.031) compared to the waitlist-control group. For MAAS, the intervention group also had an increased score at T2 (p = 0.025).

CONCLUSION

The 20-minute mindfulness breathing exercise has an immediate effect in improving depression and quality of life among people with epilepsy.

Dengue virus infection and neurological manifestations: an update

Dengue virus is a flavivirus transmitted by the mosquitoes, Aedes aegypti and Aedes albopictus. Dengue infection by all four serotypes (DEN 1 to 4) is endemic globally in regions with tropical and subtropical climates, with an estimated 100-400 million infections annually. Among those hospitalized, the mortality is about 1%. Neurological involvement has been reported to be about 5%. The spectrum of neurological manifestations spans both the peripheral and central nervous systems. These manifestations could possibly be categorized into those directly related to dengue infection, i.e. acute and chronic encephalitis, indirect complications leading to dengue encephalopathy, and post-infectious syndrome due to immune-mediated reactions, and manifestations with uncertain mechanisms, such as acute transverse myelitis, acute cerebellitis and myositis. The rising trend in global dengue incidence calls for attention to a more explicit definition of each neurological manifestation for more accurate epidemiological data. The actual global burden of dengue infection with neurological manifestation is essential for future planning and execution of strategies, especially in the development of effective antivirals and vaccines against the dengue virus. In this article, we discuss the recent findings of different spectrums of neurological manifestations in dengue infection and provide an update on antiviral and vaccine development and their challenges.

Feasibility of psychological screening in a tertiary epilepsy clinic

OBJECTIVE

People with epilepsy (PWE) have a high prevalence of developing depression and anxiety. The objective is to determine the feasibility of brief screening tools to screen for depression and anxiety in epilepsy, and the predictive factors.

METHOD

This is a cross-sectional study in the neurology clinic in a tertiary teaching hospital in Kuala Lumpur. The screening tools used were the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) and the General Anxiety Disorder Form (GAD-7).

RESULTS

Five hundred and eighty-five patients were recruited in this study, and 50.8% of them were male, predominantly Chinese (46.7%), with a mean age of seizure onset of 21.8 ± 16.1 years. The majority had focal seizures (75.0%), and 41.9% had seizure remission. There were 15.5% who scored ≥15 in the NDDI-E, and 17.0% had moderate or severe anxiety (scored ≥10 in the GAD-7). In a regression model to predict the NDDI-E score, the age of seizure onset recorded a higher beta value (β = -0.265, p =< 0.001), followed by the duration of epilepsy (β = -0.213, p =< 0.001), use of levetiracetam (LEV) (β = 0.147, p = 0.002), clonazepam (CLZ) (β = 0.127, p = 0.011), and lamotrigine (LTG) (β = 0.125, p = 0.011), number of current antiseizure medications (β = -0.124, p = 0.049), seizure remission for ≥1 year (β = -0.108, p = 0.011), and female (β = 0.082, p = 0.049). For the GAD-7 score, the predictors included current age (β = -0.152, p = 0.001), the use of LEV (β = 0.122, p = 0.011), Indian ethnicity (β = 0.114, p = 0.006), and the use of carbamazepine (β = -0.090, p = 0.043).

CONCLUSION

Implementation of simple psychological screening using self-administered questionnaires was feasible in a busy tertiary epilepsy clinic.

Integrating real-world data in cost-effectiveness analysis of universal HLA-B*15:02 screening in Malaysia

AIMS

Despite the availability of newer antiseizure medications, carbamazepine (CBZ) remains the gold standard. However, patients of Asian ancestry are susceptible to CBZ-related severe cutaneous adverse reactions. Universal HLA-B*15:02 screening is a promising intervention to address this. With the increasing recognition of integrating real-world evidence in economic evaluations, the cost-effectiveness of universal HLA-B*15:02 screening was assessed using available real-world data in Malaysia.

METHODS

A hybrid model of a decision tree and Markov model was developed to evaluate 3 strategies for treating newly diagnosed epilepsy among adults: (i) CBZ initiation without HLA-B*15:02 screening (current practice); (ii) universal HLA-B*15:02 screening prior to CBZ initiation; and (iii) alternative prescribing without HLA-B*15:02 screening. The model was populated with real-world inputs derived from the Malaysian population. From a societal perspective, base-case analysis and sensitivity analyses estimated the costs and outcomes over a lifetime. Incremental cost-effectiveness ratios were calculated.

RESULTS

In the base-cases analysis, universal HLA-B*15:02 screening yielded the lowest total costs and the highest total quality-adjusted life years (QALYs) gained. Compared with current practice, universal screening was less costly by USD100 and more effective by QALYs increase of 0.1306, while alternative prescribing resulted in 0.1383 QALYs loss at additional costs of USD332. The highest seizure remission rate (56%) was estimated for universal HLA-B*15:02 screening vs. current practice (54%) and alternative prescribing (48%).

CONCLUSION

Our study suggests that universal HLA-B*15:02 screening is a cost-effective intervention in Malaysia. With the demonstrated value of real-world evidence in economic evaluations, more relevant standardization efforts should be emphasized to better inform decision-making.

The Impact of COVID-19 on Values and Religiosity in a Multi-Ethnic Population

We investigated the COVID-19 pandemic's impact on values and religiosity in multi-ethnic Malaysia. Values were measured as changes in values, daily activities, and life priorities using a 5-point Likert scale (-2 to +2). Centrality of Religiosity Scale measured changes in religiosity. Around 176 predominantly female (66.5%), Chinese (68.2%) respondents, aged 35.5 ± 14.1 completed the survey. Most life values changed positively: a sense of security at home (2, interquartile range [IQR]: 1-2), connection with family (1, 1-2), and contribution to society (1, 1-2). Certain life priorities' importance increased: health (2, IQR 2-2), family (2, 2-2), and happiness (2, 1-2); except power and money. These significant positive changes in values and religiosity varied between genders and ethnicities.

Caregiver burden for adults with epilepsy in Malaysian families: A qualitative study

BACKGROUND

Caregivers of adults with epilepsy (AWE) play an important role in the healthcare pathway of AWE and are described as the "co-client." Being caregivers can be stressful and the negative impacts might accumulate over time, affecting their quality of life and well-being.

OBJECTIVES

This qualitative study aimed to explore the lived experience of caregivers of AWE in Malaysian families and understand their caregiving challenges. Individual semi-structured interviews were held with 12 primary caregivers of AWE. Interpretative Phenomenological Approach (IPA) was used. The interview transcripts were analyzed using NVivo12 software.

RESULTS

Primary caregivers of AWE were parents or siblings, with ages ranging from 56 to 80 years old and years of caregiving from 24 to 40 years. Most AWE (58%) were intellectually disabled and fully dependent on ADL needs. Two categories of themes emerged, including four themes on caregiver burden, i.e., physical, emotional, and social burdens, and challenges in future planning of care, and two themes on coping strategies (problem- or emotional-focused). In future planning of care, most caregivers especially parents carried a burden of responsibility and were reluctant to depend on others or institutional services.

CONCLUSION

The caregiving burden among caregivers for adult AWE was not confined to current burdens only but also challenges in future planning. A better understanding of the caregiving burden for AWE and coping strategies is needed to provide tailored psychoeducation or psychosocial intervention to support this population.

Affordability of newer antiseizure medications in Asian resource-limited countries

OBJECTIVE

One of the objectives of the Intersectoral Global Action Plan on epilepsy and other neurological disorders for 2022 to 2031 is to ensure at least 80% of people with epilepsy (PWE) will have access to appropriate, affordable, and safe antiseizure medications (ASMs) by 2031. However, ASM affordability is a significant issue in low- and middle-income countries, preventing PWE from accessing optimal treatment. This study aimed to determine the affordability of the newer (second and third generation) ASMs in resource-limited countries in Asia.

METHODS

We conducted a cross-sectional survey by contacting country representatives in lower-middle-income countries (LMICs) in Asia, including Indonesia, Lao People's Democratic Republic (PDR), Myanmar, Philippines, Vietnam, India, Bangladesh, and Pakistan, and the upper-middle-income country Malaysia, from March 2022 to April 2022. The affordability of each ASM was calculated by dividing the 30-day ASM cost by the daily wage of the lowest paid unskilled laborers. Treatment costing 1 day's wage or less for a 30-day supply of chronic disease is considered affordable.

RESULTS

Eight LMICs and one upper-middle-income country were included in this study. Lao PDR had no newer ASM, and Vietnam had only three newer ASMs. The most frequently available ASMs were levetiracetam, topiramate, and lamotrigine, and the least frequently available was lacosamide. The majority of the newer ASMs were unaffordable, with the median number of days' wages for a 30-day supply ranging from 5.6 to 14.8 days.

SIGNIFICANCE

All new generation ASMs, whether original or generic brands, were unaffordable in most Asian LMICs.

Management of status epilepticus in Malaysia: A national survey of current practice and treatment gap

INTRODUCTION

Early and effective treatment is fundamental in status epilepticus (SE) management. At the initiative of the Epilepsy Council of Malaysia, this study aimed to determine the treatment gap in SE across different healthcare settings in Malaysia.

METHODS

A web-based survey was sent to clinicians involved in the management of SE, across all states and at all levels of healthcare services.

RESULTS

A total of 158 responses were received from 104 health facilities, including 23 tertiary government hospitals (95.8% of all government tertiary hospitals in Malaysia), 4 (80.0%) universities, 14 (6.7%) private, 15 (11.5%) district hospitals and 21 clinics. Intravenous (IV) diazepam was available in 14 (93.3%) district and 33 (80.5%) tertiary hospitals for prehospital management. Non-IV benzodiazepine (rectal diazepam and intramuscular midazolam) was not widely available in prehospital services (75.8% and 51.5%). Intramuscular midazolam was underutilised (60.0% in district and 65.9% in tertiary hospitals). IV sodium valproate and levetiracetam were only available in 66.7% and 53.3% of the district hospitals, respectively. Electroencephalogram (EEG) services were available in only 26.7% of the district hospitals. Non-pharmacological therapies such as ketogenic diet, electroconvulsive therapy, and therapeutic hypothermia were not available in most district and tertiary hospitals for refractory and super-refractory SE.

CONCLUSIONS

We identified several gaps in the current practice of SE management, including limited availability and underutilization of non-IV midazolam in prehospital services, underutilization of non-IV midazolam and other second-line ASMs, and lack of EEG monitoring in district hospitals and limited treatment options for refractory and super-refractory SE in tertiary hospitals.

From parasomnia to agrypnia excitata - An illustrative case on diagnostic approach

The diagnostic approach to sleep-related movements disorders is seldom discussed. We report a case of fatal familial insomnia who initially presented with persistent limb movements in sleep, which later progressed to a state of agrypnia excitata. Here, the evaluation of abnormal movements in sleep is discussed using a step-by-step diagnostic approach. Although no cure is available for fatal familial insomnia, prompt recognition of this condition is important to facilitate proper management, including the involvement of interdisciplinary neuropalliative care.

Development and Validation of a Deep Learning Model for Predicting Treatment Response in Patients With Newly Diagnosed Epilepsy

Importance

Selection of antiseizure medications (ASMs) for epilepsy remains largely a trial-and-error approach. Under this approach, many patients have to endure sequential trials of ineffective treatments until the "right drugs" are prescribed.

Objective

To develop and validate a deep learning model using readily available clinical information to predict treatment success with the first ASM for individual patients.

Design, Setting, and Participants

This cohort study developed and validated a prognostic model. Patients were treated between 1982 and 2020. All patients were followed up for a minimum of 1 year or until failure of the first ASM. A total of 2404 adults with epilepsy newly treated at specialist clinics in Scotland, Malaysia, Australia, and China between 1982 and 2020 were considered for inclusion, of whom 606 (25.2%) were excluded from the final cohort because of missing information in 1 or more variables.

Exposures

One of 7 antiseizure medications.

Main Outcomes and Measures

With the use of the transformer model architecture on 16 clinical factors and ASM information, this cohort study first pooled all cohorts for model training and testing. The model was trained again using the largest cohort and externally validated on the other 4 cohorts. The area under the receiver operating characteristic curve (AUROC), weighted balanced accuracy, sensitivity, and specificity of the model were all assessed for predicting treatment success based on the optimal probability cutoff. Treatment success was defined as complete seizure freedom for the first year of treatment while taking the first ASM. Performance of the transformer model was compared with other machine learning models.

Results

The final pooled cohort included 1798 adults (54.5% female; median age, 34 years [IQR, 24-50 years]). The transformer model that was trained using the pooled cohort had an AUROC of 0.65 (95% CI, 0.63-0.67) and a weighted balanced accuracy of 0.62 (95% CI, 0.60-0.64) on the test set. The model that was trained using the largest cohort only had AUROCs ranging from 0.52 to 0.60 and a weighted balanced accuracy ranging from 0.51 to 0.62 in the external validation cohorts. Number of pretreatment seizures, presence of psychiatric disorders, electroencephalography, and brain imaging findings were the most important clinical variables for predicted outcomes in both models. The transformer model that was developed using the pooled cohort outperformed 2 of the 5 other models tested in terms of AUROC.

Conclusions and Relevance

In this cohort study, a deep learning model showed the feasibility of personalized prediction of response to ASMs based on clinical information. With improvement of performance, such as by incorporating genetic and imaging data, this model may potentially assist clinicians in selecting the right drug at the first trial.

Impact of seizures and antiseizure medication on survival in patients with glioma

PURPOSE

Seizures are a common presenting symptom among patients with low- and high-grade glioma. However, the impact and inter-relationship between the presence of seizures, anti-seizure medication (ASM) and survival are unclear. We retrospectively analyzed the incidence of seizures and identified the pattern and relationship of anti-seizure medication on survival in our cohort of patients with glioma.

METHODS

We evaluated all glioma patients who underwent treatment at the University of Malaya Medical Centre (UMMC) between 2008 and 2020. Demographic and clinical data of seizures and pattern of ASM administration in comparison to overall survival were analyzed.

RESULTS

A total of 235 patients were studied, with a minimum of one year clinical follow-up post-treatment. The median survival for low-grade glioma was 38 months whereas high-grade glioma was 15 months. One-third of our glioma patients (n = 74) presented with seizures. All patients with seizures and a further 31% of patients without seizures were started on anti-seizure medication preoperatively. Seizure and Levetiracetam (LEV) were significantly associated with OS on univariate analysis. However, only LEV (HR 0.49; 95% CI 0.23-0.87; p=0.02) was significantly associated with improving overall survival (OS) on multivariate analysis. Once ASM was adjusted for relevant factors and each other, LEV was associated with improved survival in all grade gliomas (HR 0.52; 95% CI 0.31-0.88; p=0.02) and specifically high-grade gliomas (HR 0.53; 95% CI 0.30-0.94; p=0.03).

CONCLUSIONS

Pre-operative seizures among patients with glioma indicated a better overall prognosis. The administration of ASM, specifically LEV was associated with a  significant survival advantage in our retrospective cohort of patients.

Seizure remission rates remain low in a resource-limited country, a multicentre comparison study in Malaysia

Seizure remission rates of 60% with antiseizure medications were reported in developed countries, but might be lower in resource-limited countries. The challenges in epilepsy care in resource-limited regions were highlighted 10 years ago, and still remain an ongoing issue. This study aimed to determine the seizure freedom rates in level-2 epilepsy care centres (centres with general neurologists) compared to level-3/4 centres (centres with epileptologists providing epilepsy surgery evaluation) in Malaysia. This is a retrospective study of 1,347 adult epilepsy patients from two level-2 (n = 290) and two level-3/4 epilepsy care centres (n = 1,057). The seizure remission rates were significantly lower in level-2 centres (42.5%) compared to the level 3/4 centres (61.9%, p < 0.05). Level-2 centres had significantly more patients with undetermined seizure types compared to level-3/4 centres (6.6% vs 3.1%, p < 0.05). Level-3/4 centres had significantly more patients with epilepsy of structural and genetic origins, whereas more patients in level-2 centres had unknown aetiology (46.2% vs. 34.0% in level-3/4, p < 0.05). Level-2 centres had a lower neurologist-to-patient ratio (1:97 vs. 1:50 in level-3/4 centres, p < 0.05). Level-2 centres also had fewer patients, who underwent investigations such as EEG (74.1% vs. 89.6%) and brain MRI (54.1% vs. 72.4%, p < 0.05) in comparison with level-3/4 centres. Our study emphasized the existing challenges in epilepsy care in a resource-limited country to achieve the ideal 60% seizure remission rate.

Incidence of Anti-Seizure Medication-Induced Severe Cutaneous Adverse Reactions in Malaysia

Anti-seizure medication (ASM) can potentially cause severe cutaneous adverse reactions (SCAR), and certain ASM-induced SCAR is associated with specific HLA alleles. This caused a change in ASM prescribing pattern, which may influence the incidence of ASM-induced SCAR. Thus, we aimed to determine the incidence of ASM-induced SCAR and its change over 15 years (2006-2019) in Malaysia. This retrospective analysis combined ASM-induced SCAR cases from the national Adverse Drug Reaction (ADR) database in the National Pharmaceutical Regulatory Agency (NPRA), ASM-drug utilisation data from the Malaysian Statistics of Medicine, and prescribing data from UMMC, a national level tertiary hospital to calculate ASM-induced SCAR incidence in Malaysia. We observed an upward trend in reported ASM-induced SCAR cases from 28 cases in 2006 to 92 in 2016. The incidence of carbamazepine (CBZ)-induced SCAR increased from 7.5 per 1,000 person-year (2006) to 17.8 per 1,000 person-year (2016) but dropped to 7.2 per 1,000 person-year (2019) subsequently. Concurrently, there was an increase in the incidence of SCAR secondary to phenytoin and lamotrigine. The prevalent users of CBZ had reduced from 22.8% (2006) to 14.1% (2016), whereas the levetiracetam and sodium valproate users increased by 5.5% and 4.8%, respectively. The incidence of CBZ-induced SCAR had reduced since 2016, probably related to the implementation of HLA-B*1502 screening in Malaysia or substitution of CBZ with other ASM. However, this was accompanied with an increase of SCAR incidence related to phenytoin and lamotrigine. This article is protected by copyright. All rights reserved.

Impact of COVID-19 pandemic on people with epilepsy: An interventional study using early physical consultation

BACKGROUND

Telehealth use is limited in developing countries. Therefore, a modified approach with early physical consultation was designed and applied in our hospital. This study aimed to determine the efficacy of this early physical consultation in reducing the clinical and psychological impacts of coronavirus disease-19 (COVID-19), which enabled insight into its global feasibility.

METHOD

Participants were contacted and offered early physical consultation with a neurologist. Patients who participated in the Phase 1 study on the impacts of the COVID-19 pandemic on people with epilepsy and treated in our hospital were recruited. Clinical and psychological outcomes of COVID-19 were assessed with the Hospital Anxiety Depression Scale (HADS) and Quality of Life in Epilepsy Inventory (QOLIE-31).

RESULT

A total of 312 patients completed this study with a mean age of 39.13 ± 16.13 years, majority female (51.0%), and experienced seizures at least once yearly (64.7%). There was 12.6% who experienced seizure worsening related to the COVID-19 pandemic. After receiving early clinical intervention, 30.8% achieved better seizure control with another 51.1% had no seizure occurrence. The mean HADS anxiety score improved immediately post-intervention (5.27 ± 4.32 vs. 4.79 ± 4.26, p < 0.01), and at 2-week post-intervention (5.58 ± 4.46 vs. 4.73 ± 3.95, p < 0.01). The mean HADS depression score also improved immediately post-intervention (4.12 ± 3.69 vs. 3.84 ± 3.76, p < 0.05) and at 2-week post-intervention (4.38 ± 3.81 vs. 3.73 ± 3.63, p < 0.05). The intervention resulted in significant improvement in energy-fatigue and social function subscales in QOLIE-31 but a reduction in cognitive and medication effects subscales.

CONCLUSION

Early physical consultation with stringent precautionary measures is feasible and effective in improving the psychological outcome during COVID-19 pandemic.

Perceptions associated with the public attitudes toward epilepsy (PATE) scale: A mixed-method study

BACKGROUND

In epilepsy stigma, certain perceptions are culturally dependent and greatly influence a person's attitudes. Hence, we aimed to explore the perceptions associated with attitudes toward epilepsy in various urban subpopulations.

METHOD

This is a mixed-method study employing the Public Attitude Toward Epilepsy (PATE) scale as the quantitative measure, followed by a semi-structured interview. The qualitative data were then counted and analyzed concurrently with the quantitative data.

RESULT

A total of 410 respondents (104 people with epilepsy [PWE]; 104 family members [FM]; 100 medical students [MS]; 102 public [Pb]) aged 37 years (IQR 23-55) were recruited. They were mostly female (57.3%), Chinese (52.0%), and highly educated (63.7%). The attitudes toward epilepsy among medical students are the best, followed by the PWE and their family members, and the worst among the public. The qualitative results revealed 4 main themes, which were "general social values", "epilepsy severity and control", "PWE's abilities", and "harms and burdens to the respondents and others". A two-dimensional perception model was constructed based on these themes, which consisted of general-personal and universal-specific dimensions. Generally, the PWE/FM subgroup focused more on PWE's abilities, whereas the MS/Pb subgroup more on general social values, and harms and burden. In the education aspect, most attitudes were related to the epilepsy severity and PWE's abilities, whereas in employment, the main consideration was the PWE's abilities. Burden to life and concern about inheritance were major considerations in the marital relationship. Those with positive attitudes tend to highlight the importance of general social values, while negative attitudes associated more with epilepsy severity. In general domain, general social values were the main considering factor but in personal domain, most participants will consider epilepsy severity and control, harms and burden to themselves.

CONCLUSION

The perceptions underlying attitudes toward epilepsy were complex and varied between subpopulations, attitude levels, domains, and aspects of life. (304 words).

Impact of COVID-19 on quality of life in people with epilepsy, and a multinational comparison of clinical and psychological impacts

BACKGROUND

This study aimed to determine the relationship among the clinical, logistic, and psychological impacts of COVID-19 on people with epilepsy (PWE), and the impact of COVID-19 on the quality of life.

METHOD

This is a cross-sectional anonymized web-based study on PWE, using an online questionnaire to assess the clinical, logistic, and psychological impacts of COVID-19, including Hospital Anxiety Depression Scale (HADS) and Quality of Life in Epilepsy Inventory (QOLIE-31).

RESULT

461 patients were recruited, with a mean age of 39.21 ± 15.88 years, majority female (50.1%), with focal epilepsy (54.0%), and experienced seizures at least once yearly (62.5%). There were 13.0% experienced seizure worsening during COVID-19 period, which were associated with baseline seizures frequency ≥ 1 per month (32.0% vs. 6.2%, p < 0.001), worries of seizure worsening (18.0% vs. 10.9%, p < 0.001), difficulty to go emergency unit (24.4% vs. 10.4%, p < 0.001), AEDs ran out of stock (23.2% vs. 11.6%, p < 0.05), self-adjustment of AED dosages (26.4% vs. 11.3%, p < 0.001), inadequate sleep (22.4% vs. 9.2%, p < 0.001), and stress (23.4% vs.10.1%, p < 0.01). Participants experiencing seizure worsening reported greater anxiety (8.10 ± 5.011 vs. 4.84 ± 3.989, p < 0.001) and depression (6.05 ± 3.868 vs. 3.86 ± 3.589, p < 0.001). Logistic regression showed baseline seizures frequency >1 per month (OR, 14.10) followed by anxiety (OR, 3.90), inadequate sleep (OR, 0.37), and treated in UMMC (OR, 0.31) as the predictors for seizure worsening during COVID-19 period. Poorer total QOLIE-31 score was noted in those with seizure worsening (48.01 ± 13.040 vs. 62.15 ± 15.222, p < 0.001). Stepwise regression highlighted depression as the main negative predictor for quality of life (β = -0.372, p < 0.001), followed by anxiety (β = -0.345, p < 0.001).

CONCLUSION

A significant number of PWE experienced seizure worsening during COVID-19 period, which was related to the clinical, logistic, and psychological factors. Quality of life was affected by the seizure worsening and the psychological stress.

Mortality in adult epilepsy patients in Malaysia: a hospital-based study

BACKGROUND

The standardized mortality ratio (SMR) of epilepsy in Asia ranges from 2.5 to 5.1. However, there are no such published data in Malaysia to date. Understanding the mortality rate and related factors will allow us to better assess and monitor the health status of PWE, thereby, preventing premature deaths among PWE. Hence, this study aimed to determine the mortality rate of adults with epilepsy (PWE) at the University Malaya Medical Centre (UMMC), a tertiary hospital in Malaysia.

METHOD

A total of 2218 PWE were recruited retrospectively into this study. Deceased cases from 2009-2018 were identified from the National Registry Department of Malaysia. Age-, gender-, and ethnic-specific SMR were calculated.

RESULT

There was a total of 163 deaths, of which 111 (68.1%) were male. The overall case-fatality rate (CFR) was 7.3%. Male PWE had higher CFR (9.2%) compared to females (5.1%, p<0.001). The annual death rate of PWE was 867 per 100, 000 persons. The overall all-cause SMR was 1.6 (CI 95% 1.3-1.8). The SMR for younger age groups (15-19 and 20-29 years) were higher (5.4-5.5) compared to other age groups (0.4-2.5). Overall SMR for male PWE (1.8, 95% CI 1.5-2.1) was higher than females (1.2, 95% CI 0.9-1.6). However, the SMR for female PWE in the younger age groups (15-19, 20-29 and 30-39 years) was higher. SMR among the Indian PWE was the highest (1.6, 95% CI 1.2-2.0) compared to the Chinese (1.5, 95% CI 1.2-1.9) and the Malays (1.4, 95% 1.0-1.9). The CFR was higher in those with focal epilepsy (8.5% vs. 2.5-3.7% in genetic and other generalized epilepsies, p=0.003), epilepsy with structural cause (9.5% vs. 5.9% in others, p=0.005) and uncontrolled seizures (7.9% vs. 5.2% in seizure-free group, p<0.001).

CONCLUSION

The mortality rate of PWE in Malaysia is higher than that of the general population but lower compared to other Asian countries. Specifically, the rates are higher in the younger age group, male gender, and Indian ethnicity. Those with focal epilepsy, structural causes and uncontrolled seizures have higher mortality rates.

Prevalence study of epilepsy in Malaysia

INTRODUCTION

The lifetime prevalence of epilepsy varies greatly from 1.5-14.0 per 1000 persons among the Asian countries. We aim to study the prevalence of epilepsy in Malaysia to have a better insight into the burden of disease in the country.

METHODS

A population-based door-to-door survey was carried out throughout the country, using questionnaire for brief screening in ascertainment of epilepsy, using a questionnaire and its validated multilingual versions. Respondents who were screened positive underwent second-stage diagnostic phone interview by neurologists/ research assistants.

RESULTS

A total 16, 686 respondents participated in the survey and 646 (3.8 %) respondents were screened positive during the first stage interview. A total of 185 consented for second stage diagnostic interview and 118 (63.8 %) respondents were contacted successfully for the second stage diagnostic phone interview, of which 17 (14.4 %) respondents were diagnosed to have epilepsy. An additional 68 (57.6 %) respondents had febrile seizures only. After applying a weighting factor to each respondent to adjust for non-response and for the varying probabilities of selection, the adjusted lifetime epilepsy prevalence was 7.8 in 1000 population, and the adjusted prevalence for active epilepsy was 4.2 in 1000 population in Malaysia.

CONCLUSION

The prevalence of lifetime epilepsy in Malaysia is 7.8 per 1000 persons.

Attitudes toward epilepsy in East Malaysia using the Public Attitudes Toward Epilepsy (PATE) scale

BACKGROUND

Epilepsy stigma is an important issue affecting people with epilepsy (PWE) in various social aspects of life. Most studies on stigma were among the metropolitan population but rarely on indigenous people. Hence, this study aimed to understand the attitudes toward epilepsy of the East Malaysians, comparing with the West Malaysians previously reported.

METHOD

This study was performed among the indigenous people in Kuching and Sibu (Sarawak) and Kota Kinabalu (Sabah) using the Public Attitudes Toward Epilepsy (PATE) scale. A higher score indicates poorer attitude.

RESULT

A total of 360 respondents (41.7% Kadazan-Dusun, 30.6% Bidayuh, and 24.7% Iban) aged 34.6 ± 12.6 years completed the questionnaire. They were predominantly females and had lower education level and income compared with the West Malaysians. The Sabah population had significantly lower mean scores (better attitudes) than those in Sarawak, in both personal and general domains (p < .001). As compared with West Malaysia, the mean score in the personal domain was significantly lower in Sabah, while Sarawak had significantly higher scores in general domain (p < .001). Subanalysis showed that the Sabah population had better attitudes toward marriage and employment in PWE than the West Malaysians, whereas Sarawak had poorer attitudes toward education and social contact in PWE.

CONCLUSION

The attitudes toward epilepsy were different among the indigenous populations in Sabah and Sarawak, and from the West Malaysians, which could be attributable to their sociocultural differences.

EEG Source Imaging (ESI) utility in clinical practice

Epilepsy surgery is an important treatment modality for medically refractory focal epilepsy. The outcome of surgery usually depends on the localization accuracy of the epileptogenic zone (EZ) during pre-surgical evaluation. Good localization can be achieved with various electrophysiological and neuroimaging approaches. However, each approach has its own merits and limitations. Electroencephalography (EEG) Source Imaging (ESI) is an emerging model-based computational technique to localize cortical sources of electrical activity within the brain volume, three-dimensionally. ESI based pre-surgical evaluation gives an overall clinical yield of 73-91%, depending on choice of head model, inverse solution and EEG electrode density. It is a cost effective, non-invasive method which provides valuable additional information in presurgical evaluation due to its high localizing value specifically in MRI-negative cases, extra or basal temporal lobe epilepsy, multifocal lesions such as tuberous sclerosis or cases with multiple hypotheses. Unfortunately, less than 1% of surgical centers in developing countries use this method as a part of pre-surgical evaluation. This review promotes ESI as a useful clinical tool especially for patients with lesion-negative MRI to determine EZ cost-effectively with high accuracy under the optimized conditions.

48-hour video-EEG monitoring for epilepsy presurgical evaluation is cost-effective and safe in resource-limited setting

INTRODUCTION

Video-EEG monitoring is one of the key investigations in epilepsy pre-surgical evaluation but limited by cost. This study aimed to determine the efficacy and safety of a 48-hour (3-day) video EEG monitoring, with rapid pre-monitoring antiepileptic drugs withdrawal.

MATERIAL AND METHODS

This is a retrospective study of epilepsy cases with VEM performed in University Malaya Medical Center (UMMC), Kuala Lumpur, from January 2012 till August 2016.

RESULTS

A total of 137 cases were included. The mean age was 34.5 years old (range 15-62) and 76 (55.8 %) were male. On the first 24 -h of recording (D1), 81 cases (59.1 %) had seizure occurrence, and 109 (79.6 %) by day 2 (D2). One-hundred and nine VEMs (79.6 %) were diagnostic, in guiding surgical decision or further investigations. Of these, 21 had less than 2 seizures recorded in the first 48 h but were considered as diagnostic because of concordant interictal ± ictal activities, or a diagnosis such as psychogenic non-epileptic seizure was made. Twenty-eight patients had extension of VEM for another 24-48 h, and 11 developed seizures during the extension period. Extra-temporal lobe epilepsy and seizure frequency were significant predictors for diagnostic 48 -h VEM. Three patients developed complications, including status epilepticus required anaesthetic agents (1), seizure clusters (2) with postictal psychosis or dysphasia, and all recovered subsequently.

CONCLUSIONS

48-h video EEG monitoring is cost-effective in resource limited setting.

Validation of Malay brief screening instrument for ascertainment of epilepsy

INTRODUCTION

Prevalence studies of epilepsy in Asia revealed a prevalence ranging from 1.5 to 14.0 per 1000 among Asian populations. However, the prevalence of epilepsy in Malaysia is not available for comparison with other countries. This study aimed to translate and validate a Malay brief screening instruments for ascertainment of epilepsy.

METHOD

We translated into Malay a brief screening instrument for ascertainment of epilepsy designed and validated by Ottman et al., using the three-stage cross-cultural adaptation process developed by the International Quality of Life Assessment (IQOLA) project. We then administered the translated questionnaire via online survey to 162 cases (patients with epilepsy under follow-up care at the neurology clinic in University of Malaya Medical Centre, Kuala Lumpur) and 146 controls with no known history of epilepsy for validation.

RESULTS

Applying the most liberal definition for a positive screen, we obtained a sensitivity of 96.3% (95% confidence interval [CI]: 91.8-98.5%), with a specificity of 66.4% (95% CI: 58.1-73.0%) and positive predictive value (PPV) of 2.0%. The most stringent definition for a positive screen (only epilepsy) resulted in a sensitivity of 97.4% (95% CI: 62.0-72.6%), specificity of 98.6% (95% CI: 94.6-99.7%), and PPV of 26.6%. Narrowing the definition of a positive screen decreased sensitivity but improved PPVs. When compared to the original English questionnaire, the sensitivities were similar for all four definitions of a positive screen.

CONCLUSION

This is the first validated epilepsy screening questionnaire in the Malay language and represents a useful tool for the ascertainment of epilepsy in population-based studies.

Underutilization of epilepsy surgery in ASEAN countries

PURPOSE

This survey was performed to determine the availability of epilepsy surgery, and understand the limiting factors to epilepsy surgery in ASEAN countries with total of 640 million population.

METHOD

A cross-sectional survey was completed by national representatives in all ASEAN countries (Brunei, Cambodia, East Timor, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam).

RESULTS

Overall facilities for initial epilepsy pre-surgical evaluation are available in most countries, but further non-invasive and invasive investigations are limited. Three countries (Brunei, Cambodia, and East Timor) have no epilepsy center, and 2 countries (Laos, Myanmar) have level 2 centers doing tumor surgery only. Level-3 epilepsy centers are available in 6 countries (Indonesia, Malaysia, Philippine, Singapore, Thailand, Vietnam); only 5 countries (Indonesia, Malaysia, Philippine, Singapore, Thailand) has at least one level-4 epilepsy care facility. Indonesia with 261 million population only has one level 3 and another level 4 center. The costs of presurgical evaluation and brain surgery vary within and among the countries. The main barriers towards epilepsy surgery in ASEAN include lack of expertise, funding and facilities.

CONCLUSIONS

Epilepsy surgery is underutilized in ASEAN with low number of level 3 centers, and limited availability of advanced presurgical evaluation. Lack of expertise, facilities and funding may be the key factors contributing to the underutilization.

The partial primary structure of bovine rhodopsin and its topography in the retinal rod cell disc membrane

The amino-terminal 39 amino acids of bovine rhodopsin have the sequence where both carbohydrate attachment sites (CHO) contain GlcNAc(3)Man(3). This region of rhodopsin's sequence is exposed at the internal membrane surface of the rod cell disc membrane. Rhodopsin's carboxyl-terminal 40 amino acids have the sequence where amino acid 1? is the carboxyl-terminal amino acid of rhodopsin. Serines and threonines in the sequence 6? ? 15? are phosphorylated by rhodopsin kinase in a light-dependent reaction. Trypsin can digest native rhodopsin, in the disc membrane at and thermolysin can hydrolyze bonds , and . Limited proteolysis by thermolysin at a site internal in the molecule has been exploited in order to prepare rhodopsin as two large fragments, F1 and F2. Cysteine(33)?, is highly reactive in the dark and is modified by N-ethylmaleimide and several alkylating agents. The carboxyl-terminal region 1?-39? reacts with the membrane-impermeable nitrene from N-(4-azido-2-nitrophenyl)-2-aminoethyl sulfonate and is therefore exposed at the external (cytoplasmic) surface of the disc membrane. 1-azldopyrene, a hydrophobic nitrene precursor, is being used to map those regions of the rhodopsin sequence which are located in a hydrophobic environment.

Preparation of carboxyl-terminal tryptic peptides from proteins by cleavage at arginine

A method has been developed for selectively preparing the carboxyl-terminal tryptic peptide of proteins by cleavage at arginyl residues. The succinylated protein is digested with trypsin and the peptides produced are maleylated. Maleylated peptides are then submitted to cation-exchange chromatography in urea at low pH and ionic strength. Arginine-containing peptides are retained by the resin. The carboxyl-terminal peptide emerges unretarded and in pure form. This method has been applied to four proteins of known sequence. Yields as high as 88% have been obtained.

Retinal degeneration in cone photoreceptor cell-ablated transgenic mice

PURPOSE

To examine the effect of loss of cone photoreceptor cells on retinal degeneration.

METHODS

We previously identified a cone photoreceptor cell-specific promoter of human cone transducin a-subunit (GNAT2) gene. In this report, a minigene, Trc-Tox176, that contains the GNAT2 promoter, an attenuated diphtheria toxin A-chain gene, and an enhancer element from human interphotoreceptor retinoid-binding protein (IRBP) was used to generate coneless transgenic mice. Transgenic mice were identified by PCR and the copy number of the transgene was determined by Southern hybridization, and examined by histology.

RESULTS

The results of immunostaining with anti-mouse GNAT2 antibodies and reverse transcription-PCR (RT-PCR) analysis with mRNA from the retinas of transgenic mice showed that cone photoreceptor cells were ablated in one of four transgenic mouse lines. The ablation of cone cells began at postnatal day 8, at the same time as the expression of endogenous GNAT2. An age-related rod degeneration was also found in this cone-ablated mouse line, beginning at postnatal day 9, proceeding from the central retina to the peripheral retina.

CONCLUSIONS

Cone photoreceptor cells may play an important role in the survival of rod photoreceptor cells during mouse retina development.

Repair of muscle and musculotendinous junction injuries with an autogenous fascial patch

We have used an autogenous fascia lata patch to repair muscle and musculotendinous junction injuries affecting 99 individual muscles in 23 patients with multiple incised wounds to the upper limbs. All patients were followed up for at least 2 years. Two patients with severe dystrophic changes following nerve injuries were excluded from the final analysis. Satisfactory grip strength was restored 6 months following the repair in 19 of the 21 patients we evaluated. Complete active and passive range of wrist and digital motion was seen in 18 of these 21 patients. Tightness of the flexor pollicis longus was seen in 2 patients, one of whom had a deformity of the interphalangeal joint of the thumb that was passively stretched and subsequently reduced. Scar adhesions were noted in 4 other patients, but this did not affect wrist or finger motion, except in one. The autogenous fascial patch repair technique provides strong and good apposition of muscle fibres simply by distributing the force and tension over a large area of the muscle, thereby allowing early mobilization and functional restoration of the extremity.

Elements regulating the transcription of human interstitial retinoid-binding protein (IRBP) gene in cultured retinoblastoma cells

PURPOSE

To identify cis-acting elements and trans-acting factors involved in the expression of human IRBP gene.

METHODS

Transient transfection of WERI-Rb1 and HeLa cells, DNase 1 footprinting, gel mobility-shift assay and yeast one-hybrid system were used to study the regulatory elements that are involved in the expression of human IRBP gene.

RESULTS

A region between -1620 and -1411 was shown to have enhancer properties. Using nuclear extracts from WERI-Rb1 and HeLa cells, four footprints were identified in the proximal promoter region (-206 to +68). The core promoter element IP1 binds to OTX2 in the yeast one-hybrid system. By cotransfecting HeLa cells, OTX2 could transactivate the irbp promoter. The functions of IP2 (from -119 to -86) and IP3 (from -183 to -147) remain to be determined. The region containing the HeLa cell-specific footprint IP4 (from -202 to -180) could silence the OTX2 transactivation of the irbp promoter.

CONCLUSION

The 5'-flanking region of irbp contains an enhancer sequence. The possible silencer upstream from the core promoter may serve to suppress expression of irbp in HeLa cells. When the proximal promoter is used to identify binding proteins in a human retina library by the yeast one hybrid system, nine of the identified clones contained the cDNA sequence for the homeodomain protein OTX2. Since no clones for the homeodomain protein CRX were found, and since OTX2 can transcriptionally activate irbp in normally non-expressing HeLa cells, it is possible that OTX2 rather than CRX is the transcriptional activator for irbp in human photoreceptors.

Repression of Stat3 activity by activation of mitogen-activated protein kinase (MAPK)

STAT proteins are activated by phosphorylation at specific tyrosine residue at the carboxy-terminus which is required for dimer-formation, nuclear translocation, DNA binding and transcriptional activity in cells treated with cytokines and growth factors. Recent studies have indicated that STATs are also phosphorylated by MAPK, or extracellular signal-regulated kinase (ERK) on serine. We investigated the role of ERK on the regulation of STAT activity. Here, we report that ERK2 activated by its upstream kinase, MEK1, represses Stat3 transcriptional activity induced by Src or Jak-2. To unravel the mechanism of repression, we further showed that Stat3 DNA binding activity and its tyrosine phosphorylation are also inhibited under the same conditions. ERK2 phosphorylates Stat3 on three serine-containing peptides and decreases its tyrosine phosphorylation induced by EGF treatment. We also detected an association of ERK2 and Stat3 in vivo which is modulated positively by activation of ERK2, but negatively by Jak2. We propose that MAP kinase cascade may negatively regulate Stat3 activities by decreasing its tyrosine phosphorylation and also possibly by association.

A CAT reporter construct containing 277bp GNAT2 promoter and 214bp IRBP enhancer is specifically expressed by cone photoreceptor cells in transgenic mice

PURPOSE

The alpha-subunit of human cone transducin plays an important role in interacting with visual pigment and activating the cGMP-dependent phosphodiesterase (cGMP-PDE). The human GNAT2 gene (cone transducin alpha-subunit) has been cloned and characterized by Fong et al. In this report, we describe the use of transgenic mice to characterize the tissue specificity of the GNAT2 promoter.

METHODS

A chimeric reporter gene construct which consists of a 277 bp 5'-flanking fragment of the GNAT2 gene at 5' end of the chloramphenicol acetyltransferase (CAT) gene and a 214 bp enhancer region from the human interphotoreceptor retinoid-binding protein (IRBP) gene at the 3' end of the CAT gene was used to generate transgenic mice. Transgenic mice were identified by Southern blot hybridization and polymerase chain reaction (PCR) analysis using tail DNA from experimental animals. Immunostaining was used to study the developmental expression of CAT and the endogenous GNAT2 gene.

RESULTS

Analysis of four transgenic mouse lines revealed that three lines had low CAT activity in the retina. The CAT gene, along with the endogenous GNAT2 gene, was expressed at high levels in cone photoreceptor cells in the fourth transgenic mouse line as determined by CAT enzyme assays and immunostaining.

CONCLUSION

The results show that the 277 bp 5'-flanking sequence from the human GNAT2 gene coupled with the 214 bp IRBP enhancer can direct a tissue-specific expression pattern of CAT reporter gene in mouse retina, which parallels the expression pattern of endogenous GNAT2.

Resurfacing of thumb-pulp loss with a heterodigital neurovascular island flap using a nerve disconnection/reconnection technique

The problems of late deterioration of sensation and a "double sensibility" phenomenon, either in the thumb or donor finger, are a known deficiency of the conventional heterodigital neurovascular island flap. This is probably related to unsatisfactory cortical reorientation following flap transfer. To obviate this problem, the authors have used a disconnection/reconnection technique for heterodigital island flaps in 17 patients, to resurface defects in the skin of the thumb. All patients were followed-up for 1 year, while 15 were followed-up for 2 years or more. There were no flap complications or failures, and the length of the thumb tip was preserved in all cases. The classic two-point discrimination was less than 6 mm in eight of these patients, and the remaining nine patients had two-point discrimination of between 6 and 8 mm. This technique was found to provide sensitive, supple, and well-vascularized skin with proper cortical representation, to replace the loss of the tactile pump of the thumb tip in one operative stage.

Localization of upstream silencer elements involved in the expression of cone transducin alpha-subunit (GNAT2)

PURPOSE

To localize cis-acting elements involved in the expression of the cone-specific G-protein, cone transducin alpha-subunit (GNAT2).

METHODS

In this study, the authors used a genomic clone, HGLG3, to sequence 3139 base pairs of the upstream region of the GNAT2 gene and to localize cis-acting elements involved in the expression of GNAT2. Upstream elements were localized functionally by transfection of chloramphenicol acetyltransferase gene constructs containing nested deletions of this upstream region into WERI-Rb1 cells. Cell specificity of the localized elements was determined by transfection of the HeLa cells. Trans-acting factor-binding sites to functional cis-acting elements were determined by DNasel footprinting. Cell specificity of protein interaction with footprinted regions was tested by electrophoretic mobility shifts with nuclear extracts from WERI-Rb1 and HeLa cells.

RESULTS

Transfection of WERI-Rb1 and HeLa cells revealed the presence of a strong, noncell-specific silencer region between -1130 and -23, a weak, cell-specific promoter between -151 and -10, and a stronger, noncell-specific element between +143 and +167. DNaseI footprinting showed three major footprints (S1, S2, and S3) between -807 and -176, indicating the binding sites for putative negative trans-acting factors. Individual footprinted sequences had similar electrophoretic mobility shifts when they were incubated with nuclear extracts from either WERI-Rb1 or HeLa cells, suggesting that these cells express the same negative factors.

CONCLUSIONS

The expression of the GNAT2 gene is controlled by a strong silencer region, a weak upstream cell-specific promoter, and a strong downstream element. The silencer region interacts with similar proteins from retina- and nonretina-derived cell lines.

Mapping of the human cone transducin alpha-subunit (GNAT2) gene to 1p13 and negative mutation analysis in patients with Stargardt disease

We report localization of the human cone transducin (GNAT2) gene using fluorescence in situ hybridization on chromosome 1 in band p13. The recent assignment of a gene for Stargardt disease to the same chromosomal region by linkage analysis prompted us to investigate the possible role of GNAT2 in the pathogenesis of this disease. We investigated 66 unrelated patients for mutations in the coding region of the GNAT2 gene using polymerase chain reaction-single strand conformation polymorphism analysis (SSCP) and direct sequencing. No disease-specific mutations were found, indicating that GNAT2 is probably not involved in the pathogenesis of most cases of Stargardt disease.

Characterization of the gene encoding human cone transducin alpha-subunit (GNAT2)

The human cone transducin alpha-subunit (GNAT2) gene has been completely characterized. The human GNAT2 transcription unit is 9967-bp in length and consists of eight exons with seven introns. The eight exons are identical to the reported cDNA sequence (Lerea et al., 1989). Northern blot analysis of RNA from human retinas and a retinoblastoma cell line, WERI-RB1, reveals a 1.7-kb transcript for GNAT2. Multiple transcription initiation sites were mapped for human retina and WERI-RB1 RNA by primer extension and S1 nuclease protection assays. This gene has seven initiation sites spanning 31 bp. The sequence upstream of the GNAT2 gene shows a TATA box consensus sequence at -29, a CCAAT box consensus sequence at -58 (reverse orientation), and a sequence (CCATAT) similar to the CCAAT box consensus at -76. The GNAT2 upstream sequence shows no significant identity with the upstream region of the human rod transducin alpha-subunit gene (GNAT1) or with the upstream regions of the color visual pigment genes, indicating that the expression of GNAT2 may be regulated differently than these other rod- and cone-specific proteins.

Characterization of the human rod transducin alpha-subunit gene

The human rod transducin alpha subunit (Tr alpha) gene has been cloned. A cDNA clone, HG14, contained a 1.1 kb insertion when compared with the human Tr alpha cDNA published by Van Dop et al. (1). Based on two overlapping clones isolated from a human genomic library, the human Tr alpha gene is 4.9 kb in length and consists of nine exons interrupted by eight introns. Northern blots of human retina total RNA showed that the gene is transcribed by rod photoreceptors into two species of mRNA, 1.3 kb and 2.4 kb in size. Apparently, this is the result of alternative splicing. Two putative transcription initiation sites were determined by primer extension and S1 nuclease protection assays. The putative promoter regions of the human and mouse Tr alpha genes have an identity of 78.1%. As found in the mouse gene (2), no TATA consensus sequence is present in the human gene.

Antigen-specific suppressor cells in experimental autoimmune uveitis

Anti-I-A antibodies, administered in vivo at the time of S-antigen injection, suppress development of experimental autoimmune uveitis (EAU) in Lewis rats. While the effects of anti-I-A are profound, the exact mechanism for this suppression is unknown. We attempted adoptive transfer of this form of suppression by injecting lymphocytes from anti-I-A-treated animals into syngeneic recipients which were later injected with S-antigen. Histologically, globes of 75% of the anti-I-A-treated animals showed no inflammation while 25% of these animals developed mild uveitis. In the group of animals which were injected with S-antigen and also received spleen cells from anti-I-A-treated rats, only 1 showed mild uveitis while the remaining 7 had no inflammation. The animals undergoing adoptive transfer of spleen cells and which were primed with an irrelevant antigen, readily developed uveitis. Suppression of S-antigen-induced EAU was abrogated by pretreatment of donor animals with cyclophosphamide. In vitro studies revealed that spleen cells of S-antigen-primed, anti-I-A-treated donors specifically suppressed lymphocyte responses to S-antigen. These in vivo and in vitro results suggest that generation of antigen-specific suppressor cells play a role in the anti-I-A immunotherapy of EAU.

Compliance among adults with cystic fibrosis

Advances in therapy have largely contributed to the increased life expectancy of patients with cystic fibrosis. Unlike children, adults with cystic fibrosis must take responsibility for their own care. We administered a questionnaire to 23 adult patients (aged 18-39 years) with cystic fibrosis to (1) determine patients' degree of compliance with medications and chest physiotherapy; (2) collect information on their self-assessment of health motivation, disease severity, and benefits of treatment; and (3) identify barriers to receiving medical care. Patients reported better compliance with medications than with chest physiotherapy. Nine percent of the patients missed at least 25 percent of prescribed medication, whereas 47 percent missed at least 25 percent of prescribed physiotherapy. We observed a trend toward better compliance in patients who were highly worried about their health, who believed their illness to be serious, and who felt that their medications were very effective. Less than half of the study participants believed physiotherapy to be effective, and that adhering to a physiotherapy schedule was very difficult. Among adults with cystic fibrosis, compliance can be a serious problem that minimizes the benefits of good medical care. We suggest that emphasizing the severity of disease and usefulness of therapy may improve compliance and requires study.

IRBP: preparation and characterization of site-specific monoclonal antibodies

Interstitial retinoid binding protein (IRBP) is a 136,000 molecular weight photoreceptor cell protein which is a highly pathogenic autoantigen for the induction of experimental autoimmune uveitis (EAU). In this study we produced a series of monoclonal antibodies (MAbs) which define different epitopes in the native molecule. These MAbs were further subdivided into three distinct groups based on a radioimmunoassay, and by ELISA assay using native IRBP and synthetic peptides corresponding to its entire amino acid sequence. Group I MAbs (MAbD7-B1 and MAbC6-B4) bound to native IRBP but not to any synthetic peptides, suggesting that their antigenic epitopes are strictly conformation dependent. Group II MAbs (MAbC7-D3 and MAbG8-H4) bound weakly to multiple peptides which shared amino acid sequence similarity located within each of four homology domains indicating that these epitopes are also conformation dependent. In group III (MAbH3-B5, MAbH7-A5, and MAbB6-D12) MAb binding was localized to a specific peptide. The MAbH3-B5 binding site was further refined to amino acid positions 361 to 367 in the native molecule. MAbH3-B5 was also useful in localizing IRBP in the mouse retina by immunohistochemical techniques. The application of these MAbs in the study of EAU and interphotoreceptor transport mechanisms is discussed.

Characterization and comparative structural features of the gene for human interstitial retinol-binding protein

We have cloned the gene for human interstitial retinol-binding protein (IRBP) and compared its nucleotide sequence with that of the corresponding cloned cDNA. The human IRBP gene is approximately 9.5 kilobase pairs (kbp) in length and consists of four exons separated by three introns. The introns are 1.6-1.9 kbp long. The gene is transcribed by photoreceptor and retinoblastoma cells into an approximately 4.3-kilobase mRNA that is translated and processed into a glycosylated protein of 135,000 Da. The amino acid sequence of human IRBP can be divided into four contiguous homology domains with 33-38% identity, suggesting a series of gene duplication events. In the gene, the boundaries of these domains are not defined by exon-intron junctions, as might have been expected. The first three homology domains and part of the fourth are all encoded by the first large exon, which is 3,180 base pairs long. The remainder of the fourth domain is encoded in the last three exons, which are 191, 143, and approximately 740 base pairs long, respectively. This unusual structure is shared with the bovine IRBP gene. A large (1.7 kbp) fragment appears to have been lost from the 3'-noncoding region of the last human exon. We conclude that the human and bovine genes have similar evolutionary histories.

Human interstitial retinoid binding protein. A potent uveitopathogenic agent for the induction of experimental autoimmune uveitis

Human interstitial retinoid binding protein (HIRBP) is a 136,000 m.w. photoreceptor cell protein which transports retinoids between the retina and the retinal pigment epithelium of the eye. The amino acid sequence of HIRBP suggests that the molecule consists of four continuous homology domains which arose by several gene duplications some 600 to 800 million years ago. When injected into susceptible animal species, including primates, it induces an experimental autoimmune uveitis (EAU), a predominantly T cell-mediated autoimmune disease of the retina and uveal tract of the eye, and the pineal gland. In order to further refine specific sites in HIRBP responsible for its uveitopathogenicity, we synthesized 120 overlapping peptide corresponding to its entire 1262 amino acid sequence, and tested each peptide for its ability to induce an EAU in Lewis rats. Five peptides with extensive amino acid sequence homology, designated HIRBP 715, HIRBP greater than 730 and HIRBP 745, HIRBP 778, and HIRBP 808 were uveitopathogenic when used at a 50 micrograms immunizing dose. The most potent peptide for the induction of EAU was HIRBP 715 (amino acid positions 521 to 540). In dose response studies as little as 0.1 microgram/animal was capable of inducing an inflammatory response. In addition, peptide HIRBP 946 which corresponds to the mid portion of peptide HIRBP 715 and contains only eight amino acids (RTATAAEE) was uveitopathogenic under our experimental conditions. Our study identifies multiple uveitopathogenic sites in HIRBP and further defines the amino acids necessary for the induction of EAU in one of these sites.

Human interstitial retinoid binding protein. A potent uveitopathogenic agent for the induction of experimental autoimmune uveitis

Human interstitial retinoid binding protein (HIRBP) is a 136,000 m.w. photoreceptor cell protein which transports retinoids between the retina and the retinal pigment epithelium of the eye. The amino acid sequence of HIRBP suggests that the molecule consists of four continuous homology domains which arose by several gene duplications some 600 to 800 million years ago. When injected into susceptible animal species, including primates, it induces an experimental autoimmune uveitis (EAU), a predominantly T cell-mediated autoimmune disease of the retina and uveal tract of the eye, and the pineal gland. In order to further refine specific sites in HIRBP responsible for its uveitopathogenicity, we synthesized 120 overlapping peptide corresponding to its entire 1262 amino acid sequence, and tested each peptide for its ability to induce an EAU in Lewis rats. Five peptides with extensive amino acid sequence homology, designated HIRBP 715, HIRBP greater than 730 and HIRBP 745, HIRBP 778, and HIRBP 808 were uveitopathogenic when used at a 50 micrograms immunizing dose. The most potent peptide for the induction of EAU was HIRBP 715 (amino acid positions 521 to 540). In dose response studies as little as 0.1 microgram/animal was capable of inducing an inflammatory response. In addition, peptide HIRBP 946 which corresponds to the mid portion of peptide HIRBP 715 and contains only eight amino acids (RTATAAEE) was uveitopathogenic under our experimental conditions. Our study identifies multiple uveitopathogenic sites in HIRBP and further defines the amino acids necessary for the induction of EAU in one of these sites.

Retinoids bound to interstitial retinol-binding protein during light and dark-adaptation

High-performance liquid chromatography was used to determine the types and amounts of retinoids bound to interstitial retinol-binding protein (IRBP) during light- and dark-adaptation in frogs. IRBP was separated from CRBP and CRA1BP by ion-exchange chromatography and quantitated by determining the amount of Serva Blue R dye bound to it in stained sodium dodecyl sulfate polyacrylamide gels. The amount of IRBP was not significantly different in light- and dark-adapted eyes (0.15 +/- 0.05 nmol/eye compared with 0.18 +/- 0.08 nmol/eye). In the dark-adapted state, IRBP bound mainly 11-cis retinol and 11-cis retinal in quantities that summed to about 1 mol/mol IRBP. After the onset of light-adaptation, all-trans retinol increased from its very low dark-adapted level, peaked at 0.2 mol/mol IRBP and then declined to the dark-adapted level again. Concomitantly, the total retinoid bound to IRBP fell, mainly because there was a drop in the amount of 11-cis retinal. During dark-adaptation, the amount of 11-cis retinal increased. No significant changes were seen in the amount of 11-cis retinol in light and darkness. These findings support the hypothesis that when rhodopsin is bleached IRBP transports all-trans retinol from the retina to the pigment epithelium and that it delivers 11-cis retinal to the rod outer segments for rhodopsin regeneration.