Breathing control training for functional seizures: A multi-site, open-label pilot study

There are no well-validated treatments for functional seizures. While specialist psychotherapy is usually recommended, the evidence for its benefit is qualified, and it can be difficult to obtain. Given the association between hyperventilation and functional seizures we explored an alternative modality, breathing control training, in a multi-site open label pilot trial. Participants with functional seizures over the age of 16 received an hour of breathing training from a respiratory physiotherapist, with a half-hour booster session a month later. Seizure frequency and Nijmegen scores (a measure of hyperventilation) were reported at baseline and follow-up, 3-4 months later. Eighteen subjects were recruited, and 10 completed follow-up. Seven of these 10 had improved seizure frequency, and 3 did not (Wilcoxon signed rank test, p = 0.09), with seizure frequency correlating with Nijmegen score (Spearman's rank correlation = 0.75, p = 0.034). The intervention was well tolerated, with no adverse events reported. These preliminary results support a potentially new approach to treating functional seizures that should prove cost-effective and acceptable, though require confirmation by a randomised controlled trial.

Aneurysmal bone cysts: A UK wide tumor center experience

BACKGROUND AND OBJECTIVES

This multicenter retrospective series of consecutive extra-spinal aneurysmal bone cysts aims to identify risk factors for treatment failure.

METHODS

Aneurysmal bone cysts treated within seven collaborating centers with over 12-months follow-up were eligible for inclusion. Survival analyses were performed to identify variables associated with recurrence using log-rank tests and Cox proportional hazard regression.

RESULTS

One hundred and fifteen (M:F 60:55) patients were included. Median age at presentation was 13 years and median follow-up was 27 months. Seventy-five patients underwent surgical curettage and 27% of these required further intervention for recurrence. Of the 30 patients who underwent biopsy with limited percutaneous curettage as initial procedure, 47% required no further treatment. Patients under 13 years (log-rank p = 0.006, HR 2.3, p = 0.011) and those treated who had limited curettage (log-rank p = 0.001, HR 2.7, p = 0.002) had a higher risk of recurrence/persistence.

CONCLUSIONS

There is a high risk of recurrence following surgical treatment for aneurysmal bone cysts and this risk is higher in young patients. However, the cyst heals in a substantial number of patients who have a limited curettage at the time of biopsy.

Adverse life events in patients with functional seizures: Assessment in clinical practice and association with long-term outcome

BACKGROUND

A history of adverse life events (ALE) is a risk factor for functional seizures (FS). Their influence on long-term outcome remains unclear. International guidelines recommend assessing ALE in patients presenting with associated disorders. It is not clear to what extent patients evaluated for FS are regularly asked about ALE.

OBJECTIVES

We hypothesised that the presence of ALE would relate to worse outcome at follow-up and, that the rate of detection of ALE in clinical work-up would be inferior to that based on self-report questionnaires.

METHODS

53 patients with FS from the National Centre for Epilepsy in Norway, aged 16-62 years were included. Symptom severity, health-related quality of life (HRQoL), and antecedent ALE were assessed at baseline. Medical records were examined for disclosure of ALE. At a mean of 70.45 (SD 29.0, range 22-130) months after inclusion, participants were inquired about FS status, FS-related health care utilization and HRQoL.

FINDINGS

A history of emotional abuse documented in the medical record was an independent risk factor for worse HRQoL at follow-up. Prevalence of ALE documented in medical records was lower compared with rates measured by a self-report questionnaire.

CONCLUSIONS

These findings indicate an association between antecedent ALE and HRQoL years after diagnosis. A substantial proportion of the adverse life events by a self-report questionnaire had not been documented in the clinical records.

CLINICAL IMPLICATIONS

The supplemental use of a self-report questionnaire in the diagnostic work-up of patients with FS may be valuable for detecting ALE.

Glycogen storage disease type IV without detectable polyglucosan bodies: importance of broad gene panels

Glycogen storage disease type IV (GSD IV) is caused by mutations in the glycogen branching enzyme 1 (GBE1) gene and is characterized by accumulation of polyglucosan bodies in liver, muscle and other tissues. We report three cases with neuromuscular forms of GSD IV, none of whom had polyglucosan bodies on muscle biopsy. The first case had no neonatal problems and presented with delayed walking. The other cases presented at birth: one with arthrogryposis, hypotonia, and respiratory distress, the other with talipes and feeding problems. All developed a similar pattern of axial weakness, proximal upper limb weakness and scapular winging, and much milder proximal lower limb weakness. Our cases expand the phenotypic spectrum of neuromuscular GSD IV, highlight that congenital myopathy and limb girdle weakness can be caused by mutations in GBE1, and emphasize that GSD IV should be considered even in the absence of characteristic polyglucosan bodies on muscle biopsy.

From left to right: an unusual presentation of Tolosa-Hunt syndrome with bilateral eye involvement

Here we discuss a presentation of Tolosa-Hunt syndrome (THS) in a 44-year-old female with new right-eye ptosis, ophthalmoplegia and headache. Four days prior, she had almost identical ptosis and ophthalmoplegia in her left eye, which resolved. Cavernous sinus inflammation and symptom improvement with glucocorticoid treatment indicated THS with bilateral eye involvement, a presentation which may be undervalued by the current THS classification.

1098 Prophylactic Doxycycline Prior To The Excision of Ulcerated Skin Lesions. An Audit of Dose Timings and Adverse Effects

Aim

Antibiotic prophylaxis to reduce the incidence of surgical site infections following excision of ulcerated skin lesions is frequently recommended, although the evidence base is limited. Current Swansea Bay guidelines recommend pre-operative administration of antibiotics: for procedures performed under local anaesthetic in the Plastic Surgery Treatment Centre (PSTC), oral route is preferable. It was noted that a number of patients were experiencing nausea and vomiting following administration of the recommended oral agent (doxycycline). The aim of this audit was to quantify the proportion of patients experiencing adverse effects, and to assess whether the prophylactic dose was being administered within the recommended time frame.

Method

Data was collected over a three-week period (28/10/20- 18/11/20). All patients that received doxycycline pre-operatively during this period were included: the time the doxycycline was given, the time of operation and whether there were any adverse effects was recorded for each patient.

Results

14 patients received doxycycline during the monitored period. On average the doxycycline was given 52 minutes prior to the procedure. 2 patients received their doxycycline dose after their procedures. 4 patients experienced side effects from the doxycycline (3 vomited, 1 nausea), the average time this subset of patients received their dose was 50 minutes prior to their procedure.

Conclusions

A significant proportion of patients experience adverse after receiving doxycycline, whilst there is limited evidence to prove its benefits. Trust guidelines are under review to consider alternative antibiotics, but better evidence is required to clarify the need for antibiotic prophylaxis for ulcerated lesions.

Incidence and prevalence of psychogenic nonepileptic seizures in a Norwegian county: A 10-year population-based study

OBJECTIVE

This study was undertaken to measure the incidence and prevalence of active psychogenic nonepileptic seizures (PNES) in a Norwegian county.

METHODS

Using the Norwegian patient registry, we identified patients in Møre and Romsdal County in Norway diagnosed with F44.5 (conversion disorder with seizures or convulsions) or R56.8 (convulsions, not elsewhere classified) in the period January 2010 to January 2020. A review of the patients' medical records and an assessment of diagnostic validity were performed. PNES were diagnosed according to the recommendations by the International League Against Epilepsy Nonepileptic Seizures Task Force. Point prevalence of PNES on January 1, 2020 and incidence rates for the period 2010-2019 were determined.

RESULTS

Based on PNES within the past 5 years, we found a PNES prevalence of 23.8/100 000 (95% confidence interval [CI] = 17.9-29.6), including all levels of diagnostic certainty. For the highest level of diagnostic certainty (video-electroencephalographically confirmed), the prevalence was 10.6/100 000 (95% CI = 6.7-14.5). The highest prevalence was found in the age group 15-19 years, at 59.5/100 000 (95% CI = 22.6-96.3). The mean annual incidence rate between 2010 and 2019 was 3.1/100 000/year (95% CI = 2.4-3.7).

SIGNIFICANCE

We report for the first time a population-based estimate of the prevalence of PNES. Our findings suggest that the prevalence of PNES is within the range of estimates from non-population-based data. We found a strikingly high prevalence of PNES in the 15-19-year age group.

Routine Use of Tenecteplase for Thrombolysis in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

In ischemic stroke, intravenous tenecteplase is noninferior to alteplase in selected patients and has some practical advantages. Several stroke centers in New Zealand changed to routine off-label intravenous tenecteplase due to improved early recanalization in large vessel occlusion, inconsistent access to thrombectomy within stroke networks, and for consistency in treatment protocols between patients with and without large vessel occlusion. We report the feasibility and safety outcomes in tenecteplase-treated patients.

METHODS

We performed a retrospective analysis of consecutive patients thrombolyzed with intravenous tenecteplase at 1 comprehensive and 2 regional stroke centers from July 14, 2018, to February 29, 2020. We report the baseline clinical characteristics, rates of symptomatic intracranial hemorrhage, and angioedema. These were then compared with patient outcomes with those treated with intravenous alteplase at 2 other comprehensive stroke centers. Multivariable mixed-effects logistic regression models were performed assessing the association of tenecteplase with symptomatic intracranial hemorrhage and independent outcome (modified Rankin Scale score, 0-2) at day 90.

RESULTS

There were 165 patients treated with tenecteplase and 254 with alteplase. Age (75 versus 74 years), sex (56% versus 60% male), National Institutes of Health Stroke Scale scores (8 versus 10), median door-to-needle times (47 versus 48 minutes), or onset-to-needle time (129 versus 130 minutes) were similar between the groups. Symptomatic intracranial hemorrhage occurred in 3 (1.8% [95% CI, 0.4-5.3]) tenecteplase patients compared with 7 (2.7% [95% CI, 1.1-5.7]) alteplase patients (P=0.75). There were no differences between tenecteplase and alteplase in the rates of angioedema (4 [2.4%; 95% CI, 0.7-6.2] versus 1 [0.4%; 95% CI, 0.01-2.2], P=0.08) or 90-day functional independence (100 [61%] versus 140 [57%], P=0.47), respectively. In mixed-effects logistic regression models, there was no significant association between thrombolytic choice and symptomatic intracranial hemorrhage (odds ratio tenecteplase, 0.62 [95% CI, 0.14-2.80], P=0.53) or functional independence (odds ratio tenecteplase, 1.20 [95% CI, 0.74-1.95], P=0.46).

CONCLUSIONS

Routine use of tenecteplase for stroke thrombolysis was feasible and had comparable safety profile and outcome to alteplase.

Functional neurological disorders presenting as emergencies to secondary care

BACKGROUND

Functional neurological disorders (FND) represent a significant proportion of presentations to outpatient adult neurology services. There is little information relating to patients presenting to acute inpatient care.

METHODS

We identified patients presenting as acute admissions with FND to Christchurch Hospital, Christchurch, New Zealand, from 2016 to 2018. We analyzed relevant demographic and clinical data from electronic records and measured incidence of presentation to secondary care and healthcare utilization.

RESULTS

One hundred sixty-two patients presented on 173 occasions with FND, representing 9% of all admissions to the neurology service during the 3-year study period. The mean age was 40 (SD 17) years, 111 (69%) patients were female and the median length of stay was 3 (IQR 2-4) days. A total of 92 computed tomography brain scans, 77 magnetic resonance imaging brain scans and 42 electroencephalograms were carried out. On 22 (13%) occasions, patients were referred for outpatient psychological therapy. In the 3 years prior to each patient's last presentation in the study period, these 162 patients had a total of 671 presentations to the emergency department. Healthcare demand did not decrease after the index admission. The rate of acute inpatient admission for FND was 10 per 100,000 per year for the total Christchurch Hospital catchment, 6/100,000/year in rural areas, and 11/100,000/year in urban areas.

CONCLUSION

FND represented almost 1 in 10 acute neurology admissions with significant inpatient healthcare resource utilization.

Two Consecutive Invasive Surgeries Utilizing Zymogen Protein C (ZPC) That Enhanced Patient Safety and Reduced Costs

This case report describes a major surgical procedure for a protein C-deficient, hypercoagulable patient who underwent two back-to-back invasive surgeries, hip replacement, and spinal stenosis correction. The patient, an 84-year-old male with a history of deep vein thromboses (DVT) and pulmonary emboli (PE), was treated pre-, peri-, and postoperatively with zymogen protein C (ZPC-Baxter, International) and recovered without clotting or increased bleeding. During the procedure, the patient was not administered any other anticoagulants. There have now been several case reports on different patients with unrelated teams in various locations worldwide using zymogen protein C during surgical procedures. Thus, this procedure is becoming a viable choice for patients with a high probability of clotting during and after invasive surgery. This case focuses on accomplishing safer surgery and reducing costs, by using less ZPC while accomplishing two surgeries in one procedure. As a result, this procedure might be useful for many medical situations where acquired protein C deficiency could be a problem (e.g., sepsis, pregnancy, etc.). This approach may have greater application to medical conditions other than protein C deficiency, where clotting and inflammation can become issues.

Letter to the Editor: Healthy for Life: An Innovative and Collaborative Approach to COVID 19 Lockdown in New Zealand

Recently Boreskie and colleagues published an editorial in the Journal of Frailty and Aging on Preventing Frailty Progression During the COVID-19 Pandemic (1). In it they proposed the SAVE programme (Socialization, Adequate nutrition, Vitamin D, Exercise) to prevent frailty. They concluded that creative thinking and concerted efforts would be needed to disseminate health recommendations to maintain the health of pre-frail and frail older adults in unprecedented times, such as those posed by the COVID-19 pandemic.

Endovascular thrombectomy: 31 hours from symptom onset

Endovascular thrombectomy is an effective intervention for symptomatic intracranial large-vessel occlusion. This treatment has proven benefit up to 24 hours following onset in selected patients with prestroke functional independence. Limited case reports suggest that thrombectomy beyond 24 hours may also be effective. We describe a young woman managed with endovascular thrombectomy beyond 24 hours.

Psychogenic nonepileptic seizures that remit when the diagnosis is given: Just good luck?

OBJECTIVE

Some patients with psychogenic nonepileptic seizures (PNES) remit when given the diagnosis. It is not realistically possible to test this potential therapeutic effect in an Randomized Controlled Trial (RCT) so we aim to statistically demonstrate it using the temporal relationship between the communication of the diagnosis and the timing of remission.

METHOD

Re-analysis of data from a study of PNES, where diagnosis was communicated, and outcomes recorded in 54 patients. Making conservative assumptions and using the binomial distribution, the Poisson distribution and the chi-squared test distribution, we calculated likelihoods of the null hypothesis: that communication of the diagnosis and remission of seizures had occurred in random temporal relationship.

RESULTS

Remission occurred in the week following communication of the diagnosis in 15 out of 54 patients. The χ² test assigned this result a p value of <0.00001. Binomial and Poisson distribution calculations also indicated that remission was highly unlikely to have occurred by chance and that, in a dataset similar to ours, was unlikely to be due to chance if occurring in more than 9 patients (16.7%).

CONCLUSIONS

We showed that the observed remissions were highly unlikely to be due to chance. Where an intervention is 'short and sharp' and the outcome can be measured with reasonable temporal acuity, then this type of method may provide an alternative to RCT methodology when the latter is impracticable.

The use of laser-based diagnostics for the rapid identification of infectious agents in human blood

AIMS

To investigate the use of a laser-based method of detection as a potential diagnostic test for the rapid identification of infectious agents in human blood.

METHODS AND RESULTS

In this study, the successful differentiation of blood spiked with viruses, bacteria or protozoan parasites to clinically relevant levels is demonstrated using six blood types (O+, O-, AB+, A+, A-, B+) using blood from different individuals with blood samples prepared in two different laboratories. Experiments were performed using various compositions of filters, experimental set-ups and experimental parameters for spectral capture.

CONCLUSIONS

The potential for developing a laser-based diagnostic instrument to detect the presence of parasites, bacteria and viruses in human blood capable of providing analysis results within minutes was demonstrated.

SIGNIFICANCE AND IMPACT OF THE STUDY

There is an ongoing need for clinical diagnostics to adapt to newly emerging agents and to screen simultaneously for multiple infectious agents. A laser-based approach can achieve sensitive, multiplex detection with minimal sample preparation and provide rapid results (within minutes). These properties along with the flexibility to add new agent detection by simply adjusting the detection programming make it a promising tool for clinical diagnosis.

Hiding in Plain Sight: Functional Neurological Disorders in the News

OBJECTIVE

Functional movement and seizure disorders are still widely misunderstood and receive little public and academic attention. This is in stark contrast to their high prevalence and levels of associated disability. In an exploratory observational study, the authors examined whether the relative lack of media coverage of functional neurological disorders is in part due to misidentification in "human interest" news stories.

METHODS

Thirteen recent news stories from high-impact English-language media outlets that portrayed patients with complex symptoms either attributed to other diagnoses or presented as medical mysteries were identified using online keyword searches. All selected news stories contained video or still images displaying relevant symptoms. Cases were categorized into movement disorders or seizure disorders and were then independently assessed by 10 respective expert raters. For each category, one story of a patient whose symptoms were due to a well-recognized neurological disease was also included. Both the diagnostic category and the respective confidence level were reported by each rater for each case. The interrater agreement was calculated for each group of disorders.

RESULTS

The raters confirmed almost unanimously that all presented news stories except the negative control cases portrayed misidentified functional movement or seizure disorders. The interrater agreement and average diagnostic confidence were high.

CONCLUSIONS

Functional neurological disorders are often wrongly considered a rare medical curiosity of the past. However, these findings suggest that, while they are largely absent from public discourse, they often appear in the news incognito, hiding in plain sight.

Generating the perception of choice: the remarkable malleability of option-listing

The normative view that patients should be offered more choice both within and beyond the UK's National Health Service (NHS) has been increasingly endorsed. However, there is very little research on whether - and how - this is enacted in practice. Based on 223 recordings of neurology outpatient consultations and participants' subsequent self-reports, this article shows that 'option-listing' is a key practice for generating the perception of choice. The evidence is two-fold: first, we show that neurologists and patients overwhelmingly reported that choice was offered in those consultations where option-listing was used; second, we demonstrate how option-listing can be seen, in the interaction itself, to create a moment of choice for the patient. Surprisingly, however, we found that even when the patient resisted making the choice or the neurologist adapted the practice of option-listing in ways that sought acceptance of the neurologist's own recommendation, participants still agreed that a choice had been offered. There was only one exception: despite the use of option-listing, the patient reported having no choice, whereas the neurologist reported having offered a choice. We explore this deviant case in order to shed light on the limits of option-listing as a mechanism for generating the perception of choice.

Helsinki Stroke Model Is Transferrable With "Real-World" Resources and Reduced Stroke Thrombolysis Delay to 34 min in Christchurch

Background

Christchurch hospital is a tertiary hospital in New Zealand supported by five general neurologists with after-hours services provided mainly by onsite non-neurology medical residents. We assessed the transferrability and impact of the Helsinki Stroke model on stroke thrombolysis door-to-needle time (DNT) in Christchurch hospital.

Methods

Key components of the Helsinki Stroke model were implemented first in 2015 with introduction of patient pre-notification and thrombolysis by the computed tomography (CT) suite, followed by implementation of direct transfer to CT on ambulance stretcher in May 2017. Data from the prospective thrombolysis registry which began in 2012 were analyzed for the impact of these interventions on median DNT.

Results

Between May and December 2017, 46 patients were treated with alteplase, 25 (54%) patients were treated in-hours (08:00–17:00 non-public holiday weekdays) and 21 (46%) patients were treated after-hours. The in-hours, after-hours, and overall median (interquartile range) DNTs were 34 (28–43), 47 (38–60), and 40 (30–51) minutes. The corresponding times in 2012–2014 prior to interventions were 87 (68–106), 86 (72–116), and 87 (71–112) minutes, representing median DNT reduction of 53, 39, and 47 minutes, respectively (p-values <0.01). The interventions also resulted in significant reductions in the overall median door-to-CT time (from 49 to 19 min), CT-to-needle time (32 to 20 min) and onset-to-needle time (168 to 120 min).

Conclusion

The Helsinki stroke model is transferrable with real-world resources and reduced stroke DNT in Christchurch by over 50%.

Evaluating quality of life in epilepsy: The role of screening for adverse drug effects, depression, and anxiety

OBJECTIVE

The objective of this study was to evaluate the contribution of validated screening tools for antiepileptic drug (AED) adverse effects, depression, and anxiety to measure the quality of life (QoL) in people with epilepsy (PWE).

METHODS

Patients in a tertiary epilepsy service were screened for quality of life (using QOLIE-31), major depressive disorder (MDD) (NDDI-E), generalized anxiety disorder (GAD) (GAD-7), and AED effects (AEP). Mini International Neuropsychiatric Interview (MINI) generalized anxiety disorder module was also performed. For AEP validation in French, the internal structural validity was analyzed. Dimensional (NDDI-E and GAD-7 scores) and categorical (MDD and GAD) analyses were performed to investigate interactions between QoL and AEP.

RESULTS

A total of 132 (87 females) subjects were included. The French version of the AEP demonstrated satisfactory psychometric properties (Cronbach's α 0.87). Correlations between NDDI-E, GAD-7, AEP, and QOLIE-31 scores were high, and significant for all subscales of QOLIE-31; no effect of seizure-related variables was seen. Some sex differences in QOLIE-31 subscales were found, and mean AEP score was higher in females. Age, sex, NDDI-E, GAD-7, and AEP scores accounted for 61% of variance of QOLIE-31 scores. Differential effects were seen on QOLIE-31 subscales: AEP strongly correlated with all subscales; GAD-7 scores more strongly correlated with "Seizure Worry"; NDDI-E with "Energy-Fatigue"; and both NDDI-E and GAD-7 scores strongly correlated with "Emotional Well-Being". Categorical analysis of groups with MDD alone, GAD alone, MDD+GAD, and neither MDD nor GAD showed significant differences in AEP and QOLIE-31 scores, with MDD+GAD showing the most AED effects and the poorest QoL.

SIGNIFICANCE

The combination of screening tools for depression (NDDI-E), anxiety (GAD-7), and AED effects (AEP) has a strong power for evaluating QoL in PWE. Coexisting MMD and GAD were associated with the poorest quality of life and the highest AEP scores.

PNES around the world: Where we are now and how we can close the diagnosis and treatment gaps-an ILAE PNES Task Force report

An international consensus clinical practice statement issued in 2011 ranked psychogenic nonepileptic seizures (PNES) among the top three neuropsychiatric problems. An ILAE PNES Task Force was founded and initially charged with summarizing the current state of the art in terms of diagnosis and treatment, resulting in two publications. The first described different levels of diagnostic certainty. The second summarized current knowledge of management approaches. The present paper summarizes an international workshop of the ILAE PNES Task Force that focused on the current understanding and management of PNES around the world. We initially provide a knowledge update about the etiology, epidemiology, and prognosis of PNES-in adults and in special patient groups, such as children, older adults, and those with intellectual disability. We then explore clinical management pathways and obstacles to optimal care for this disorder around the world by focusing on a number of countries with different cultural backgrounds and at very different stages of social and economic development (United Kingdom, U.S.A., Zambia, Georgia, China, and Japan). Although evidence-based methods for the diagnosis and treatment of PNES have now been described, and much is known about the biopsychosocial underpinnings of this disorder, this paper describes gaps in care (not only in less developed countries) that result in patients with PNES not having adequate access to healthcare provisions. A range of challenges requiring solutions tailored to different healthcare systems emerges. Continued attention to PNES by the ILAE and other national and international neurologic, psychiatric, and health organizations, along with ongoing international collaboration, should ensure that patients with PNES do not lose out as healthcare services evolve around the world.

Genetic regulation of gene expression in the epileptic human hippocampus

Epilepsy is a serious and common neurological disorder. Expression quantitative loci (eQTL) analysis is a vital aid for the identification and interpretation of disease-risk loci. Many eQTLs operate in a tissue- and condition-specific manner. We have performed the first genome-wide cis-eQTL analysis of human hippocampal tissue to include not only normal (n = 22) but also epileptic (n = 22) samples. We demonstrate that disease-associated variants from an epilepsy GWAS meta-analysis and a febrile seizures (FS) GWAS are significantly more enriched with epilepsy-eQTLs than with normal hippocampal eQTLs from two larger independent published studies. In contrast, GWAS meta-analyses of two other brain diseases associated with hippocampal pathology (Alzheimer's disease and schizophrenia) are more enriched with normal hippocampal eQTLs than with epilepsy-eQTLs. These observations suggest that an eQTL analysis that includes disease-affected brain tissue is advantageous for detecting additional risk SNPs for the afflicting and closely related disorders, but not for distinct diseases affecting the same brain regions. We also show that epilepsy eQTLs are enriched within epilepsy-causing genes: an epilepsy cis-gene is significantly more likely to be a causal gene for a Mendelian epilepsy syndrome than to be a causal gene for another Mendelian disorder. Epilepsy cis-genes, compared to normal hippocampal cis-genes, are more enriched within epilepsy-causing genes. Hence, we utilize the epilepsy eQTL data for the functional interpretation of epilepsy disease-risk variants and, thereby, highlight novel potential causal genes for sporadic epilepsy. In conclusion, an epilepsy-eQTL analysis is superior to normal hippocampal tissue eQTL analyses for identifying the variants and genes underlying epilepsy.

Are psychogenic non-epileptic seizures just another symptom of conversion disorder?

BACKGROUND

Psychogenic non-epileptic seizures (PNES) are classified with other functional neurological symptoms as 'Conversion Disorder', but there are reasons to wonder whether this symptomatology constitutes a distinct entity.

METHODS

We reviewed the literature comparing PNES with other functional neurological symptoms.

RESULTS

We find eight studies that directly examined this question. Though all but one found significant differences-notably in presenting age, trauma history, and dissociation-they were divided on whether these differences represented an important distinction.

CONCLUSION

We argue that the aetiological and mechanistic distinctions they support, particularly when bolstered by additional data, give reason to sustain a separation between these conditions.

Systematic review and qualitative evidence synthesis of patient-reported outcome measures for abdominal aortic aneurysm

BACKGROUND

The aim was to identify and evaluate existing patient-reported outcome measures (PROMs) for use in patients with an abdominal aortic aneurysm (AAA) to inform the selection for use in surgical practice.

METHODS

Two reviews were conducted: a systematic review to identify valid, reliable and acceptable PROMs for patients with an AAA, and a qualitative evidence synthesis to assess the relevance to patients of the identified PROM items. PROM studies were evaluated for their psychometric properties using established assessment criteria, and for their methodological quality using the COSMIN checklist. Qualitative studies were synthesized using framework analysis, and concepts identified were then triangulated using a protocol with the item concepts of the identified PROMs.

RESULTS

Four PROMs from three studies were identified in the first review: Short Form 36, Australian Vascular Quality of Life Index, Aneurysm Dependent Quality of Life (AneurysmDQoL) and Aneurysm Symptoms Rating Questionnaire (AneurysmSRQ). None of the identified PROMs had undergone a rigorous psychometric evaluation within the AAA population. Four studies were included in the qualitative synthesis, from which 28 concepts important to patients with an AAA were identified. The AneurysmDQoL and AneurysmSRQ together provided the most comprehensive assessment of these concepts. Fear of rupture, control, ability to forget about the condition and size of aneurysm were all concepts identified in the qualitative studies but not covered by items in the identified PROMs.

CONCLUSION

Further research is needed to develop PROMs for AAA that are reliable, valid and acceptable to patients.

Potential of Sugar Residues Attached to N-(2- Hydroxypropyl)methacryl amide Copolymers as Targeting Groups for the Selective Delivery of Drugs

Soluble copolymers of N-(2-hydroxypropyl)methacrylamide (HPMA) have already shown potential as targetable drug-carriers. Here HPMA copolymers were synthesized which contained N-linked aminosugars attached to the poly mer backbone via a diglycyl side-chain. Following radioiodination their body distribution in rats was investigated. Incorporation of mannosamine or glu cosamine caused enhanced deposition in liver macrophages following intra venous and intraperitoneal administration, and increased retention at the site of injection when the carrier was administered subcutaneously. Macrophage pinocytic uptake of certain HPMA copolymers was also assessed using rat peri toneal macrophages cultured in vitro. It was demonstrated that polymers bear ing mannosamine or glucosamine are internalized rapidly by a common recep tor and that the interaction can be inhibited by free D-mannose, L-fucose, but not by D-glucose.

Effect of the Chemical Modification of Dextran on the Degradation by Dextranase

Dextran was modified using three different methods: a) partial periodate oxidation and subsequent reduction of the aldehyde groups, b) suc cinoylation and c) chloroformate activation with subsequent reaction with 2- hydroxypropylamine, ethylenediamine and tris(2-aminoethyl)amine. Degrada tion of these dextran derivatives by dextranases was investigated. It was observed that the rate of degradation decreased with increasing degree of chemical modification of the parent polysaccharide. The nature of modification had no significant influence on the rate of degradation.

Effect of the Chemical Modification of Dextran on the Degradation by Rat Liver Lysosomal Enzymes

The biodegradation of dextran, reduced dextran dialdehyde and dextran monosuccinate ester was investigated using isolated rat liver lysosomes. It was demonstrated that chemical modification of the parent dex tran resulted in a reduced degradability. The action of the exo-enzyme α-glucos idase (α-D-glucoside glucohydrolase) was nearly the same for parent dextran as for the derivatives. In order to explain the degradation data, the presence of the endo-acting enzyme dextranase (1,6-α-D-glucan 6-glucanohydrolase) in the lysosomes was taken into account.

Poly(Glyceryl Methacrylate) Hydrogels - Effect of Composition and Crosslinking Density on Structure and Release of Dextran as a Model Macromolecule

A series of hydrogels based on glyceryl methacrylate (pGMA) were prepared with different ratios of ethylene glycol dimethacrylate (EGDMA) and ethyl methacrylate (EMA) in order to vary the degree of crosslinking and the degree of hydrophobicity of the matrices, respectively. The swelling be haviour and the crosslinking density of the hydrogels were characterized and the structure was determined by scanning electron microscopy and porosime try. FITC-dextran (molecular weight 20,000) was imbibed into the gels and the release rate studied. It was found that the initial rate of release and the total amount of dextran release varied as an inverse function of crosslinking and monomer concentration, but as a linear function of EMA concentration.

Immunogenicity of Protein-N-(2-Hydroxypropyl)methacrylamide Copolymer Conjugates in A/J and B10 Mice

Two proteins (model targeting residues) human immunoglobulin fraction (IgG) and human transferrin have been conjugated to N-(2-hydroxy propyl)methacrylamide (HPMA) copolymer and the antibody titer elicited, after subcutaneous or intraperitoneal administration to A/J and B10 mice of free and conjugated protein, was measured using the ELISA technique. The measured IgG titer against protein-HPMA copolymer conjugates was always higher than the IgM titer. Also, the titer (IgG) measured against native protein was up to 250-fold greater than that raised against protein-HPMA copolymer conjugates. This reduction in antibody titer against conjugate had a limited de pendence on its molecular weight.

An integrative in silico system for predicting dysregulated genes in the human epileptic focus: Application to SLC transporters

OBJECTIVE

Many different gene families are currently being investigated for their potential role in epilepsy and in the response to antiepileptic drugs. A common research challenge is identifying the members of a gene family that are most significantly dysregulated within the human epileptic focus, before taking them forward for resource-intensive functional studies. Published data about transcriptomic changes within the human epileptic focus remains incomplete. A need exists for an accurate in silico system for the prediction of dysregulated genes within the epileptic focus. We present such a bioinformatic system. We demonstrate the validity of our approach by applying it to the solute carrier (SLC) gene family. There are >400 known SLCs. SLCs have never been systematically studied in epilepsy.

METHODS

Using our in silico system, we predicted the SLCs likely to be dysregulated in the epileptic focus. We validated our in silico predictions by identifying ex vivo the SLCs dysregulated in epileptic foci, and determining the overlap between our in silico and ex vivo results. For the ex vivo analysis, we used a custom oligonucleotide microarray containing exon probes for all known SLCs to analyze 24 hippocampal samples obtained from surgery for pharmacoresistant mesial temporal lobe epilepsy and 24 hippocampal samples from normal postmortem controls.

RESULTS

There was a highly significant (p < 9.99 × 10(-7) ) overlap between the genes identified by our in silico and ex vivo strategies. The SLCs identified were either metal ion exchangers or neurotransmitter transporters, which are likely to play a part in epilepsy by influencing neuronal excitability.

SIGNIFICANCE

The identified SLCs are most likely to mediate pharmacoresistance in epilepsy by enhancing the intrinsic severity of epilepsy, but further functional work will be needed to fully evaluate their role. Our successful in silico strategy can be adapted in order to prioritize genes relevant to epilepsy from other gene families.

Medically unexplained symptoms in patients with PNES: Do they explain poor employment outcome in patients with good seizure outcomes?

BACKGROUND

Many patients with psychogenic nonepileptic seizures (PNES) have other medically unexplained symptoms (MUS). In order to assess their long-term contribution to ill-health and unemployment, we recorded MUS, employment, healthcare utilization, and seizure outcomes in a cohort of patients with PNES.

METHODS

We had complete computerized healthcare records and employment information in 120 patients with PNES, 5-10years postdiagnosis. We analyzed these data to assess the contribution of MUS to ill-health and to determine whether MUS could explain differences among seizure, employment, and healthcare utilization outcomes in PNES.

RESULTS

At 5-10years, 41/120 patients (34.2%) were attending primary or secondary care for seizures, 42/120 patients (35.0%) had MUS other than PNES, and 36/120 patients (30.0%) were employed. Unemployment was predicted by age at presentation (OR: 0.90 (0.86-0.94), p<0.001), presenting to primary or secondary care with seizures (OR: 0.16 (0.05-0.52), p=0.003), and contact with psychiatric services at 5-10years (OR: 0.16 (0.05-0.58), p=0.005). No outcome measures were predicted by additional MUS, though MUS themselves were predicted by psychiatric contact (OR: 2.27 (1.01-5.01), p=0.048).

CONCLUSIONS

Our data suggest that MUS do not contribute independently to unemployment in the population with PNES, whereas psychiatric morbidity appears to do so. Nonetheless, MUS and psychiatric morbidity persist in the long term in a substantial minority of patients with PNES. We found no evidence that seizures in patients whose PNES have resolved are replaced with other MUS.

Careful assessment the key to diagnosing adolescent heel pain

The most common cause of adolescent heel pain is calcaneal apophysitis also known as Sever's disease. The condition may occur in adolescent athletes, particularly those involved in running or jumping activities, during the pubertal growth spurt. The mean age of presentation in Sever's disease is ten, (range 7-15). It presents with posterior heel pain that is worse with activity and relieved by rest in most cases. Sever's disease, Osgood Schlatter's disease (tibial tuberosity) and Sinding-Larsen Johansson syndrome (distal patella) are all overuse syndromes brought about by repetitive submaximal loading and microtrauma. They are, however, entirely self-limiting and resolve at skeletal maturity or earlier. Careful assessment is required to differentiate them from other rare pathologies. Achilles tendinitis is rare under the age of 14. As in Sever's disease, it may occur in jumping athletes, those who suddenly increase their sporting activities and in individuals with relative gastrosoleus tightness. It may also occur in those with inflammatory arthropathies and merit rheumatological investigation if there are other suggestive signs or symptoms. Benign and malignant tumours of the adolescent calcaneus are extremely rare In a unilateral case, atypical features such as night pain or absence of a precipitating activity should raise the index of suspicion. There may be localised swelling and bony expansion.

Standardized methods to generate mock (spiked) clinical specimens by spiking blood or plasma with cultured pathogens

AIMS

To demonstrate standardized methods for spiking pathogens into human matrices for evaluation and comparison among diagnostic platforms.

METHODS AND RESULTS

This study presents detailed methods for spiking bacteria or protozoan parasites into whole blood and virus into plasma. Proper methods must start with a documented, reproducible pathogen source followed by steps that include standardized culture, preparation of cryopreserved aliquots, quantification of the aliquots by molecular methods, production of sufficient numbers of individual specimens and testing of the platform with multiple mock specimens. Results are presented following the described procedures that showed acceptable reproducibility comparing in-house real-time PCR assays to a commercially available multiplex molecular assay.

CONCLUSIONS

A step by step procedure has been described that can be followed by assay developers who are targeting low prevalence pathogens.

SIGNIFICANCE AND IMPACT OF THE STUDY

The development of diagnostic platforms for detection of low prevalence pathogens such as biothreat or emerging agents is challenged by the lack of clinical specimens for performance evaluation. This deficit can be overcome using mock clinical specimens made by spiking cultured pathogens into human matrices. To facilitate evaluation and comparison among platforms, standardized methods must be followed in the preparation and application of spiked specimens.

Psychogenic nonepileptic seizures: EEG and investigation

In the investigation of psychogenic nonepileptic seizures (PNES), the main differential diagnoses are between convulsive PNES and tonic-clonic seizures, between swoon PNES and syncope, and between pseudoabsence PNES and absence seizures. For the best diagnostic certainty, events must be captured, ideally using video-electroencephalogram (EEG), including an electrocardiographic channel. The "video" part of video-EEG allows EEG changes (or lack of them) to be interpreted in the appropriate clinical context. When the diagnosis is based on less good data (e.g., video alone or EEG alone), then the limitations and constraints of the tests should borne in mind, and a lesser degree of certainty must be accepted. Tests such as serum prolactin (PRL) level and postictal EEG should be regarded as adjunctive rather than definitive. Excluding additional epilepsy with a good probability is not possible using investigations alone. In particular, one standard interictal EEG recording is of little value in excluding additional epilepsy, though multiple or prolonged recordings may offer additional sensitivity.

Regulation of skeletal remodeling by parathyroid hormone

PTH is responsible for the maintenance of calcium homeostasis and normocalcemia. Secretion of PTH is stimulated or suppressed by perturbations in the serum calcium level. The calciotropic effects of PTH are mediated primarily by bone, where PTH-stimulated remodeling may release calcium to the extracellular fluid, and by the kidneys, where calcium reabsorption and phosphate excretion are increased. The effects of PTH in bone are bipolar: including regulation of multiple cell types, especially, both osteoblasts and osteoclasts, and stimulating both bone formation (anabolic effects) and bone resorption (catabolic) effects. The purpose of this review is to discuss the available data regarding PTH-regulated bone remodeling, the role of second messengers produced by polyphosphoinositide hydrolysis, the possible role of G proteins in regulating this reaction, and the biologic effects of activating this system. Greater insight into the complexities of parathyroid hormone-regulated bone remodeling are still required.

Delivering patient choice in clinical practice: a conversation analytic study of communication practices used in neurology clinics to involve patients in decision-making

Background

The NHS is committed to offering patients more choice. Yet even within the NHS, the meaning of patient choice ranges from legal ‘rights to choose’ to the ambition of establishing clinical practice as a ‘partnership’ between doctor and patient. In the absence of detailed guidance, we focused on preciselyhowto engage patients in decision-making.

Objectives

To contribute to the evidence-base about whether or not, and how, patient choice is implemented to identify the most effective communication practices for facilitating patient choice.

Design

We used conversation analysis to examine practices whereby neurologists offer choice. The main data set consists of audio- and video-recorded consultations. Patients completed pre- and post-consultation questionnaires and neurologists completed the latter.

Setting and participants

The study was conducted in neurology outpatient clinics in Glasgow and Sheffield. Fourteen neurologists, 223 patients and 120 accompanying others took part.

Results

Patients and clinicians agreed that choice had featured in 53.6% of consultations and that choice was absent in 14.3%. After 32.1% of consultations,eitherpatientorneurologist thought choice was offered. The presence or absence of choice was not satisfactorily explained by quantitatively explored clinical or demographic variables. For our qualitative analysis, the corpus was divided into four subsets: (1) patient and clinician agree that choice was present; (2) patient and clinician agree that choice was absent; (3) patient ‘yes’, clinician ‘no’; and (4) patient ‘no’, clinician ‘yes’. Comparison of all subsets showed that ‘option-listing’ was the only practice for offering choice that was presentonly(with one exception, which, as we show, proves the rule) in those consultations for which participantsagreed there was a choice. We show how option-listing can be used to engage patients in decision-making, but also how very small changes in the machinery of option-listing [for instance the replacement or displacement of the final component of this practice, the patient view elicitor (PVE)] can significantly alter the slot for patient participation. In fact, a slightly modified form of option-listing can be used to curtail choice. Finally, we describe two forms of PVE that can be used to hand a single-option decision to the patient, but which, we show, can raise difficulties for patient choice.

Conclusions

Choice features in the majority of recorded consultations. If doctors want to ensure a patient knows she or he has a choice, option-listing is likely to be best understood by patients as an invitation to choose. However, an important lesson from this study is that simply asking doctors to adopt a practice (like option-listing) will not automatically lead to a patient-centred approach. Our study shows that preciselyhowa practice is implemented is crucial.

Future research

Future research should investigate (1) links between the practices identified here and relevant outcome measures (like adherence); (2) whether being given a choice is better or worse for patients than receiving a doctor’s recommendation, taking account of clinical and demographic factors; and (3) how our approach could be fruitfully applied in other settings.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.