Vagus nerve stimulation: a 20-year Australian experience.

BACKGROUND: Vagus nerve stimulation (VNS) therapy was first approved in the mid-1990s in the USA, Europe and Australia, with demonstrable efficacy in paediatric populations. Benefit in seizure frequency reduction can be observed up to 2 years post-intervention; however, few studies assess outcomes beyond this period. Furthermore, paediatric cohort sizes are small, limiting generalisability of outcome assessments. We evaluate VNS insertion outcomes and complications or side-effects in a large paediatric cohort, over a 20-year period from Queensland's first VNS insertion. METHODS: A retrospective review was conducted of all paediatric VNS insertions at the Queensland Children's Hospital (QCH) and the Mater Children's Hospital/Mater Children's Private Hospital (MCH/MCPH) Brisbane. A minimum of 1-year follow-up from 1999 to 2020 was required for inclusion. Patients were assessed on demographics, epilepsy details, seizure outcomes and complications or side-effects. RESULTS: In this extended follow-up cohort (76 patients, 7.2 ± 5.3 years), 51.3% of patients had ≥ 50% seizure frequency reduction, while 73.7% experienced an Engel III outcome (worthwhile benefit) or better. Eleven patients (14.9%) were seizure-free at follow-up, and 81.6% retained long-term therapy. Stimulation-related side-effects are common (17.1%) but rarely result in stimulation cessation (3.9%). Cessation occurred in 14 patients (18.4%) and most commonly related to minimal benefit (13.2%). Demographics, aetiology, seizure nature and surgical factors did not influence outcomes. CONCLUSION: Over extended treatment periods, a large proportion of patients will benefit significantly from VNS therapy. Approximately 4 of 5 patients will retain VNS therapy, and in cases of cessation, this is most commonly related to minimal benefit. Underlying demographics, aetiology or seizure nature do not influence outcomes. This 20-year Queensland assessment of VNS therapy outcomes informs long-term expectation of VNS therapy.

Internal standards in regulated bioanalysis: putting in place a decision-making process during method development.

It is common practice to utilize an internal standard (IS) to minimize variance in bioanalytical assays employing liquid chromatography coupled to mass spectrometry. For assays to be deployed in regulated drug development studies, ensuring the IS will compensate for differences in recovery, liquid handling and ionization efficiency should be determined early in the method development process. In this perspective article, we outline key considerations when selecting an IS and propose experiments to perform within the method development phase to demonstrate suitability of the IS within the assay prior to validation. Finally, a series of case studies will be presented, which illustrate analytical challenges related to internal standardization that we have observed in our laboratory.

Anti-NMDA-receptor Encephalitis in an Adolescent With HIV Infection and Review of the Literature.

Anti-N-Methyl-D-Aspartate-receptor encephalitis is the most common antibody-mediated autoimmune encephalopathy. A HIV-infected African boy presented with subacute psychosis as manifestation of anti-N-Methyl-D-Aspartate-receptor encephalitis. Intravenous immunoglobulin and corticosteroids induced complete remission. Although this is the first pediatric case described, 5 adult cases have been reported. The role of HIV in the etiology of this autoimmune condition requires further exploration.

Sensitive and robust LC-MS/MS analysis of digoxin in human plasma through optimization of in-source adduct formation.

AIM: To develop and validate an LC-MS/MS assay for the quantification of digoxin in human plasma. An LLOQ of 10 pg/ml using a 100 µl sample was required to support drug-drug interactions studies. RESULTS: Digoxin formed multiple precursor ions in positive and negative ESI and methods based on several of these have been reported previously. After screening viable precursor ions, we found the ammonium adduct gave the best combination of sensitivity and selectivity on our LC-MS/MS platform. Samples were extracted using a simple liquid-liquid procedure. CONCLUSION: The assay was successfully validation to current EMA guidelines. To the best of our knowledge the developed assay is the most sensitive published to date.

The validation & verification of an LC/MS method for the determination of total docosahexaenoic acid concentrations in canine blood serum.

Docosahexaenoic acid (DHA), is an omega 3 fatty acid (n-3 FA) that has been shown to play a role in canine growth and physiological integrity and improvements in skin and coat condition. However, potential adverse effects of n-3 FA specifically, impaired cellular immunity has been observed in dogs fed diets with elevated levels of n-3 FA. As such, a safe upper limit (SUL) for total n-3 FAs (DHA and EPA) in dogs has been established. Considering this SUL, sensitive methods detecting DHA in blood serum as a biomarker when conducting n-3 FA supplementation trials involving dogs are required. In this study, an LC-ESI-MS/MS method of DHA detection in dog serum was validated and verified. Recovery of DHA was optimized and parallelism tests were conducted with spiked samples demonstrating that the serum matrix did not interfere with quantitation. The stability of DHA in serum was also investigated, with -80 °C considered suitable when storing samples for up to six months. The method was linear over a calibration range of 1-500 µg/mL and precision and accuracy were found to meet the requirements for validation. This method was verified in an alternative laboratory using a different analytical system and operator, with the results meeting the criteria for verification.

Validation and Verification of a Liquid Chromatography-Mass Spectrometry Method for the Determination of Total Docosahexaenoic Acid in Pig Serum.

The paper presents the validation and verification of an analytical method for the determination of total docosahexaenoic acid (DHA) in pig serum by liquid chromatography-electrospray ionization-tandem mass spectrometry. The characteristics studied during the validation included precision and accuracy, limit of quantitation (LOQ), selectivity, calibration range and linearity, parallelism, and stability. A separate verification study was also performed. The method was linear over the range. Precision and accuracy met acceptance criteria at all levels, and the LOQ was determined as 1 µg/mL. Parallelism experiments were conducted to show that there was no bias introduced in using a surrogate matrix to quantify DHA. Recoveries of free DHA were obtained for quality control samples, and stability studies were conducted over 1, 7, 31, and 180 days. The results of the verification study were in line with the validation study, and in conclusion, the method was deemed fit for purpose for measuring total DHA in pig serum.

An Accurate Assessment of Docosahexaenoic Acid in Laying Hen Serum for Regulatory Studies.

Diets rich in omega-3 fatty acids (n-3 FA) have been associated with several health benefits. With the increased interest in n-3 FA both scientifically and societally, the accurate detection of such analytes has become increasingly important. Recently, tandem mass spectrometry (MS/MS) with electrospray ionization interface (ESI), hyphenated to both gas chromatography (GC) and liquid chromatography (LC), has become a valuable tool in the detection of docosahexaenoic acid (DHA). Liquid chromatography-electrospray ionization interface-tandem mass spectrometry methods have been developed for the determination of DHA in canine and poultry species. The objective of this article is to investigate whether LC-ESI-MS/MS is fit for purpose for the determination of DHA in laying hen serum. The disclosure of this work will be beneficial for researchers investigating poultry enrichment for regulatory and toxicological studies. The method was found to be linear over the range. Precision and accuracy results met acceptance criteria and the Limit of Quantitation (LOQ) was established as 1 µg/mL. Recoveries of DHA were obtained for quality control samples and stability studies were performed. The results of the verification study complimented those of the validation study. In summation, the method was established as fit for purpose for measuring total DHA in laying hen serum.

Pediatric Hereditary Neuralgic Amyotrophy: Successful Treatment With Intravenous Immunoglobulin and Insights Into SEPT9 Pathogenesis.

Hereditary neuralgic amyotrophy is a rare disorder characterized by the sudden onset of recurrent episodes of painful brachial plexus neuropathies, followed by atrophy within a few weeks. The authors present the case of a 5-year-old boy who developed hereditary neuralgic amyotrophy in the right upper limb after a gastroenteritis illness. He made a full and rapid recovery with the use of intravenous immunoglobulin. A subsequent episode in the left upper limb during the course of intravenous immunoglobulin was significantly attenuated. A de novo c.262C>T mutation in exon 2 of the SEPT9 gene was identified. To our knowledge, he is the first pediatric patient with SEPT9 hereditary neuralgic amyotrophy to be treated with intravenous immunoglobulin. The authors hypothesize that the c.262C>T mutation in exon 2 of the SEPT9 gene generates pathology via the numerous isoforms under specific conditions and that intravenous immunoglobulin can play a role at the epigenetic level of improving dysfunctional SEPT9 expression.

Prospective memory and pediatric traumatic brain injury: effects of cognitive demand.

This study investigated the effects of pediatric traumatic brain injury (TBI) on prospective memory. Fourteen children and 14 adolescents with TBI were compared with 25 and 23 noninjured children and adolescents, respectively. Based on a prefrontal model, the cognitive demand on the ongoing component of a prospective-memory task was manipulated. Overall, those with TBI had poorer prospective-memory performance than their noninjured peers. Performance was worse in a high cognitive-demand condition than a low, and younger children performed worse than adolescents. Decreases in performance from the low- to high-demand conditions were not significantly different between the two children's groups but were between the two adolescents' groups. Furthermore, the age and injury effects were reflected in the performances on executive function tests: the Self-ordered Pointing Task (SOPT), and the Stroop Color Word Interference Test. The Tower of London (TOL), which did not produce age or injury effects, was nevertheless found to be an important predictor of performance on the high-demand task in those with TBI. Although previous research has demonstrated impaired prospective memory performance in children with TBI, this study attempted to explain why this might occur, specifically that the prefrontal regions might be implicated.

Childhood encephalopathy: viruses, immune response, and outcome.

This study examined children with an acute encephalopathy illness for evidence of viral infection, disordered blood-brain barrier function, intrathecal immunoglobulin synthesis, and interferon (IFN) production, and related their temporal occurrence to outcome. A prospective study of 22 children (13 males, 9 females; age range 1mo to 13y, median 2y 4mo), recorded clinical details, with serum and cerebrospinal fluid (CSF) analysis near presentation and then on convalescent specimens taken up to day 39 of the neurological illness. Outcome was assessed with standard scales between 18 months and 3 years after presentation. A history consistent with viral infection was given in 17 children but laboratory evidence of viral infection was found in only 7 (7/17). In 18 out of 21 children, an elevated CSF:serum albumin ratio indicative of impairment of the blood-CSF and blood-brain barriers was detected at some stage of the illness. In 14 of the 15 children with a raised immunoglobulin G index, and in 12 of the 14 children where the CSF was positive for oligoclonal bands, this was preceded by, or was observed at the same time as, an abnormal albumin ratio. Sixteen children (16/18) had elevated IFN-alpha levels in serum, or CSF, or in both. We conclude that these findings indicate an initial disruption of the blood-brain barrier followed by intrathecal antibody production by activated lymphocytes, clonally restricted to a few antigens. This is the first in vivo study to show this as an important pathogenetic mechanism of encephalitis in children. Poor outcome was associated with young age, a deteriorating electroencephalogram pattern from grade 1 to grade 2, and the degree of blood-brain barrier impairment, particularly when prolonged, but not with Glasgow Coma Scale score. The persistence of IFN-alpha was associated with a good prognosis.

Development of prospective memory: tasks based on the prefrontal-lobe model.

This study investigated the development of prospective memory using tasks based on the prefrontal-lobe model. Three groups each of 30 children, adolescents, and young adults were compared on prospective-memory performance using ongoing tasks with two levels of cognitive demand (low and high), and two levels of importance (unstressed and stressed) of remembering prospective cues. The Self-Ordered Pointing Task (SOPT), Stroop Color Word Interference Test, and Tower of London were also used to assess relationships between prospective memory and prefrontal-lobe functions. The children remembered fewer prospective cues than either the adolescents or adults, but the adolescents and adults remembered equally well. This trend increased significantly as the cognitive demand of the ongoing tasks increased. However, stressing or not stressing the importance of remembering made no difference to prospective-memory performance. Performance on the SOPT and Stroop Colour Word Interference predicted performance on the high- but not on the low-demand condition. These findings implicate the maturation of the brain's prefrontal region in the development of prospective memory.

Pediatric traumatic brain injury and procedural memory.

This study investigated the effects of pediatric Traumatic brain injury (TBI) on procedural memory. Fifteen children with moderate to severe TBI and 15 matched controls were compared on two procedural-memory tasks: motor-perceptual (rotary pursuit) and cognitive (mirror reading). Explicit-memory tasks were also completed: recall or recognition of rotary-pursuit items and mirror-reading words. On both procedural tasks, the TBI group learned at a similar rate and retained equally well as the controls. On the explicit-memory tasks, however, the TBI group recalled and recognized fewer test items than the controls. These results are consistent with those reported in the adult TBI literature and suggest that procedural memory, a type of implicit memory, is preserved in children with TBI. Implications of these findings for the management and rehabilitation of children with TBI were discussed.