Exploration of urine metabolic biomarkers for new-onset, untreated pediatric epilepsy: A gas and liquid chromatography mass spectrometry-based metabolomics study.

OBJECTIVE: The discovery of objective indicators for recent epileptic seizures will help confirm the diagnosis of epilepsy and evaluate therapeutic effects. Past studies had shortcomings such as the inclusion of patients under treatment and those with various etiologies that could confound the analysis results significantly. We aimed to minimize such confounding effects and to explore the small molecule biomarkers associated with the recent occurrence of epileptic seizures using urine metabolomics. METHODS: This is a multicenter prospective study. Subjects included pediatric patients aged 2 to 12 years old with new-onset, untreated epilepsy, who had had the last seizure within 1 month before urine collection. Controls included healthy children aged 2 to 12 years old. Those with underlying or chronic diseases, acute illnesses, or recent administration of medications or supplements were excluded. Targeted metabolome analysis of spot urine samples was conducted using gas chromatography (GC)- and liquid chromatography (LC)-tandem mass spectrometry (MS/MS). RESULTS: We enrolled 17 patients and 21 controls. Among 172 metabolites measured by GC/MS/MS and 41 metabolites measured by LC/MS/MS, only taurine was consistently reduced in the epilepsy group. This finding was subsequently confirmed by the absolute quantification of amino acids. No other metabolites were consistently altered between the two groups. CONCLUSIONS: Urine metabolome analysis, which covers a larger number of metabolites than conventional biochemistry analyses, found no consistently altered small molecule metabolites except for reduced taurine in epilepsy patients compared to healthy controls. Further studies with larger samples, subjects with different ages, expanded target metabolites, and the investigation of plasma samples are required.

Folic acid inhibits 5-methyltetrahydrofolate transport across the blood-cerebrospinal fluid barrier: Clinical biochemical data from two cases.

Objective: The use of folic acid (FA) has been discouraged in cerebral folate deficiency (CFD) because, theoretically, it could inhibit the transport of 5-methyltetrahydrofolic acid (5MTHF) across the blood-cerebrospinal fluid (CSF) barrier. We present the clinical biochemical data of two cases with CFD to support this hypothesis. Methods: We measured CSF and serum 5MTHF concentrations in a patient with Kearns-Sayre syndrome (KSS) and a patient homozygous for MTHFR C677T polymorphism before and during folate supplementation therapy. To evaluate these 5MTHF concentrations, we also analyzed CSF and serum samples in pediatric patients without folate supplementation. Results: Both patients had low CSF 5MTHF before treatment and high-dose FA therapy did not normalize CSF 5MTHF. There was a dissociation between serum total folate and 5MTHF concentrations during FA therapy, which was considered to be due to the appearance of unmetabolized FA. The addition of folinic acid did not improve low CSF 5MTHF in the KSS patient and the cessation of FA resulted in the normalization of CSF 5MTHF. In the patient homozygous for MTHFR C677T, minimization of the FA dosage resulted in the normalization of CSF 5MTHF and an increased CSF-to-serum 5MTHF ratio. Conclusions: Our data suggest that excess supplementation of FA impaired 5MTHF transport across the blood-CSF barrier. In the treatment of CFD, supplementation of folinic acid or 5MTHF (in cases of impaired 5MTHF synthesis) is preferred over the use of FA. The reference values of CSF 5MTHF concentration based on 600 pediatric cases were also provided.

Identification of new biomarkers of pyridoxine-dependent epilepsy by GC/MS-based urine metabolomics.

α-Aminoadipic semialdehyde and its cyclic form (Δ1-piperideine-6-carboxylate) accumulate in patients with α-aminoadipic semialdehyde dehydrogenase (AASADH; antiquitin; ALDH7A1) deficiency. Δ1-Piperideine-6-carboxylate is known to react with pyridoxal 5'-phosphate (PLP) to form a Knoevenagel condensation product, resulting in pyridoxine-dependent epilepsy. Despite dramatic clinical improvement following pyridoxine supplementation, many patients still suffer some degree of intellectual disability due to delayed diagnosis. In order to expedite the diagnosis of patients with suspected AASADH deficiency and minimize the delay in treatment, we used gas chromatography-mass spectrometry-based metabolomics to search for potentially diagnostic biomarkers in urine from four patients with ALDH7A1 mutations, and identified Δ2-piperideine-6-carboxylate, 6-oxopipecolate, and pipecolate as candidate biomarkers. In a patient at postnatal day six, but before pyridoxine treatment, Δ2-piperideine-6-carboxylate and pipecolate were present at very high concentrations, indicating that these compounds may be good biomarkers for untreated AASADH deficiency patients. On the other hand, following pyridoxine/PLP treatment, 6-oxopipecolate was shown to be greatly elevated. We suggest that noninvasive urine metabolomics screening for Δ2-piperideine-6-carboxylate, 6-oxopipecolate, and pipecolate will be useful for prompt and reliable diagnosis of AASADH deficiency in patients within any age group. The most appropriate combination among Δ2-piperideine-6-carboxylate, 6-oxopipecolate, and pipecolate as biomarkers for AASADH deficiency patients appears to depend on the age of the patient and whether pyridoxine/PLP supplementation has been implemented. We anticipate that the present bioanalytical information will also be useful to researchers studying glutamate, proline, lysine and ornithine metabolism in mammals and other organisms.

Determination of CSF 5-methyltetrahydrofolate in children and its application for defects of folate transport and metabolism.

OBJECTIVE: To describe an assay of 5-methyltetrahydrofolate (5MTHF) in the cerebrospinal fluid (CSF) of children, to determine reference values, and to report the clinical significance of this assay in metabolic disorders affecting folate transport and metabolism. METHODS: CSF 5MTHF was determined by high-performance liquid chromatography with fluorescent detection in pediatric patients including one with FOLR1 gene mutation and one with methylenetetrahydrofolate reductase (MTHFR) deficiency. CSF total folate was measured using an automated analyzer. RESULTS: 5MTHF and total folate were determined in 188 and 93 CSF samples, respectively. CSF 5MTHF was high throughout the first six months of life and subsequently declined with age. Reference values of CSF 5MTHF and total folate were determined from 162 and 82 samples, respectively. The patient with FOLR1 gene mutation had extremely low CSF 5MTHF and total folate, though these values normalized after folinic acid supplementation. The patient with MTHFR deficiency had extremely low 5MTHF and moderately low total folate; these values were not associated and showed no significant change after folic acid supplementation. CONCLUSIONS: This 5MTHF assay is simple, rapid, sensitive, reliable, and cost-effective. It will aid in the diagnosis and therapeutic monitoring of metabolic disorders affecting folate transport and metabolism.

Early effects of oral administration of lafutidine with peppermint oil, compared with lafutidine alone, on intragastric pH values.

BACKGROUND/AIMS: Ideally, medications for the treatment of acid-related diseases should have a rapid onset of action to promote hemostasis and the resolution of symptoms. The aim of our study was to investigate the inhibitory effects on gastric acid secretion of a single oral administration of lafutidine alone or combined with peppermint oil. METHODOLOGY: Ten Helicobacter pylori-negative male subjects participated in this randomized, two-way crossover study. Intragastric pH was monitored continuously for 4 hours after a single oral administration of lafutidine (10 mg) or the administration of lafutidine (10 mg) with peppermint oil (0.64 mL). Each administration was separated by a 7-day washout period. RESULTS: No significant difference in the average pH was observed during the 4-hour period after the combined administration of lafutidine and peppermint oil and after the administration of lafutidine alone (median gastric pH: 5.09 versus 5.29; p = 0.3122). CONCLUSIONS: In H. pylori-negative healthy male subjects, an oral dose of lafutidine combined with peppermint oil did not increase the intragastric pH faster than lafutidine alone.

Cortical gamma-oscillations modulated by auditory-motor tasks-intracranial recording in patients with epilepsy.

Human activities often involve hand-motor responses following external auditory-verbal commands. It has been believed that hand movements are predominantly driven by the contralateral primary sensorimotor cortex, whereas auditory-verbal information is processed in both superior temporal gyri. It remains unknown whether cortical activation in the superior temporal gyrus during an auditory-motor task is affected by laterality of hand-motor responses. Here, event-related γ-oscillations were intracranially recorded as quantitative measures of cortical activation; we determined how cortical structures were activated by auditory-cued movement using each hand in 15 patients with focal epilepsy. Auditory-verbal stimuli elicited augmentation of γ-oscillations in a posterior portion of the superior temporal gyrus, whereas hand-motor responses elicited γ-augmentation in the pre- and postcentral gyri. The magnitudes of such γ-augmentation in the superior temporal, precentral, and postcentral gyri were significantly larger when the hand contralateral to the recorded hemisphere was required to be used for motor responses, compared with when the ipsilateral hand was. The superior temporal gyrus in each hemisphere might play a greater pivotal role when the contralateral hand needs to be used for motor responses, compared with when the ipsilateral hand does.

Does postprandial coffee intake enhance gastric emptying?: a crossover study using continuous real time 13C breath test (BreathID system).

BACKGROUND/AIMS: Coffee is one of the most popular beverages worldwide, however, few studies have examined the effects of coffee on the gastrointestinal system. The aim of this study was to determine whether there was a correlation between coffee intake and gastric emptying using a novel non-invasive technique for measuring gastric emptying with a continuous real time 13C breath test (BreathID system: Oridion, Israel). METHODOLOGY: Six healthy male volunteers participated in this randomized, two-way crossover study. The subjects were randomly assigned to receive a test meal (200 kcal per 200 mL) plus postprandial 190 mL black coffee or the test meal alone after fasting overnight. A 13C-acetic acid breath test was continuously performed using the BreathID system, which monitors gastric emptying, for 4 hours after the administration of the test meal. Using Oridion Research Software (beta version), the time for emptying of 50% of the labeled meals (T 1/2) and the analog to the scintigraphy lag time for 10% emptying of the labeled meal (T lag) were calculated. The parameters between two occasions were compared using the Wilcoxon signed-rank test. RESULTS: After coffee intake the T 1/2 and T lag constant were significantly decreased. CONCLUSIONS: The decrease in the T 1/2 and T lag suggests the acceleration of gastric emptying. This study showed that postprandial coffee intake enhances gastric emptying, suggesting the potential use of coffee in clinical settings for patients with functional gastrointestinal disorders.

Penetration of the sigmoid colon to the posterior uterine wall secondary to diverticulitis: a case report.

INTRODUCTION: Penetration of the colon to the posterior uterine wall secondary to diverticulitis is unusual, with diagnostic methods not yet established. Non-invasive imaging, such as computed tomography and magnetic resonance imaging may help to establish a proper diagnosis, but confirmation may be reached only after surgical exploration. CASE PRESENTATION: We report the case of a 78-year-old Japanese woman who presented with a low grade fever and mild diarrhea which occurred two or three times a week. Computed tomography and magnetic resonance imaging demonstrated a capsular lesion including an air structure with a diameter of 5 cm, between the posterior aspect of the uterine body and the sigmoid colon. A gastrograffin enema and colonoscopy demonstrated a giant diverticulum of the sigmoid colon with no evidence of malignancy. These data confirmed the diagnosis of diverticulitis complicated by a giant diverticulum. Because of a relapsing fever after therapy with antibiotics, the patient had en bloc surgical treatment of the uterus, fallopian tubes, ovaries and sigmoid colon, the organs involved in the diverticulitis, followed by an uneventful recovery. CONCLUSION: This is a rare case report of penetration of the sigmoid colon to the posterior uterine wall secondary to diverticulitis.

Early effects of peppermint oil on gastric emptying: a crossover study using a continuous real-time 13C breath test (BreathID system).

BACKGROUND: The aim of this study was to determine whether there was a correlation between peppermint oil and gastric emptying by using a novel noninvasive technique for measuring gastric emptying with a continuous real-time (13)C breath test (BreathID system, Oridion, Israel). METHODS: Ten healthy male volunteers participated in this randomized, two-way crossover study. The subjects were randomly assigned to receive a test meal (200 kcal per 200 ml) containing 0.64 ml of peppermint oil or the test meal alone, after fasting overnight. A (13)C-acetic acid breath test was continuously performed with the BreathID system, which monitors gastric emptying, for 4 h after the administration of the test meal. Using Oridion Research Software (beta version), the time for emptying of 50% of the labeled meals (T 1/2), the analog to the scintigraphy lag time for 10% emptying of the labeled meal (T lag), the gastric emptying coefficient (GEC), and the regression-estimated constants (beta and kappa) were calculated. The parameters between two occasions were compared using the Wilcoxon signed-rank test. RESULTS: After peppermint oil intake, the T lag and beta constant were significantly decreased. No significant differences in T 1/2, GEC, or kappa were observed between the two occasions. CONCLUSIONS: The decrease in the T lag and beta constant suggests acceleration of gastric emptying during the early phase. This study showed that peppermint oil enhances gastric emptying, suggesting the potential use of peppermint oil in clinical settings for patients with functional gastrointestinal disorders.

Systematic source estimation of spikes by a combination of independent component analysis and RAP-MUSIC. II: Preliminary clinical application.

OBJECTIVES: We tried to estimate epileptic sources by a combination of independent component analysis (ICA) and recursively applied and projected multiple signal classification (RAP-MUSIC) in real epileptiform EEG discharges. METHODS: EEG data including an array of spikes from 3 patients were decomposed by ICA, and source estimation was performed by applying RAP-MUSIC to the spatial information defined by the set of ICA components that showed epileptiform activity in their waveform. Sources were also estimated from the same data using RAP-MUSIC based on eigen-decomposition of the covariance matrix of averaged spikes, and common spatial pattern decomposition for comparison. RESULTS: RAP-MUSIC based on ICA could estimate generally correct epileptic sources in the 3 patients, and its results were better than those of the other methods, when compared to intracerebral data. The present analysis proceeded without introduction of subjective decision after data selection. The separation of epileptiform discharges from the background is essential for this analysis, and was successfully performed in the real EEG data. CONCLUSIONS: RAP-MUSIC based on ICA appears promising for estimation of epileptic sources with minimal dependence on subjective decisions in the process of analysis. In particular, it was not necessary to select the number of sources.