Development of the clinical assessment scale in autoimmune encephalitis.

OBJECTIVE: There is no scale for rating the severity of autoimmune encephalitis (AE). In this study, we aimed to develop a novel scale for rating severity in patients with diverse AE syndromes and to verify the reliability and validity of the developed scale. METHODS: The key items were generated by a panel of experts and selected according to content validity ratios. The developed scale was initially applied to 50 patients with AE (development cohort) to evaluate its acceptability, reproducibility, internal consistency, and construct validity. Then, the scale was applied to another independent cohort (validation cohort, n = 38). RESULTS: A new scale consisting of 9 items (seizure, memory dysfunction, psychiatric symptoms, consciousness, language problems, dyskinesia/dystonia, gait instability and ataxia, brainstem dysfunction, and weakness) was developed. Each item was assigned a value of up to 3 points. The total score could therefore range from 0 to 27. We named the scale the Clinical Assessment Scale in Autoimmune Encephalitis (CASE). The new scale showed excellent interobserver (intraclass correlation coefficient [ICC] = 0.97) and intraobserver (ICC = 0.96) reliability for total scores, was highly correlated with modified Rankin scale (r = 0.86, p < 0.001), and had acceptable internal consistency (Cronbach α = 0.88). Additionally, in the validation cohort, the scale showed high interobserver reliability (ICC = 0.99) and internal consistency (Cronbach α = 0.92). INTERPRETATION: CASE is a novel clinical scale for AE with a high level of clinimetric properties. It would be suitable for application in clinical practice and might help overcome the limitations of current outcome scales for AE. ANN NEUROL 2019;85:352-358.

Fermented Wild Ginseng by Rhizopus oligosporus Improved l-Carnitine and Ginsenoside Contents.

We conducted this study to investigate the beneficial effects of Rhizopus oligosporus fermentation of wild ginseng on ginsenosides, l-carnitine contents and its biological activity. The Rhizopus oligosporus fermentation of wild ginseng was carried out at 30 °C for between 1 and 14 days. Fourteen ginsenosides and l-carnitine were analyzed in the fermented wild ginseng by the ultra high pressure liquid chromatography-mass spectrometry (UPLC-MS) system. Our results showed that the total amount of ginsenosides in ginseng increased from 3,274 to 5,573 mg/kg after 14 days of fermentation. Among the 14 ginsenosides tested, the amounts of 13 ginsenosides (Rg1, Rb2, Rb3, Rc, Rd, Re, Rf, Rg2, Rg3, Rh1, compound K, F1 and F2) increased, whereas ginsenoside Rb1 decreased, during the fermentation. Furthermore, l-carnitine (630 mg/kg) was newly synthesized in fermented ginseng extract after 14 days. In addition, both total phenol contents and DPPH radical scavenging activities showed an increase in the fermented ginseng with respect to non-fermented ginseng. These results show that the fermentation process reduced the cytotoxicity of wild ginseng against RAW264.7 cells. Both wild and fermented wild ginseng showed anti-inflammatory activity via inhibition of nitric oxide synthesis in RAW264.7 murine macrophage cells.

Neurobiological findings related to Internet use disorders.

In the last 10 years, numerous neurobiological studies have been conducted on Internet addiction or Internet use disorder. Various neurobiological research methods - such as magnetic resonance imaging; nuclear imaging modalities, including positron emission tomography and single photon emission computed tomography; molecular genetics; and neurophysiologic methods - have made it possible to discover structural or functional impairments in the brains of individuals with Internet use disorder. Specifically, Internet use disorder is associated with structural or functional impairment in the orbitofrontal cortex, dorsolateral prefrontal cortex, anterior cingulate cortex, and posterior cingulate cortex. These regions are associated with the processing of reward, motivation, memory, and cognitive control. Early neurobiological research results in this area indicated that Internet use disorder shares many similarities with substance use disorders, including, to a certain extent, a shared pathophysiology. However, recent studies suggest that differences in biological and psychological markers exist between Internet use disorder and substance use disorders. Further research is required for a better understanding of the pathophysiology of Internet use disorder.

Comparison of Stent-Assisted Coil Embolization Versus Coil Embolization Alone for Ruptured Cerebral Aneurysms with Mild Symptoms: A Single-Clinic Experience.

Purpose: To evaluate the safety and efficacy of stent-assisted coil embolization (SAC) in acutely ruptured cerebral aneurysms without severe symptoms, and thus, the usefulness of the stent itself in patients with subarachnoid hemorrhages. Materials and Methods: From January 2017 to June 2019, 118 patients were treated with coil embolization for acutely ruptured cerebral aneurysms without severe symptoms (Hunt & Hess grade ≤ 3). The periprocedural complications, six-month modified Rankin scores (mRS), and six-month radiologic outcomes were compared between 56 patients with SAC and 62 patients without SAC (non-SAC). Results: The rate of good clinical outcomes (mRS ≤ 2), as well as the rate of hemorrhagic and ischemic complications, showed no significant difference between the SAC and non-SAC groups. Moreover, compared to the non-SAC group, the SAC group showed a lower recanalization rate on the six-month follow-up angiogram (20% vs. 39.3%, p = 0.001). Conclusion: Although stent use was not significantly associated with clinical outcomes in coil embolization of ruptured cerebral aneurysms with non-severe symptoms (Hunt & Hess grade ≤ 3), it significantly decreased the rate of recanalization on follow-up cerebral angiograms.

Motion Correction of Dual Volume Reconstruction of Three­dimensional Digital Subtraction Angiography for Follow­up Evaluation of Intracranial Coiled Aneurysms.

PURPOSE: To evaluate the usefulness of the "Motion Correction" function of the dual volume-3D-volume-rendering technique (DV-3D-VRT) in follow-up digital subtraction angiography (DSA) of intracranial coiled aneurysms. MATERIALS AND METHODS: This study used data collected from consecutive, follow-up DSAs after the coiling of 64 intracranial aneurysms in 59 patients. We performed subtracted 3D-rotational angiographies (3D-RAs) on all DSAs and obtained DV-3D-VRT images. We then assessed recurrence using DV-3D-VRT images with and without the motion correction functions (MC(+) vs. MC(-)) and observed which method showed better agreement with the reference assessment (using a combination of 2D DSA and TOF MRA images). RESULTS: The recurrence of MC(-) DV-3D-VRT images showed 51.6% (33/64) agreement with the reference assessment, whereas the MC(+) DV-3D-VRT images showed 78.1% (50/64) (P = 0.035, McNemar test). CONCLUSION: Motion correction is a useful complementary imaging technique in evaluating aneurysm recurrence after endovascular embolization. MC(+) DV-3D-VRT image showed higher inter-observer agreement than MC(-) DV-3D-VRT.

Enzymatic synthesis and biological characterization of a novel mangiferin glucoside.

Mangiferin, a major constituent of Mangifera indica L., has attracted substantial attention due to its anti-oxidant, anti-diabetic, anti-inflammatory, and anti-microbial activities. However, its poor solubility in water limits its use in food and pharmaceutical industries. In this study, novel mangiferin-(1→6)-α-d-glucopyranoside (Mg-G1) was enzymatically synthesized from mangiferin and sucrose using glucansucrase from Leuconostoc mesenteroides B-512F/KM, and optimized using response surface methodology. The water solubility of Mg-G1 was found to be 824.7 mM, which is more than 2300-fold higher than that of mangiferin. Mg-G1 also showed DPPH radical scavenging activity and superoxide dismutase (SOD)-like scavenging activity, which were 4.77- and 3.71-fold higher than that of mangiferin, respectively. Mg-G1 displayed inhibitory activity against human intestinal maltase and COX-2. Thus, the novel glucosylated mangiferin may be used as an ingredient in functional food and pharmaceutical application.

Synthesis and characterization of stevioside having low degree polymerized glucosides using dextransucrase and dextranase.

Transglycosylation is one of enzymatic methods to improve the physical and biochemical properties of various functional compounds. In this study, stevioside glucosides were synthesized using sucrose as a substrate, stevioside (Ste) as an acceptor, and dextransucrase from Leuconostoc mesenteroides B-512 F/KM. The highest Ste conversion yield of 98% was obtained with 50 mg/mL Ste, 800 mM sucrose, and dextransucrase 4 U/mL at 28 °C for 6 h. The concentration of Ste was unchanged while of Ste-G1 was increased from 7.7 mM to 9.1 mM as the Ste acceptor reaction digest was treated with dextranase from Lipomyces starkeyi. Ste-G1 (13-O-ß-sophorosyl-19-O-ß-isomaltosyl-steviol), Ste-G2 (13-O-(ß-(1→6) glucosyl)-ß-glucosylsophorosyl-19-O-ß-isomaltosyl-steviol), and Ste-G2' (13-O-ß-sophorosyl-19-O-ß-isomaltotriosyl-steviol) were determined by NMR. These glucosylated Ste showed increased stabilities at pH 2, 60 °C for 48 h as compared to Ste. Ste-G1, Ste-G2, and Ste-G2' inhibited the insoluble glucan synthesis from sucrose by mutansucrase from Streptococcus muntans by the transfer of the glucosyl group of sucrose to Ste-G1, Ste-G2, and Ste-G2'. The relative water solubility of curcumin, pterostilbene or idebenone was increased by Ste or Ste glucosides treatment. Ste and Ste-G1 restored cell viability in RAW264.7 cells at concentrations up to 8 mg/mL and inhibited nitric oxide production in LPS-induced RAW264.7 cells with IC50 of 3.29 and 1.87 mg/mL.

HLAs associated with perampanel-induced psychiatric adverse effects in a Korean population.

Perampanel (PER) is a new-generation antiepileptic drug that has an occasional but significant shortcoming, psychiatric adverse effects (PAEs). Recently, antiepileptic drug-related adverse reactions, such as skin rash and even PAEs, have been discovered to be correlated with certain human leukocyte antigen (HLA) types. Thus, we aimed to analyze specific HLA alleles as risk factors for PER-PAEs. We prospectively enrolled 17 patients with epilepsy who were prescribed PER between May 2016 and Jul 2018 at Seoul National University Hospital and developed PAEs while taking PER. Their HLA types were analyzed compared to those of 19 patients in the PAE-tolerant group and the general Korean population. In silico docking was performed with two different computational programs, AutoDock Vina and SwissDock, to theoretically evaluate the binding affinity of PER in the grooves of the specific HLA alleles. The HLA-DQB1*06:01, DRB1*08:03, and B*54:01 alleles were significantly associated with the patients who developed PER-PAEs compared with the general Korean population (odds ratio [OR] 3.94, p = 0.008, OR 9.24, p = 0.037, and OR 3.25, p = 0.041, respectively). As a haplotype, the combination of the three alleles was significantly more frequent in the PER-PAE group than in both the PER-tolerant group and the general Korean population. DQB1*06:01 and B*54:01 also demonstrated higher docking scores with PER than other alleles. This is the first study to analyze the association of PER-PAEs with specific HLA genotypes. Our results suggest that an HLA-associated genetic predisposition and a possible immunological mechanism are involved in the occurrence of PER-PAEs.

Correction: Clustering of spontaneous recurrent seizures separated by long seizure-free periods: An extended video-EEG monitoring study of a pilocarpine mouse model.

[This corrects the article DOI: 10.1371/journal.pone.0194552.].

Brain regions associated with periodic leg movements during sleep in restless legs syndrome.

The neural substrates related to periodic leg movements during sleep (PLMS) remain uncertain, and the specific brain regions involved in PLMS have not been evaluated. We investigated the brain regions associated with PLMS and their severity using the electroencephalographic (EEG) source localization method. Polysomnographic data, including electromyographic, electrocardiographic, and 19-channel EEG signals, of 15 patients with restless legs syndrome were analyzed. We first identified the source locations of delta-band (2-4 Hz) spectral power prior to the onset of PLMS using a standardized low-resolution brain electromagnetic tomography method. Next, correlation analysis was conducted between current densities and PLMS index. Delta power initially and most prominently increased before leg movement (LM) onset in the PLMS series. Sources of delta power at -4~-3 seconds were located in the right pericentral, bilateral dorsolateral prefrontal, and cingulate regions. PLMS index was correlated with current densities at the right inferior parietal, temporoparietal junction, and middle frontal regions. In conclusion, our results suggest that the brain regions activated before periodic LM onset or associated with their severity are the large-scale motor network and provide insight into the cortical contribution of PLMS pathomechanism.

Fatal familial insomnia presenting with agrypnia excitata and very low atonia index level: A case report and literature review.

RATIONALE: Fatal familial insomnia (FFI) is a human prion disease that is characterized by sleep-wake cycle deterioration, loss of slow-wave sleep, and motor overactivation over the daily 24-hour period. PATIENT CONCERNS: Here, we report the case of a 57-year-old man who had an irregular sleep-wake cycle and exhibited frequent movements and vocalizations during sleep. DIAGNOSES: Video-polysomnography showed disrupted sleep structure, rapid alternation between sleep stages, and an absence of sleep spindles and slow-wave sleep. Moreover, body movements persisted throughout the entire sleep period, including rapid eye movement (REM) sleep. The atonia index was very low (<0.025) during REM sleep. Genetic testing revealed a prion protein gene mutation at codon 178, and the patient was diagnosed with FFI. INTERVENTIONS: We tried to treat with amantadine, doxycycline, and immunotherapies, but the disease progressed. OUTCOMES: Sleep disturbance is the most frequent and essential symptom of FFI. LESSONS: FFI is difficult to diagnose due to the low sensitivity of diagnostic tools. Diagnoses can be further supported by better knowledge of typical polysomnographic findings.

Clustering of spontaneous recurrent seizures separated by long seizure-free periods: An extended video-EEG monitoring study of a pilocarpine mouse model.

Seizure clustering is a common and significant phenomenon in patients with epilepsy. The clustering of spontaneous recurrent seizures (SRSs) in animal models of epilepsy, including mouse pilocarpine models, has been reported. However, most studies have analyzed seizures for a short duration after the induction of status epilepticus (SE). In this study, we investigated the detailed characteristics of seizure clustering in the chronic stage of a mouse pilocarpine-induced epilepsy model for an extended duration by continuous 24/7 video-EEG monitoring. A seizure cluster was defined as the occurrence of one or more seizures per day for at least three consecutive days and at least five seizures during the cluster period. We analyzed the cluster duration, seizure-free period, cluster interval, and numbers of seizures within and outside the seizure clusters. The video-EEG monitoring began 84.5±33.7 days after the induction of SE and continued for 53.7±20.4 days. Every mouse displayed seizure clusters, and 97.0% of the seizures occurred within a cluster period. The seizure clusters were followed by long seizure-free periods of 16.3±6.8 days, showing a cyclic pattern. The SRSs also occurred in a grouped pattern within a day. We demonstrate that almost all seizures occur in clusters with a cyclic pattern in the chronic stage of a mouse pilocarpine-induced epilepsy model. The seizure-free periods between clusters were long. These findings should be considered when performing in vivo studies using this animal model. Furthermore, this model might be appropriate for studying the unrevealed mechanism of ictogenesis.

Efficacy of Propranolol, Bisoprolol, and Pyridostigmine for Postural Tachycardia Syndrome: a Randomized Clinical Trial.

Postural tachycardia syndrome (POTS) is a form of dysautonomia which presents with complex symptoms including orthostatic intolerance. Several medications are prescribed for POTS; however, the efficacy of sustained medical treatment has not been well-investigated. Here, we conducted a 2 × 2 factorial design, randomized, clinical trial of a 3-month medical treatment regimen in POTS patients. Patients were randomly allocated to 4 treatment groups (Group 1: propranolol; Group 2: bisoprolol; Group 3: propranolol + pyridostigmine; Group 4: bisoprolol + pyridostigmine). The orthostatic intolerance questionnaire (OIQ), Beck depression inventory-II (BDI-II), and short-form health survey (SF-36) were conducted at baseline, 1 and 3 months after treatment. Seventy-seven patients who completed the 3-month follow-up were analyzed. In total, every clinical score improved significantly after medical treatment. The OIQ score was significantly lower than that at baseline (18.5 ± 6.7) after 1 month (12.5 ± 4.5, P < 0.01), which decreased further after 3 months (7.8 ± 5.7, P < 0.01). The OIQ score improvements were consistent across every treatment group. In the subgroup analysis of 59 patients who did not receive antidepressants, the BDI-II score significantly decreased after treatment, regardless of the regimen. Physical components of the SF-36 improved after 3 months in every group, while mental components improved only in Group 3. The amount of changes in each score was similar among groups throughout the comparisons. Sustained medical treatment is beneficial to POTS patients, not only for orthostatic intolerance symptoms but also for depression and diminished quality of life, even without prescriptions for antidepressants. The efficacy of each regimen in POTS patients was comparable. TRIAL REGISTRATION: NCT02171988.

Dysregulated long non-coding RNAs in the temporal lobe epilepsy mouse model.

PURPOSE: To perform comprehensive profiling of long non-coding RNAs (LncRNAs) in temporal lobe epilepsy. METHODS: We performed extensive profiling of LncRNAs and mRNAs in the mouse pilocarpine model in specific brain regions, the hippocampus and cortex, and compared the results to those of the control mouse. Differentially expressed LncRNAs and mRNAs were identified with a microarray analysis (Arraystar Mouse LncRNA Expression Microarray V3.0). Then, gene ontology (GO) and pathway analysis were performed to investigate the potential roles of the differentially expressed mRNAs in the pilocarpine model. Protein-protein interactions transcribed by dysregulated mRNAs with/without co-dysregulated LncRNAs were analyzed using STRING v10 (http://string-db.org/). RESULTS: A total of 22 and 83 LncRNAs were up- and down-regulated (≥2.0-fold, all P < .05), respectively, in the hippocampus of the epilepsy model, while 46 and 659 LncRNAs were up- and down-regulated, respectively, in the cortex of the epilepsy model. GO and pathway analysis revealed that the dysregulated mRNAs were closely associated with a process already known to be involved in epileptogenesis: acute inflammation, calcium ion regulation, extracellular matrix remodeling, and neuronal differentiation. Among the LncRNAs, we identified 10 LncRNAs commonly dysregulated with corresponding mRNAs in the cortex. The STRING analysis showed that the dysregulated mRNAs were interconnected around two centers: the mTOR pathway-related genes and REST pathway-related genes. CONCLUSION: LncRNAs were dysregulated in the pilocarpine mouse model according to the brain regions of the hippocampus and cortex. The dysregulated LncRNAs with co-dysregulated mRNAs might be possible therapeutic targets for the epigenetic regulation of chronic epilepsy.

Three-Year Retention Rates of Levetiracetam, Topiramate, and Oxcarbazepine: A Retrospective Hospital-Based Study.

OBJECTIVES: We evaluated and compared the 3-year retention rates of levetiracetam (LEV), topiramate (TPM), and oxcarbazepine (OXC) in patients with epilepsy in routine clinical practice. METHODS: We retrospectively reviewed medical records of patients with epilepsy who were newly prescribed LEV, TPM, or OXC from 2006 to 2010. The retention rates were estimated by the Kaplan-Meier analysis, and independent risk factors for drug discontinuation were analyzed by the Cox regression method. RESULTS: A total of 588 patients were included: LEV (n = 345), TPM (n = 190), and OXC (n = 53). Among them, 82% had focal epilepsy, whereas 14.8% had generalized epilepsy. The 3-year retention rates for LEV, TPM, and OXC, were 81.2%, 78.3%, and 54.7%, respectively. Levetiracetam and TPM had equivalent retention rates, whereas patients remained on OXC for a significantly shorter amount of time (P < 0.001). A lower retention rate for OXC was also evident in the subgroup analysis of focal epilepsy (P < 0.001). In generalized epilepsy, LEV and TPM revealed comparable retention rates (P = 0.255). The seizure-freedom rate did not differ among groups, whereas the rate of adverse effects leading to drug withdrawal of OXC (87.5%) was higher than that of LEV (34.4%, P < 0.001) and TPM (52.5%, P = 0.012). CONCLUSIONS: The current study suggested that LEV and TPM had comparable retention profiles in the long-term treatment for both focal and generalized epilepsy. Meanwhile, OXC therapy seemed to be relatively less useful because of its poor tolerability.

New feasible treatment for refractory autoimmune encephalitis: Low-dose interleukin-2.

Low-dose interleukin-2 (IL-2) restores the balance of regulatory and effector T cells. We aimed to determine the feasibility of low-dose IL-2 as a treatment for refractory autoimmune encephalitis (AE). Ten patients who had received low-dose IL-2 were retrospectively identified. We observed an improvement in the modified Rankin Scale scores of six patients at the last follow-up compared with the scores at the initiation of low-dose IL-2 (p=0.014). One patient experienced treatment-related grade 3 neutropenia. Overall, low-dose IL-2 is a feasible and relatively safe treatment for AE patients who are refractory to the first- and second-line immunotherapies.