SCN8A encephalopathy: Research progress and prospects.

On April 21, 2015, the first SCN8A Encephalopathy Research Group convened in Washington, DC, to assess current research into clinical and pathogenic features of the disorder and prepare an agenda for future research collaborations. The group comprised clinical and basic scientists and representatives of patient advocacy groups. SCN8A encephalopathy is a rare disorder caused by de novo missense mutations of the sodium channel gene SCN8A, which encodes the neuronal sodium channel Nav 1.6. Since the initial description in 2012, approximately 140 affected individuals have been reported in publications or by SCN8A family groups. As a result, an understanding of the severe impact of SCN8A mutations is beginning to emerge. Defining a genetic epilepsy syndrome goes beyond identification of molecular etiology. Topics discussed at this meeting included (1) comparison between mutations of SCN8A and the SCN1A mutations in Dravet syndrome, (2) biophysical properties of the Nav 1.6 channel, (3) electrophysiologic effects of patient mutations on channel properties, (4) cell and animal models of SCN8A encephalopathy, (5) drug screening strategies, (6) the phenotypic spectrum of SCN8A encephalopathy, and (7) efforts to develop a bioregistry. A panel discussion of gaps in bioregistry, biobanking, and clinical outcomes data was followed by a planning session for improved integration of clinical and basic science research. Although SCN8A encephalopathy was identified only recently, there has been rapid progress in functional analysis and phenotypic classification. The focus is now shifting from identification of the underlying molecular cause to the development of strategies for drug screening and prioritized patient care.

Do electronic health records affect the patient-psychiatrist relationship? A before & after study of psychiatric outpatients.

BACKGROUND: A growing body of literature shows that patients accept the use of computers in clinical care. Nonetheless, studies have shown that computers unequivocally change both verbal and non-verbal communication style and increase patients' concerns about the privacy of their records. We found no studies which evaluated the use of Electronic Health Records (EHRs) specifically on psychiatric patient satisfaction, nor any that took place exclusively in a psychiatric treatment setting. Due to the special reliance on communication for psychiatric diagnosis and evaluation, and the emphasis on confidentiality of psychiatric records, the results of previous studies may not apply equally to psychiatric patients. METHOD: We examined the association between EHR use and changes to the patient-psychiatrist relationship. A patient satisfaction survey was administered to psychiatric patient volunteers prior to and following implementation of an EHR. All subjects were adult outpatients with chronic mental illness. RESULTS: Survey responses were grouped into categories of "Overall," "Technical," "Interpersonal," "Communication & Education,," "Time," "Confidentiality," "Anxiety," and "Computer Use." Multiple, unpaired, two-tailed t-tests comparing pre- and post-implementation groups showed no significant differences (at the 0.05 level) to any questionnaire category for all subjects combined or when subjects were stratified by primary diagnosis category. CONCLUSIONS: While many barriers to the adoption of electronic health records do exist, concerns about disruption to the patient-psychiatrist relationship need not be a prominent focus. Attention to communication style, interpersonal manner, and computer proficiency may help maintain the quality of the patient-psychiatrist relationship following EHR implementation.

Conserved extracellular cysteines differentially regulate the inhibitory effect of ethanol in rat P2X4 receptors.

Relatively little information is available about the molecular mechanism of ethanol inhibition of P2X receptors. Here, we investigated the possibility that 10 conserved cysteine residues in the extracellular loop of the rat P2X4 receptor may regulate ethanol inhibition of the receptor using a series of individual cysteine to alanine point mutations. Each of the mutated receptors generated robust inward current in response to ATP and the mutations produced less than a sixfold change in the ATP EC50 value. For the C116A, C126A, C149A, and C165A mutants, 100 mM ethanol did not significantly affect the current activated by an EC40 concentration of ATP. By contrast, for the C261A and C270A mutants, ethanol inhibited ATP-activated current in a competitive manner similar to that for the wild-type receptor. Interestingly, for the C132A, C159A, C217A, and C227A mutants, ethanol inhibited ATP-activated current, but decreased the maximal response to ATP by 70-75% without significantly changing the EC50 value of ATP, thus exhibiting a noncompetitive-type inhibition. The results suggest that cysteines and disulfide bonds between cysteines are differentially involved in the inhibition of the rat P2X4 receptor by ethanol.

Developing a standardized cephalometric vocabulary: choices and possible strategies.

The science of cephalometry has been invaluable for guiding orthodontic diagnosis, treatment planning, and outcomes tracking. Though software packages easily calculate most cephalometric measurements, the ability to exchange cephalometric data between software packages is poorly developed. Hindering this effort is the lack of an agreed-upon standard for electronic exchange of cephalometric measurements. Unlike more technological issues, the problem of creating such a standard is one of formalizing decisions already established through historical precedent. Solving this problem will require education, cooperation, and consensus in order to reap the potential improvements to patient care, dental education, and research. The first step in overcoming these remaining issues is awareness. This article reviews those factors that place cephalometric measurements in an excellent position for standardization, outlines those decisions that must be made in order to realize the goal of electronic exchange of cephalometric information, and describes some of the options for these decisions as well as some advantages and disadvantages of each.

Reification of abstract concepts to improve comprehension using interactive virtual environments and a knowledge-based design: a renal physiology model.

Several abstract concepts in medical education are difficult to teach and comprehend. In order to address this challenge, we have been applying the approach of reification of abstract concepts using interactive virtual environments and a knowledge-based design. Reification is the process of making abstract concepts and events, beyond the realm of direct human experience, concrete and accessible to teachers and learners. Entering virtual worlds and simulations not otherwise easily accessible provides an opportunity to create, study, and evaluate the emergence of knowledge and comprehension from the direct interaction of learners with otherwise complex abstract ideas and principles by bringing them to life. Using a knowledge-based design process and appropriate subject matter experts, knowledge structure methods are applied in order to prioritize, characterize important relationships, and create a concept map that can be integrated into the reified models that are subsequently developed. Applying these principles, our interdisciplinary team has been developing a reified model of the nephron into which important physiologic functions can be integrated and rendered into a three dimensional virtual environment called Flatland, a virtual environments development software tool, within which a learners can interact using off-the-shelf hardware. The nephron model can be driven dynamically by a rules-based artificial intelligence engine, applying the rules and concepts developed in conjunction with the subject matter experts. In the future, the nephron model can be used to interactively demonstrate a number of physiologic principles or a variety of pathological processes that may be difficult to teach and understand. In addition, this approach to reification can be applied to a host of other physiologic and pathological concepts in other systems. These methods will require further evaluation to determine their impact and role in learning.

The mechanism by which ethanol inhibits rat P2X4 receptors is altered by mutation of histidine 241.

1. We investigated ethanol inhibition of the rat P2X(4) receptor and the contribution of the three histidine residues in the extracellular loop of this receptor to ethanol inhibition of receptor function, using site-directed mutagenesis and electrophysiological characterization of recombinant receptors. 2. In the wild-type receptor, 50, 200 and 500 mM ethanol increasingly shifted the ATP concentration-response curve to the right in a parallel manner, increasing the EC(50) value without affecting E(max). However, 750 or 900 mM ethanol did not produce a further increase in the EC(50) value of the ATP concentration-response curve, suggesting that this inhibition is not competitive. 3. The P2X(4) receptor mutations H140A and H286A did not significantly alter ethanol inhibition of ATP-activated current. By contrast, the mutation H241A changed the mechanism by which ethanol inhibits receptor function; viz., ethanol inhibition was not associated with an increased EC(50) value of the ATP concentration-response curve, instead, ethanol decreased the maximal response to ATP without affecting the EC(50) value of the ATP concentration-response curve. 4. Ethanol inhibition of the H241A mutant was voltage independent between -60 and +20 mV and ethanol did not alter the reversal potential of ATP-activated current. In addition, ethanol decreased the desensitization rate of the H241A-mediated current. 5. The purinoceptor antagonists, suramin and pyridoxal-phosphate-6-azophenyl-2',4'-disulphonic acid (PPADS), did not alter the magnitude of ethanol inhibition of ATP-activated current in the H241A mutant. 6. The results suggest that ethanol inhibits the wild-type rat P2X(4) receptor by an allosteric action to increase the EC(50) value of the ATP concentration-response curve, the P2X(4) receptor mutation H241A alters the mechanism by which ethanol inhibits P2X(4) receptor function, and ethanol and PPADS or suramin appear to inhibit H241A-mutated receptors at independent sites.

Virtual reality training improves students' knowledge structures of medical concepts.

Virtual environments can provide training that is difficult to achieve under normal circumstances. Medical students can work on high-risk cases in a realistic, time-critical environment, where students practice skills in a cognitively demanding and emotionally compelling situation. Research from cognitive science has shown that as students acquire domain expertise, their semantic organization of core domain concepts become more similar to those of an expert's. In the current study, we hypothesized that students' knowledge structures would become more expert-like as a result of their diagnosing and treating a patient experiencing a hematoma within a virtual environment. Forty-eight medical students diagnosed and treated a hematoma case within a fully immersed virtual environment. Student's semantic organization of 25 case-related concepts was assessed prior to and after training. Students' knowledge structures became more integrated and similar to an expert knowledge structure of the concepts as a result of the learning experience. The methods used here for eliciting, representing, and evaluating knowledge structures offer a sensitive and objective means for evaluating student learning in virtual environments and medical simulations.

Role of extracellular histidines in antagonist sensitivity of the rat P2X4 receptor.

The pharmacological property that most distinguishes rat P2X4 receptors from other P2X receptors is their insensitivity to the purinoceptor antagonists, suramin and pyridoxal-phosphate-6-azophenyl-2',4'-disulphonic acid (PPADS). The molecular basis of this insensitivity is not known. Here, we investigated the possibility that histidine residues in the extracellular loop of P2X4 receptors may be involved in the antagonist sensitivity of these receptors. We found that histidine mutation H241A in the rat P2X4 receptor produced receptors that are sensitive to suramin and PPADS. In contrast, mutation H140A or H286A did not significantly alter antagonist sensitivity. In addition, mutation H241A in the human P2X4 receptor significantly increased antagonist sensitivity. The results suggest that histidine 241of P2X4 receptors is involved in regulating the antagonist sensitivity of these receptors.

Role of extracellular histidines in agonist sensitivity of the rat P2X4 receptor.

Relatively little information is available about the relationship between the molecular structure of each of the seven subtypes of P2X receptors and their function. Here, we investigated the possible function of three histidine residues in the extracellular loop of rat P2X(4) receptors. Mutation of histidine 241 to alanine (H241A) in the rat P2X(4) receptor decreased the EC(50) value of the ATP concentration-response curve from 8.4 to 0.7 microM. In contrast, the histidine mutation H140A or H286A slightly increased the EC(50) value. Maximal current responses were significantly larger in oocytes expressing rat H241A-mutated receptors compared to those expressing wildtype, H140A or H286A receptors. In addition, significantly less receptor protein was detected in H241A-expressing oocytes than in oocytes expressing wildtype, H140A or H286A receptors. Moreover, ATP-activated current in H241A-expressing cells activated faster than in wildtype receptor-expressing cells. The increased maximal current amplitude, the decrease in protein expression and the more rapid activation kinetics suggest that the H241A mutation facilitates opening of the receptor-channel (gating).

Rating outlets for health care management research: an update and extension.

The ongoing discussion of our intellectual community requires that occasionally an effort be made to value the outlets for our research and erect guideposts for our colleagues to signal important contributions to our discipline. This study extends previous work through a survey sent to 1,254 academics involved in health care management research that asked them to rate 54 potential outlets for their research. Ratings were made on journal knowledge, quality, and relevance. Two survey waves resulted in 389 responses (adjusted response rate 37.8 percent). For quality and relevance, journal rankings were separated into A, B, and C categories. The results correlated strongly with the two previous studies in this area. This study extends previous research and provides a categorization of journals on knowledge, quality, and relevance that may assist in faculty performance evaluation and identification of appropriate outlets for manuscripts.

Conserved extracellular cysteines differentially regulate the potentiation produced by Zn2+ in rat P2X4 receptors.

One feature of the amino acid sequence of P2X receptors identified from mammalian species, Xenopus laevis and zebrafish is the conservation of ten cysteines in the extracellular loop. Little information is available about the role of these conserved ectodomain cysteines in the function of P2X receptors. Here, we investigated the possibility that ten conserved cysteine residues in the extracellular loop of the rat P2X4 receptor may regulate zinc potentiation of the receptor using a series of individual cysteine to alanine point mutations and functional characterization of recombinant receptors expressed in Xenopus oocytes. For the C116A, C132A, C159A, C165A, C217A and C227A mutants, 10 µM zinc did not significantly affect the current activated by an EC40 concentration of ATP. By contrast, 5 µM zinc shifted the ATP concentration-response curve to the right in a parallel manner for both the C261A and C270A mutants and the magnitudes of those shifts were similar to that of the wildtype receptor. Interestingly, for the C126A and C149A mutants, 5µM zinc potentiated ATP-activated current, but increased the maximal response to ATP by 90% and 81% respectively, without significantly changing the EC50 value of ATP. Thus, these results suggest that cysteines and disulfide bonds between cysteines are differentially involved in the potentiation of the rat P2X4 receptor by zinc.

Effect of electronic charting on the patient-psychiatrist relationship.

The impending implementation of an electronic medical record (EMR) within Behavioral Health facilities at the University of New Mexico (UNM) offers a unique opportunity to study the effects of EMR usage on a psychiatric patient population. A pre-test and post-test design using a satisfaction survey will test for changes to the patient-psychiatrist relationship before and after implementation. To date, 48 subjects have participated in the pre-implementation portion of the study.

Activation of nicotinic acetylcholine receptors increases the frequency of spontaneous GABAergic IPSCs in rat basolateral amygdala neurons.

The basolateral amygdala (BLA) is a critical component of the amygdaloid circuit, which is thought to be involved in fear conditioned responses. Using whole cell patch-clamp recording, we found that activation of nicotinic acetylcholine receptors (nAChRs) leads to an action potential-dependent increase in the frequency of spontaneous GABAergic currents in principal neurons in the BLA. These spontaneous GABAergic currents were abolished by a low-Ca2+/high-Mg2+ bathing solution, suggesting that they are spontaneous inhibitory postsynaptic currents (sIPSCs). Blockade of ionotropic glutamate receptors did not prevent this increased frequency of sIPSCs nor did blockade of alpha7 nAChRs. Among the nAChR agonists tested, cystisine was more effective at increasing the frequency of the sIPSCs than nicotine or 1,1-dimethyl-4-phenyl piperazinium iodide, consistent with a major contribution of beta4 nAChR subunits. The nicotinic antagonist, dihydro-beta-erythroidine, was less effective than d-tubocurarine in blocking the increased sIPSC frequency induced by ACh, suggesting that alpha4-containing nAChR subunits do not play a major role in the ACh-induced increased sIPSC frequency. Although alpha2/3/4/7 and beta2/4 nAChR subunits were found in the BLA by RT-PCR, the agonist and antagonist profiles suggest that the ACh-induced increase in sIPSC frequency involves predominantly alpha3beta4-containing nAChR subunits. Consistent with this, alpha-conotoxin-AuIB, a nAChR antagonist selective for the alpha3beta4 subunit combination, inhibited the ACh-induced increase in the frequency of sIPSCs. The observations suggest that nicotinic activation increases the frequency of sIPSCs in the BLA by acting mainly on alpha3beta4-containing nicotinic receptors on GABAergic neurons and may play an important role in the modulation of synaptic transmission in the amygdala.

Arginine 222 in the pre-transmembrane domain 1 of 5-HT3A receptors links agonist binding to channel gating.

Ligand-gated ion channels are integral membrane proteins that mediate fast synaptic transmission. Molecular biological techniques have been extensively used for determining the structure-function relationships of ligand-gated ion channels. However, the transduction mechanisms that link agonist binding to channel gating remain poorly understood. Arginine 222 (Arg-222), located at the distal end of the extracellular N-terminal domain immediately preceding the first transmembrane domain (TM1), is conserved in all 5-HT3A receptors and alpha7-nicotinic acetylcholine receptors that have been cloned. To elucidate the possible role of Arg-222 in the function of 5-HT3A receptors, we mutated the arginine residue to alanine (Ala) and expressed both the wild-type and the mutant receptor in human embryonic kidney 293 cells. Functional studies of expressed wild-type and mutant receptors revealed that the R222A mutation increased the apparent potency of the full agonist, serotonin (5-HT), and the partial agonist, 2-Me-5-HT, 5- and 12-fold, respectively. In addition, the mutation increased the efficacy of 2-Me-5-HT and converted it from a partial agonist to a full agonist. Furthermore, this mutation also converted the 5-HT3 receptor antagonist/very weak partial agonist, apomorphine, to a potent agonist. Kinetic analysis revealed that the R222A mutation increased the rate of receptor activation and desensitization but did not affect rate of deactivation. The results suggest that the pre-TM1 amino acid residue Arg-222 may be involved in the transduction mechanism linking agonist binding to channel gating in 5-HT3A receptors.