Perampanel Study 207: long-term open-label evaluation in patients with epilepsy.

OBJECTIVES: Evaluate interim long-term tolerability, safety and efficacy of adjunctive perampanel, a novel α-amino-3-hydroxy-5-methyl-5-isoxazolepropionic acid (AMPA)-receptor antagonist, in patients with refractory partial-onset seizures. MATERIALS AND METHODS: Study 207, an open-label extension (OLE) study (ClinicalTrials.gov identifier: NCT00368472), enrolled patients (18-70 years) who completed one of two randomized, placebo-controlled, dose-escalation Phase II studies. The OLE Treatment Phase comprised a 12-week Titration Period (2 mg increments of perampanel every 2 weeks to 12 mg/day, maximum) and a Maintenance Period, during which patients continued treatment up to a planned maximum of 424 weeks (~8 years). Interim analysis data cut-off date was 1 December, 2010. RESULTS: Of 180 patients completing the Phase II studies, 138 enrolled in study 207. At the time of interim analyses (approximately 4 years after study start), over a third (n = 53, 38.4%) remained on perampanel; 41.3% (n = 57) of patients had >3 years of exposure; and 13.0% (n = 18) had at least 4 years' exposure. Mean ± standard deviation (SD) duration of exposure was 116 ± 75 weeks and mean ± SD dose during the OLE Maintenance Period was 7.3 ± 3.3 mg. No new safety signals emerged with long-term treatment. Consistent with previous studies, the most common treatment-emergent adverse events were as follows: dizziness, headache and somnolence. Overall median (range) per cent change from baseline in seizure frequency per 28 days during open-label treatment was -31.5% (-99.2 to 512.2). CONCLUSIONS: Long-term - up to 4 years - adjunctive perampanel had a favourable tolerability profile in patients with refractory partial-onset seizures. Improvements in seizure control were maintained with long-term treatment.

Randomized phase III study 306: adjunctive perampanel for refractory partial-onset seizures.

OBJECTIVE: To evaluate the efficacy and safety of perampanel 2, 4, and 8 mg/day added to 1-3 concomitant antiepileptic drugs (AEDs) in patients with uncontrolled partial-onset seizures. METHODS: During this double-blind, placebo-controlled trial, patients with persisting seizures on 1-3 AEDs were randomized to perampanel 2, 4, and 8 mg/day or placebo following a 6-week baseline phase. Perampanel was titrated weekly by 2 mg/day and maintained at the dose achieved for 13 weeks. Primary endpoints were median percent change in seizure frequency and 50% responder rate. Analysis of covariance was performed on all treated patients with any seizure data (recorded in daily diaries) in the double-blind phase. RESULTS: A total of 706 patients were randomized and received trial medication; 623 completed the trial. Median percent change in seizure frequency-the primary efficacy endpoint-was -10.7%, -13.6%, -23.3%, and -30.8% for placebo, perampanel 2, 4, and 8 mg/day, respectively. The difference from placebo was statistically significant for perampanel 4 mg/day (p = 0.0026) and 8 mg/day (p < 0.0001). The corresponding 50% responder rates were 17.9%, 20.6%, 28.5%, and 34.9%. The difference from placebo was statistically significant for perampanel 4 mg/day (p = 0.0132) and 8 mg/day (p = 0.0003). An apparent dose response was suggested for dizziness, which was the most frequent treatment-emergent adverse event. CONCLUSIONS: This trial demonstrated that adjunctive perampanel effectively reduced seizure frequency and possessed a favorable tolerability profile in patients ≥12 years with partial-onset seizures (with or without secondary generalization), with a minimum effective dose of 4 mg/day. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that 4 and 8 mg/day doses of adjunctive perampanel are effective and tolerated in reducing partial-onset seizures.

Lacosamide for the treatment of epilepsy.

Lacosamide is a third-generation antiepilepsy drug approved for adjunctive treatment of partial-onset seizures in adults. The pharmacology of lacosamide includes linear kinetics, complete bioavailability, and no major drug interactions. Lacosamide produces slow inactivation of neuronal sodium channels, which differentiates it from other sodium channel modulators, such as carbamazepine and phenytoin. The drug was effective with no major safety problems detected in three large placebo-controlled pivotal trials and has been released in Europe and the US at 200-400 mg/day, divided b.i.d.; an intravenous formulation is approved for temporary conversion from oral therapy. This article reviews the clinical development, pharmacology, and uses of lacosamide for treating partial-onset seizures in adults.

Tolerability and safety of perampanel: two randomized dose-escalation studies.

OBJECTIVES: To evaluate, for the first time in patients with epilepsy, the tolerability and safety of escalating doses of oral perampanel, a novel, selective, non-competitive AMPA antagonist, as adjunctive therapy for refractory partial-onset seizures. MATERIALS AND METHODS: Two consecutive, randomized, double-blind, dose-escalation studies recruited adults (18-70 years) with uncontrolled partial-onset seizures receiving one to three concomitant antiepileptic drugs. In study 206, patients were treated for 12 weeks (8-week dose-titration, 4-week dose-maintenance) with placebo or perampanel (up to 4 mg/day, dosed once- or twice-daily). In study 208, patients received placebo or perampanel once-daily (up to 12 mg) for 16 weeks (12-week titration, 4-week maintenance). RESULTS: Overall, 153 patients were randomized into study 206 (perampanel twice-daily, n = 51; perampanel once-daily, n = 51; placebo, n = 51). Study 208 included 48 patients (perampanel once-daily, n = 38; placebo, n = 10). The highest dose in study 206 - 4 mg/day - was well tolerated, with similar proportions of patients tolerating once-daily (82.4%) and twice-daily (82.4%) perampanel and placebo (82.4%) treatments. In study 208 most patients tolerated doses of ≥ 6 mg perampanel once-daily in a Kaplan-Meier analysis. In both studies, the most common adverse events were CNS-related; most were of mild/moderate severity. CONCLUSIONS: Perampanel was well tolerated across doses of 4-12 mg/day. The studies showed preliminary evidence of efficacy and identified doses to be evaluated in larger clinical studies.

Minimizing pharmacodynamic interactions of high doses of lacosamide.

OBJECTIVES: To determine whether pharmacodynamic interactions between high doses of lacosamide (400-800 mg/day) and concomitant sodium channel antiepilepsy drugs (AEDs) can be minimized in patients with drug-resistant partial-onset seizures. MATERIALS AND METHODS: Patients were rapidly initiated with high-dose lacosamide (100 mg/week; increases to 400 to 800 mg/day), while simultaneously tapering concomitant sodium channel AEDs. Seizure frequency and side effects were evaluated at six time points: baseline, titration, 3, 6, 9 and 12 months. RESULTS: Twenty-three patients had a baseline median of 4 seizures/month with persisting partial-onset seizures, despite previous treatment with an average of 6.8 AEDs. Mean decreases in monthly seizure frequency were as follows: 3 months 49.9% (P = 0.011), 6 months 55.4% (P = 0.010), 9 months 60.8% (P = 0.002) and 12 months 58.2% (P = 0.011). Most adverse events were mild CNS-related symptoms and occurred transiently only during titration - there was no significant relationship (χ(2) < 1.5, P > 0.1) between lacosamide dose and the presence of side effects at 3, 6, 9 or 12 months. CONCLUSIONS: Drug-resistant patients rapidly titrated to high doses of lacosamide with simultaneous tapering of traditional sodium channel AEDs had marked reduction in CNS-related adverse events compared with patients treated in three previous pivotal trials that used fixed doses of concomitant AEDs.

Adjunctive rufinamide in Lennox-Gastaut syndrome: a long-term, open-label extension study.

OBJECTIVE: This open-label extension evaluated the long-term efficacy and tolerability of rufinamide in patients with Lennox-Gastaut syndrome (LGS) who had previously completed a 12-week double-blind study. MATERIALS AND METHODS: In total, 124 patients (aged 4-37 years), receiving 1-3 concomitant antiepileptic drugs, were treated with rufinamide approximately 25-60 mg/kg/day. Efficacy was assessed by seizure frequency; tolerability by adverse events (AEs) and laboratory tests. RESULTS: Overall, patients were treated with rufinamide for a median (range) of 432 (10-1149) days. Reductions in seizure frequency were observed throughout the study; during the last 12 months of treatment, 41.0% and 47.9% of patients had > or = 50% reduction in total and tonic-atonic seizure frequency, respectively. The most common AEs were vomiting (30.6%) and pyrexia (25.8%). CONCLUSIONS: In this open-label extension, rufinamide appeared to be an effective long-term adjunctive therapy for the treatment of LGS-associated seizures in children and young adults.

Efficient nonlinear light emission of single gold optical antennas driven by few-cycle near-infrared pulses.

Individual nanometer-sized plasmonic antennas are excited resonantly with few-cycle laser pulses in the near infrared. Intense third-harmonic emission of visible light prevails for fundamental photon energies below 1.1 eV. Interband luminescence and second harmonic generation occur solely at higher driving frequencies. We attribute these findings to multiphoton resonances with the d-band transitions of gold. The strong third-order signal allows direct measurement of a subcycle plasmon dephasing time of 2 fs, highlighting the efficient radiation coupling and broadband response of the devices.

Improved coverage of fungal diversity in polluted groundwaters by semi-nested PCR.

Traditional methods used for studying communities of aquatic hyphomycetes are based on the detection and identification of their asexual spores under a microscope. These techniques limit detection to aquatic fungi present in sufficient quantity and capable of sporulating under laboratory conditions. Our objective was to develop a molecular approach to detect and monitor all types of fungi (i.e. strictly or facultatively aquatic) in harsh habitats (i.e. groundwater wells and heavily polluted surface water) where fungal biomass may become limited. We developed a semi-nested PCR protocol for fungal 18S ribosomal RNA genes coupled to subsequent analysis of the PCR products by Temperature Gradient Gel Electrophoresis (TGGE) to monitor the fungal community structure in aquatic habitats characterized by a pollution gradient. Our TGGE-protocol was compared with the traditional morphological approach and revealed a higher diversity in groundwaters and in some polluted surface waters. Thus, PCR-TGGE is a promising alternative in particular in habitats with low fungal biomass. The dynamics of fungal biomass and sporulation rates during the first weeks of leaf colonization showed that habitats with adverse ecological conditions allow only reduced fungal growth, which might subsequently impact upper trophic levels and thus interfere with key ecological processes of leaf decomposition.

Rufinamide for generalized seizures associated with Lennox-Gastaut syndrome.

BACKGROUND: Lennox-Gastaut syndrome is a catastrophic pediatric epilepsy syndrome characterized by multiple types of treatment-resistant seizures and high rates of seizure-related injury. Current available treatments are inadequate, leaving patients with few treatment options and opportunities. METHODS: We conducted a double-blind, randomized, placebo-controlled trial of the antiepileptic drug rufinamide in patients with Lennox-Gastaut syndrome. Eligible patients between 4 and 30 years of age had multiple types of seizures (including tonic-atonic and atypical absence seizures) with a minimum of 90 seizures in the month before baseline and a recent history of a slow spike-and-wave pattern on EEG. RESULTS: After a 28-day baseline period, 139 eligible patients were randomized; 138 patients received either rufinamide (n = 74) or placebo (n = 64) in addition to their other antiepileptic drugs. The median percentage reduction in total seizure frequency was greater in the rufinamide therapy group than in the placebo group (32.7% vs 11.7%, p = 0.0015). There was a difference (p < 0.0001) in tonic-atonic ("drop attack") seizure frequency with rufinamide (42.5% median percentage reduction) vs placebo (1.4% increase). The rufinamide group had a greater improvement in seizure severity (p = 0.0041) and a higher 50% responder rate compared with placebo for total seizures (p = 0.0045) and tonic-atonic seizures (p = 0.002). The common adverse events (reported by >or=10% of patients receiving rufinamide) were somnolence (24.3% with rufinamide vs 12.5% with placebo) and vomiting (21.6% vs 6.3%). CONCLUSIONS: Rufinamide was an effective and well-tolerated treatment for seizures associated with Lennox-Gastaut syndrome.

Unexpected high stiffness of Ag and Au nanoparticles.

We studied the compressibility of silver (10 nm) and gold (30 nm) nanoparticles, n-Ag and n-Au, suspended in a methanol-ethanol mixture by x-ray diffraction (XRD) with synchrotron radiation at pressures up to 30 GPa. Unexpectedly for that size, the nanoparticles show a significantly higher stiffness than the corresponding bulk materials. The bulk modulus of n-Au, K(0)=290(8) GPa, shows an increase of ca. 60% and is in the order of W or Ir. The structural characterization of both kinds of nanoparticles by XRD and high-resolution electron microscopy identified polysynthetic domain twinning and lamellar defects as the main origin for the strong decrease in compressibility.

Aquatic hyphomycete communities as potential bioindicators for assessing anthropogenic stress.

With a profound knowledge of how physico-chemical parameters affect these communities, microbial communities could be used as indicators for environmental changes and for risk assessment studies. We studied aquatic hyphomycete communities in rivers and aquifers from sites shaped by intense mining activities (namely the "Mansfeld region") and chemical industry (cities of Halle and Bitterfeld) in Central Germany. Environmental stress factors such as high concentrations of heavy metals, sulphate, and nitrate as well as low concentrations of oxygen significantly reduced the diversity and biomass of hyphomycetes in the investigated samples. Redundancy analysis (RDA) indicates that variations in water chemistry cause a significant proportion of the change in fungal community structure (86.2%). Fungi were negatively correlated with high metal and nutrient concentrations. RDA also showed a strong influence of organic matter on individual species, with Anguillospora longissima (Sacc. et Syd.), Clavatospora longibrachiata (Ingold), Clavariopsis aquatica (De Wild), Flagellospora curvula (Ingold), Heliscus lugdunensis (Sacc. et Thérry), Tumularia aquatica (Ingold) and Lemonniera aquatica (De Wild) being most sensitive. We propose that aquatic hyphomycete communities can be used as sensitive and integrative indicators for freshwater quality.

Interaction of sulfur and nitrogen nutrition in tobacco (Nicotiana tabacum) plants: significance of nitrogen source and root nitrate reductase.

The significance of root nitrate reductase for sulfur assimilation was studied in tobacco (NICOTIANA TABACUM) plants. For this purpose, uptake, assimilation, and long-distance transport of sulfur were compared between wild-type tobacco and transformants lacking root nitrate reductase, cultivated either with nitrate or with ammonium nitrate. A recently developed empirical model of plant internal nitrogen cycling was adapted to sulfur and applied to characterise whole plant sulfur relations in wild-type tobacco and the transformant. Both transformation and nitrogen nutrition strongly affected sulfur pools and sulfur fluxes. Transformation decreased the rate of sulfate uptake in nitrate-grown plants and root sulfate and total sulfur contents in root biomass, irrespective of N nutrition. Nevertheless, glutathione levels were enhanced in the roots of transformed plants. This may be a consequence of enhanced APR activity in the leaves that also resulted in enhanced organic sulfur content in the leaves of the tranformants. The lack of nitrate reductase in the roots in the transformants caused regulatory changes in sulfur metabolism that resembled those observed under nitrogen deficiency. Nitrate nutrition reduced total sulfur content and all the major fractions analysed in the leaves, but not in the roots, compared to ammonium nitrate supply. The enhanced organic sulfur and glutathione levels in ammonium nitrate-fed plants corresponded well to elevated APR activity. But foliar sulfate contents also increased due to decreased re-allocation of sulfate into the phloem of ammonium nitrate-fed plants. Further studies will elucidate whether this decrease is achieved by downregulation of a specific sulfate transporter in vascular tissues.

Cerebellar and thalamic stimulation treatment for epilepsy.

The present chapter describes the most important available experimental and clinical evidence on the role of electrical stimulation of the cerebellum or the thalamus in the control of epilepsy. Cerebellum serves as an integrator of sensory information and regulator of motor coordinating and training. The sole output of the cerebellum is inhibitory Purkinje cell projections to deep cerebellar nuclei in the brainstem. Cerebellar stimulation in animal models of epilepsy has given mixed results. Nevertheless, more than 130 epileptic patients have been subjected to cerebellar stimulation and the results from uncontrolled studies have been encouraging. The anterior thalamic nucleus (ATN) is part of the Papez circuit, a group of limbic structures with demonstrated role in epilepsy. The centromedian thalamic nucleus (CMN) is considered part of the thalamic reticular system. Stimulation of either of these nuclei in experimental animals has been associated with considerable antiepileptic effects. On the basis of the research evidence, numerous studies have been done on humans, which gave promising results. Currently, a multicenter trial on stimulation of the ATN, the SANTE trial is in progress in the USA. On the basis of the reported studies, the authors aim to provide insights into how the electrical stimulation of the above structures exerts an antiepileptic effect and also provide suggestions regarding the future progress in this field.

Three-dimensional atom probe characterization of alloy element partitioning in cementite during tempering of alloy steel.

Hardness measurements confirm that the martensitic microstructure of an alloy steel, AISI/SAE 4340, is significantly more resistant to softening, compared to the martensitic microstructure of a high-purity Fe-0.4% C alloy, at tempering temperatures, 300-400 degrees C, just above the temperatures where cementite replaces transition carbides in the martensitic matrix. Three-dimensional atom probe (3DAP) analyses of the 4340 steel show that Si rejection from the cementite is first detected after low-temperature tempering for times of 1 h. After 10-h tempering at 400 degrees C, Mn and Cr contents are increased, and Ni contents decreased, in cementite according to their carbide- and non-carbide-forming tendencies, respectively. The results are discussed with respect to the diffusivity of the substitutional alloying elements in the 4340 steel, and the effect that such diffusion-controlled redistribution would have on maintaining fine distributions of cementite that resist softening during tempering.

Depth-resolved optical imaging and microscopy of vascular compartment dynamics during somatosensory stimulation.

The cortical hemodynamic response to somatosensory stimulus is investigated at the level of individual vascular compartments using both depth-resolved optical imaging and in-vivo two-photon microscopy. We utilize a new imaging and spatiotemporal analysis approach that exploits the different characteristic dynamics of responding arteries, arterioles, capillaries and veins to isolate their three-dimensional spatial extent within the cortex. This spatial delineation is validated using vascular casts. Temporal delineation is supported by in-vivo two-photon microscopy of the temporal dynamics and vascular mechanisms of the arteriolar and venous responses. Using these techniques we have been able to characterize the roles of the different vascular compartments in generating and controlling the hemodynamic response to somatosensory stimulus. We find that changes in arteriolar total hemoglobin concentration agree well with arteriolar dilation dynamics, which in turn correspond closely with changes in venous blood flow. For 4-s stimuli, we see only small changes in venous hemoglobin concentration, and do not detect measurable dilation or ballooning in the veins. Instead, we see significant evidence of capillary hyperemia. We compare our findings to historical observations of the composite hemodynamic response from other modalities including functional magnetic resonance imaging. Implications of our results are discussed with respect to mathematical models of cortical hemodynamics, and to current theories on the mechanisms underlying neurovascular coupling. We also conclude that our spatiotemporal analysis approach is capable of isolating and localizing signals from the capillary bed local to neuronal activation, and holds promise for improving the specificity of other hemodynamic imaging modalities.

Improved tolerability and efficacy in epilepsy patients with extended-release carbamazepine.

The authors conducted a 3-month, prospective, open-label study assessing the effects of switching from immediate-release carbamazepine formulations to an equal total daily dose of carbamazepine extended-release capsules (CBZ-ERC) in adolescents and adults with epilepsy. Using validated, epilepsy-specific measures the authors found that switching to CBZ-ERC significantly improved patients' adverse events and quality-of-life measures. Switching to CBZ-ERC also improved seizure control.

Clinical and EEG features of patients with EEG wicket rhythms misdiagnosed with epilepsy.

BACKGROUND: EEG wicket rhythms are 6- to 11-Hz medium-to-high voltage bursts that are sometimes misidentified as epileptogenic activity. The authors determined the clinical and EEG features of patients with wicket rhythms who had been incorrectly diagnosed with epilepsy. METHODS: Electroencephalographers at an epilepsy center re-read EEGs for patients referred for epilepsy management and identified patients with wicket rhythms. On further evaluation, the majority (54%; 25/46) of these patients were found not to have epilepsy. The authors compared the clinical and EEG features for the 25 patients with wickets and nonepileptic episodes with those of age- and sex-matched patients with partial-onset epilepsy using univariate and multivariate analysis. RESULTS: Several features distinguished patients with EEG wicket patterns and nonepileptic episodes (n = 25) from age- and sex-matched patients with epilepsy (n = 25): mid-adult age at onset of episodes (mean 38.4 years vs 19.8 years), prolonged clinical episodes (mean 155 minutes vs 2.3 minutes), and long duration of EEG wicket patterns (mean 0.66 seconds vs 0.11 second spikes). After controlling for other factors, patients without major confusion during episodes were unlikely to have epilepsy. CONCLUSION: Wicket patterns are often interpreted as epileptogenic. This distinctive EEG pattern should be considered in patients with clinical episodes atypical for epilepsy.

Site-specific binding of the 9.5 kilodalton DNA-binding protein ORF80 visualized by atomic force microscopy.

Atomic force microscopy (AFM) has been used to examine the binding properties of the DNA-binding protein ORF80 to DNA. ORF80 is a 9.5 kDa protein that binds site-specifically to double-stranded DNA of the sequence TTAA-N(7)-TTAA. Direct sizing of the protein complexes on DNA fragments from the plasmid pRN1 with AFM shows that the protein ORF80 binds preferentially to two positions. These positions agree well with the ORF80 binding sites determined by footprinting analysis. The measurements allow an estimate of the stoichiometry of the DNA-protein complexes. In contrast to previous results, the single-molecule experiments suggest that only a low number of ORF80 molecules bind to a DNA-binding site.

The use of the aquatic moss Fontinalis antipyretica L. ex Hedw. as a bioindicator for heavy metals: 3. Cd2+ accumulation capacities and biochemical stress response of two Fontinalis species.

We studied heavy metal stress responses of two Fontinalis species, F. antipyretica and F. dalecarlica, collected from two habitats in Germany and Canada. The capacities of the two species for extracellular adsorption (biosorption) and intracellular uptake (bioaccumulation) of Cadmium (Cd2+) were investigated in the laboratory. Time-dependent Cd2+ adsorption by cell wall and intracellular uptake differed significantly between the two species. These differences were related to the number of Cd2+ binding sites, resulting from differences in leaflet surface and cell wall composition. Glutathione (GSH) levels in response to Cd2+ exposure were monitored over a 10-day period. GSH synthesis differed significantly between the two species. Both Fontinalis species appear to be suitable for heavy metal biomonitoring in aquatic habitats.

Improved CNS tolerability following conversion from immediate- to extended-release carbamazepine.

OBJECTIVES: Tolerability of 'narrow therapeutic ratio' (NTR) antiepileptic drugs may improve with uniform drug delivery. We determined whether conversion from immediate-release carbamazepine (IR-CBZ) to extended-release carbamazepine (ER-CBZ) decreased the incidence of CNS side-effects associated with drug concentration oscillations. METHODS: We compared CNS side effects and seizure frequency for patients with partial-onset seizures (n = 61) treated with IR-CBZ for > or =1 year with conversion to ER-CBZ for > or =1 year. We compared tolerability findings with absorption variability of the formulations. RESULTS: Incidence of CNS side-effects decreased from 49% during IR-CBZ treatment to 20% following conversion to ER-CBZ. Patients also had improved tolerability of high doses (> or =1200 mg/day) during ER-CBZ treatment. Pharmacokinetic analysis showed absorption and drug concentration were much more variable for the immediate-release formulation. CONCLUSIONS: This study suggests that ER-CBZ formulations, with smoother drug delivery and less variable absorption, provide improved CNS tolerability compared with immediate-release formulations.