Epilepsy genetics: Current knowledge, applications, and future directions.

The rapid pace of disease gene discovery has resulted in tremendous advances in the field of epilepsy genetics. Clinical testing with comprehensive gene panels, exomes, and genomes are now available and have led to higher diagnostic rates and insights into the underlying disease processes. As such, the contribution to the care of patients by medical geneticists, neurogeneticists and genetic counselors are significant; the dysmorphic examination, the necessary pre- and post-test counseling, the selection of the appropriate next-generation sequencing-based test(s), and the interpretation of sequencing results require a care provider to have a comprehensive working knowledge of the strengths and limitations of the available testing technologies. As the underlying mechanisms of the encephalopathies and epilepsies are better understood, there may be opportunities for the development of novel therapies based on an individual's own specific genotype. Drug screening with in vitro and in vivo models of epilepsy can potentially facilitate new treatment strategies. The future of epilepsy genetics will also probably include other-omic approaches such as transcriptomes, metabolomes, and the expanded use of whole genome sequencing to further improve our understanding of epilepsy and provide better care for those with the disease.

Adjuvant bevacizumab for melanoma patients at high risk of recurrence: survival analysis of the AVAST-M trial.

Background: Bevacizumab is a recombinant humanised monoclonal antibody to vascular endothelial growth factor shown to improve survival in advanced solid cancers. We evaluated the role of adjuvant bevacizumab in melanoma patients at high risk of recurrence. Patients and methods: Patients with resected AJCC stage IIB, IIC and III cutaneous melanoma were randomised to receive either adjuvant bevacizumab (7.5 mg/kg i.v. 3 weekly for 1 year) or standard observation. The primary end point was detection of an 8% difference in 5-year overall survival (OS) rate; secondary end points included disease-free interval (DFI) and distant metastasis-free interval (DMFI). Tumour and blood were analysed for prognostic and predictive markers. Results: Patients (n=1343) recruited between 2007 and 2012 were predominantly stage III (73%), with median age 56 years (range 18-88 years). With 6.4-year median follow-up, 515 (38%) patients had died [254 (38%) bevacizumab; 261 (39%) observation]; 707 (53%) patients had disease recurrence [336 (50%) bevacizumab, 371 (55%) observation]. OS at 5 years was 64% for both groups [hazard ratio (HR) 0.98; 95% confidence interval (CI) 0.82-1.16, P = 0.78). At 5 years, 51% were disease free on bevacizumab versus 45% on observation (HR 0.85; 95% CI 0.74-0.99, P = 0.03), 58% were distant metastasis free on bevacizumab versus 54% on observation (HR 0.91; 95% CI 0.78-1.07, P = 0.25). Forty four percent of 682 melanomas assessed had a BRAFV600 mutation. In the observation arm, BRAF mutant patients had a trend towards poorer OS compared with BRAF wild-type patients (P = 0.06). BRAF mutation positivity trended towards better OS with bevacizumab (P = 0.21). Conclusions: Adjuvant bevacizumab after resection of high-risk melanoma improves DFI, but not OS. BRAF mutation status may predict for poorer OS untreated and potential benefit from bevacizumab. Clinical Trial Information: ISRCTN 81261306; EudraCT Number: 2006-005505-64.

Circulating tumor DNA predicts survival in patients with resected high-risk stage II/III melanoma.

Background: Patients with high-risk stage II/III resected melanoma commonly develop distant metastases. At present, we cannot differentiate between patients who will recur or those who are cured by surgery. We investigated if circulating tumor DNA (ctDNA) can predict relapse and survival in patients with resected melanoma. Patients and methods: We carried out droplet digital polymerase chain reaction to detect BRAF and NRAS mutations in plasma taken after surgery from 161 stage II/III high-risk melanoma patients enrolled in the AVAST-M adjuvant trial. Results: Mutant BRAF or NRAS ctDNA was detected (≥1 copy of mutant ctDNA) in 15/132 (11%) BRAF mutant patient samples and 4/29 (14%) NRAS mutant patient samples. Patients with detectable ctDNA had a decreased disease-free interval [DFI; hazard ratio (HR) 3.12; 95% confidence interval (CI) 1.79-5.47; P < 0.0001] and distant metastasis-free interval (DMFI; HR 3.22; 95% CI 1.80-5.79; P < 0.0001) versus those with undetectable ctDNA. Detectable ctDNA remained a significant predictor after adjustment for performance status and disease stage (DFI: HR 3.26, 95% CI 1.83-5.83, P < 0.0001; DMFI: HR 3.45, 95% CI 1.88-6.34, P < 0.0001). Five-year overall survival rate for patients with detectable ctDNA was 33% (95% CI 14%-55%) versus 65% (95% CI 56%-72%) for those with undetectable ctDNA. Overall survival was significantly worse for patients with detectable ctDNA (HR 2.63; 95% CI 1.40-4.96); P = 0.003) and remained significant after adjustment for performance status (HR 2.50, 95% CI 1.32-4.74, P = 0.005). Conclusion: ctDNA predicts for relapse and survival in high-risk resected melanoma and could aid selection of patients for adjuvant therapy. Clinical trial number: ISRCTN 81261306.

Endovenous laser ablation for major varicose tributaries.

OBJECTIVE: The purpose was to determine whether endovenous laser ablation (EVLA) could be used to treat major varicose tributaries as well as saphenous veins. METHODS: From 173 major venous systems in 95 patients treated by EVLA over a 12-month period, 108 had major varicose tributaries, of which 78 (70%) were treated by attempted EVLA of the saphenous veins and associated tributaries. RESULTS: Treatment was successful in 71 venous segments (83%). The lengths of saphenous veins treated were 3-46 (median 18) cm. and the lengths of tributaries treated were 3-38 (median 14) cm. The diameters of treated saphenous veins were 4-10 (median 6) mm, and the estimated mean diameters of treated tributaries were 3-8 (median 5) mm, as measured prior to operation with the patient in 45° reverse Trendelenburg on a tilt table. There were no early or delayed complications. CONCLUSIONS: Major varicose tributaries as well as the saphenous veins can be treated by EVLA in approximately two-thirds of cases, with success in the majority selected and with no significant complications.

Late-onset Leclercia adecarboxylata bacteraemia in a premature infant in the NICU.

UNLABELLED: Late-onset sepsis is a unique entity in the neonatal intensive care unit (NICU), as organisms involved are, by definition, nosocomial. As such, a limited number of microbes are characteristically involved. Leclercia adecarboxylata is a gram-negative bacillus rarely cultured in a clinical context, with the few published cases primarily involving immunocompromised adults. We present an ex-26-week newborn girl who developed late-onset sepsis with Leclercia adecarboxylata bacteraemia in the NICU. The infection was successfully treated with gentamicin and cefotaxime. This is the fifth paediatric report of Leclercia adecarboxylata infection, and the first in a neonate. The case raises the possibility that prior courses of antibiotics may have predisposed this individual to a rare infection essentially limited to immunocompromised individuals. CONCLUSION: Leclercia adecarboxylata is a rare infection, particularly in immunocompetent individuals. In neonates, the clinical course can be good with timely initiation of appropriate antibiotics.

Evaluation of published reports of foam sclerotherapy: what do we know conclusively?

OBJECTIVES: The aim was to evaluate the published literature to assess what is conclusively known about optimal technique and outcome for foam sclerotherapy. METHODS: A literature search was performed for randomised controlled trials, meta-analyses and observational studies using appropriate statistical techniques with survival analysis for long-term outcome. RESULTS: Foam is more effective than liquid for ultrasound-guided sclerotherapy. Both sclerosants commonly used are equally effective for sclerotherapy for small veins. Ultrasound signals appear in the systemic circulation in most patients after foam sclerotherapy but do not appear to be associated with serious complications. CONCLUSION: Little else is known about the optimal preparation of foamed sclerosants and the best technique for administering foam for sclerotherapy. Long-term studies are required to determine outcome for various techniques. There is an opportunity for many controlled trials to assess results.

Outcome of endovenous laser therapy for saphenous reflux and varicose veins: medium-term results assessed by ultrasound surveillance.

OBJECTIVE: To assess the efficacy of endovenous laser therapy (EVLT) for treating saphenous reflux associated with varicose veins. DESIGN: Out-patient treatment by EVLT with an 810nm laser wavelength with results assessed by ultrasound surveillance. PATIENTS: 361 patients who received EVLT for 509 incompetent saphenous veins over a five-year period. METHODS: EVLT was used for proximal saphenous veins and ultrasound-guided sclerotherapy (UGS) for distal saphenous veins and tributaries. Control of reflux and occlusion or obliteration of the saphenous veins was assessed by serial ultrasound studies. Univariate Kaplan-Meier life table analysis showed cumulative primary and secondary success rates, and multivariate Cox regression analysis assessed covariates that could be associated with increased risk of ultrasound failure. RESULTS: Life table analysis showed primary success at four years in 76% (95% CI 56-87%) and secondary success at four years after further treatment of recurrence by UGS in 97% (95% CI 93-99%). Cox regression analysis showed a non-significant trend towards worse primary success in male patients and worse results for older patients and limbs with clinical CEAP categories C4-6. Cox regression showed significantly worse secondary success for limbs with clinical CEAP C4-6. CONCLUSIONS: EVLT effectively controls saphenous reflux particularly with ultrasound surveillance to detect early recurrence that can be treated by UGS. Modifications in technique may be required to improve the late primary success rate.

Factors affecting the risk of deep venous occlusion after ultrasound-guided sclerotherapy for varicose veins.

OBJECTIVE: To determine which covariates predisposed to deep venous occlusion (DVO) after ultrasound-guided sclerotherapy (UGS) for varicose veins. DESIGN: Ultrasound scans before and at 3 to 7 days after UGS to detect post-procedure deep venous occlusion. MATERIALS: A consecutive series of 1931 treatment sessions in 852 patients treated by a technique for UGS. METHODS: Ultrasound examination of the full length of axial deep veins above and below knee before and soon after every procedure. Crude chi(2) analysis of all covariates allowed selection of those that showed apparent significant influence. Logistic regression analysis of these then determined which independently predisposed to post-procedure deep venous occlusion. RESULTS: Deep venous occlusion was only observed after UGS using foamed sclerosant and occurred following 28 treatment sessions. No significant difference for risk of deep venous occlusion was observed for patient characteristics or which veins were treated. Logistic regression analysis showed significant independent increased risk in a limb from using highly diluted or undiluted sclerosant (OR 0.55; 95% CI 0.19 to 1.59 for 0.6-1.0% solution, OR 10.45; 95% CI 3.12 to 34.99 for 2-2.3% and OR 0.36; 95% CI 0.07 to 1.74 for 3% solution), treating veins >or=5mm diameter (OR 3.70; 95% CI 1.23 to 11.13) and injecting >or=10 ml of foamed sclerosant for a limb (OR 3.64; 95% CI 1.21 to 10.90). CONCLUSIONS: The risk of deep venous occlusion after UGS in this series was lower when using highly diluted or undiluted sclerosant, when treating veins less than 5mm in diameter and when restricting the volume of foam injected to less than 10 ml.

Outcome of ultrasound-guided sclerotherapy for varicose veins: medium-term results assessed by ultrasound surveillance.

OBJECTIVE: To estimate medium-term success after a technique for ultrasound-guided sclerotherapy for superficial chronic venous disease. DESIGN: A prospective study in a single unit with ultrasound surveillance after treatment. MATERIALS: Results after 1189 treatment sessions for 807 venous saphenous veins and related tributaries or non-saphenous tributaries in 489 patients. METHODS: Univariate life table analysis determined primary and secondary success rates. Multivariate Cox regression analysis detected covariates that affected outcome. RESULTS: Primary and secondary success rates at 36 months for all veins were 52.4% (95%CI 46-58%) and 76.8% (95%CI 71-82%). Cox regression analysis for primary success for all veins showed significantly worse results for saphenous veins compared to tributaries (HR 3.72 - 95%CI 1.9 to 7.3). Cox regression for all saphenous veins showed independently worse results for patients less than 40 years age (HR 2.16 - 95%CI 1.27-3.66), small compared to great saphenous veins (HR 1.58 - 95%CI 1.11-2.24), veins greater than 6mm diameter compared to smaller veins (HR 2.22 - 95%CI 1.40-3.50), liquid compared to foam sclerotherapy (HR 2.20 - 95%CI 1.28-3.78), lower volumes of sclerosant compared to volumes greater than 12 ml (HR 0.51 - 95%CI 0.33-0.81) and highly diluted compared to concentrated sclerosant (HR 2.05 - 95%CI 1.21-3.46) with worse results using highly diluted or undiluted 3% sclerosant compared to a 1.5% concentration. There were no significant differences for primary success for saphenous veins for date of procedure, sex, side, primary or recurrent varicose veins, or commercial type of sclerosant. CONCLUSIONS: Ultrasound-guided sclerotherapy gives satisfactory results if it is accepted that treatment may need to be repeated to achieve secondary success. Results provide a basis for further research to explore factors that might affect outcome. Younger patients with larger diameter saphenous veins may warrant alternative forms of treatment, particularly for small saphenous reflux.

Biomechanical implications of the negative heel rocker sole shoe: gait kinematics and kinetics.

Rocker sole shoes are commonly prescribed to diabetic patients with insensate feet. Recent passage of the therapeutic shoe bill has drawn an increased focus to prescription rehabilitative footwear. The purpose of this work is to investigate the dynamics of lower extremity joints (hip, knee and ankle) with the application of a negative heel rocker sole shoe under controlled lab conditions. Forty normal adults volunteered for gait evaluations using controlled baseline and prescription negative heel rocker sole shoes. Three-dimensional motion analysis techniques were used to acquire kinematic and kinetic data using a six-camera Vicon 370 motion system and two AMTI force plates. No significant change in walking speed or stride length was seen with the negative heel rocker shoe, although cadence was increased. The most significant kinematic changes with the application of the negative heel shoe occurred at the ankle in the sagittal plane with increased plantarflexion at terminal stance. Significant hip and knee changes were also noted with increased mid-stance hip extension and knee flexion. The most significant kinetic effects were seen in the transverse plane followed by changes in the sagittal and coronal planes. Changes in power were mostly noted in the sagittal plane. Other statistically significant changes in gait kinematics and kinetics were observed, although the magnitudes and durations were limited and as a result were not considered clinically significant. The study results indicated the negative heel rocker shoe significantly altered proximal joint metrics (hip and knee). The most significant distal joint alterations were seen in sagittal plane ankle kinetics. These kinematic and kinetic changes, along with previously studied effects of pressure relief at the metatarsal heads, should aid medical professionals in prescribing prophylactic footwear.

In vivo evaluation of an EIAV vector for the systemic genetic delivery of therapeutic antibodies.

Lentiviral-based vectors hold great promise as gene delivery vehicles for the treatment of a wide variety of diseases. We have previously reported the development of a nonprimate lentiviral vector system based on the equine infectious anaemia virus (EIAV), which is able to efficiently transduce dividing and nondividing cells both in vitro and in vivo. Here, we report on the application of EIAV vectors for the systemic delivery of an antibody fusion protein designed for the treatment of cancer. The therapeutic potential of a single chain antibody against the tumour-associated antigen, 5T4, fused to immune enhancer moieties has been demonstrated in vitro and here we evaluate the genetic delivery of a 5T4 scFv fused to B7.1 (scFvB7) using an EIAV vector. The kinetics and concentration of protein produced following both intravenous (i.v.) and intramuscular (i.m.) administration was determined in immune competent adult mice. In addition, the immune response to the EIAV vector and the transgene were determined. Here, we show that a single injection of EIAV expressing scFv-B7 can give rise to concentrations of protein in the range of 1-5 microg/ml that persist in the sera for more than 50 days. After a second injection, concentrations of scFv-B7.1 rose as high as 20 microg/ml and levels greater than 2 microg/ml were present in the sera of all mice injected i.v. after 210 days despite the detection of antibodies against both the transgene and viral envelope for the duration of this study. These results demonstrate the potential of EIAV as a gene therapy vector for long-term production of therapeutic recombinant proteins.

Prevention of venous thrombosis with elastic stockings during long-haul flights: the LONFLIT 5 JAP study.

The aim of this study was to evaluate deep venous thrombosis (DVT) prophylaxis with specific elastic stockings in long-haul flights (11-13 hours), in high-risk subjects. A group of 300 subjects was included; 76 were excluded for several problems including concomitant treatments; 224 were randomized into two groups (stockings vs. controls) to evaluate prophylaxis with below-knee stockings. An exercise program was used in both groups. Scholl (UK) Flight Socks (14-17 mmHg of pressure at the ankle) were used. DVT was diagnosed with ultrasound scanning. The femoral, popliteal, and tibia] veins were scanned before and within 90 minutes after the flights. Of the 205 included subjects, 102 controls and 103 treated subjects completed the study. Drop-outs were due to flight connection problems. Age, gender, and risk distributions were comparable in the two groups. In the treatment group (103 subjects; mean age, 42; SD 9; M:F, 55:48), one limited, distal DVT was observed (0.97%). In the control group (102 subjects; mean age, 42.1; SD 10.3; M:F, 56:46), six subjects (5.8%) had a DVT. There were no superficial thromboses. The difference in DVT incidence is significant (p<0.0025; six times greater in the control group). Intention-to-treat analysis counts 18 failures in the control group (12 lost to follow-up + six thromboses) of 112 subjects (15.8%) versus eight failures (7.3%) in the treatment group (p<0.05). The tolerability of the stockings was very good and there were no complaints or side effects. All events were asymptomatic. Considering these observations, Scholl Flight Socks are effective in reducing the incidence of DVT in high-risk subjects.

Giacomini's observations on the superficial veins of the abdominal limb and principally the external saphenous.

Carlo Giacomini, later Professor of Anatomy at the University of Turin, Italy, presented a thesis on superficial and deep lower limb venous anatomy in July 1873. This resulted in his name being associated with a vein that he described in detail that passes up deep to the fascia on the back of the thigh. However, the precise nature of his detailed and insightful observations have not previously been presented, at least for the past century. The Authors were able to find and translate the original manuscript, and the first section on the superficial veins is presented here. Giacomini documented the several variations in the origin and terminations, and anterograde and retrograde flow in this vein that have only recently been rediscovered by duplex ultrasound scanning. Much can be learned from his descriptions by all who are involved in treating chronic venous disease.

Vascular ultrasound surveillance after endovascular intervention for occlusive iliac artery disease.

This paper describes vascular ultrasound surveillance after endovascular intervention for occlusive iliac artery disease. There were 105 patients who had 198 procedures in 155 limbs, consisting of 110 balloon dilatations and 88 stentings. The patients were referred to the vascular diagnostic service by several surgeons. All procedures had been considered to be initially technically successful. Colour-Doppler duplex ultrasound studies were performed shortly before and at serial intervals after operation to determine patency rates. Univariate life table analysis showed 69% primary and 96% assisted primary patency at four years. Primary patency rates at four years were significantly worse for stentings (60%) compared to balloon dilatations (71%) (P<0.05). Maximum peak systolic velocities (PSV) were recorded from the treated arteries. Receiver operating characteristics curves showed that PSV >300 cm/s was most accurate for predicting technical failure. Haemodynamic success rates at four years were 72% for PSV >300 cm/s. Results for procedures that were initially successful indicate that long-term primary patency rates for iliac endovascular intervention are acceptable and that assisted primary patency rates are excellent.

Venous thromboembolism from air travel: the LONFLIT study.

The LONFLIT study was planned to evaluate the incidence of deep venous thrombosis (DVT) occurring as a consequence of long flights. In the Lonflit study 355 subjects at low-risk for DVT and 389 at high-risk were studied. Low-risk subjects had no cardiovascular disease and used no drugs. All flights were in economy class. The average flight duration was 12.4 hours (range, 10-15 hr). The mean age of the studied subjects was 46 years (range 20-80 yr, SD 11; 56% males). DVT diagnosis was made by ultrasound scans after the flights (within 24 hours). In low-risk subjects no events were recorded while in high-risk subjects 11 had DVT (2.8%) with 13 thromboses in 11 subjects and 6 superficial thromboses (total of 19 thrombotic events in 389 patients [4.9%]). In the Lonflit2 study the authors studied 833 subjects (randomized into 422 control subjects and 411 using below-knee stockings). Mean age was 44.8 years (range, 20-80 yr, SD 12; 57% males). The average flight duration was 12.4 hours. Scans were made before and after the flights. In the control group there were 4.5% of subjects with DVT while only 0.24% of subjects had DVT in the stockings group. The difference was significant. The incidence of DVT observed when subjects were wearing stockings was 18.75 times lower than in controls. Long-haul flights are associated to DVT in some 4-5% of high-risk subjects. Below-knee stockings are beneficial in reducing the incidence of DVT.

The rational clinical examination. Does this patient have clubbing?

CONTEXT: The association between digital clubbing and a host of diseases has been recognized since the time of Hippocrates. Although the features of advanced clubbing are familiar to most clinicians, the presence of early clubbing is often a source of debate. OBJECTIVE: To perform a systematic review of the literature for information on the precision and accuracy of clinical examination for clubbing. DATA SOURCES: The MEDLINE database from January 1966 to April 1999 was searched for English-language articles related to clubbing. Bibliographies of all retrieved articles and of standard textbooks of physical diagnosis were also searched. STUDY SELECTION: Studies selected for data extraction were those in which quantitative or qualitative assessment for clubbing was described in a series of patients. Sixteen studies met these criteria and were included in the final analysis. DATA EXTRACTION: Data were extracted by both authors, who independently reviewed and appraised the quality of each article. Data extracted included quantitative indices for distinguishing clubbed from normal digits, precision of clinical examination for clubbing, and accuracy of clubbing as a marker of selected diseases. DATA SYNTHESIS: The profile angle, hyponychial angle, and phalangeal depth ratio can be used as quantitative indices to assist in identifying clubbing. In individuals without clubbing, values for these indices do not exceed 176 degrees, 192 degrees, and 1.0, respectively. When clinicians make a global assessment of clubbing at the bedside, interobserver agreement is variable, with kappa values ranging between 0.39 and 0.90. Because of the lack of an objective diagnostic criterion standard, accuracy of physical examination for clubbing is difficult to determine. The accuracy of clubbing as a marker of specific underlying disease has been determined for lung cancer (likelihood ratio, 3.9 with phalangeal depth ratio in excess of 1.0) and for inflammatory bowel disease (likelihood ratio, 2.8 and 3.7 for active Crohn disease and ulcerative colitis, respectively, if clubbing is present). CONCLUSIONS: We recommend use of the profile angle and phalangeal depth ratio as quantitative indices in identifying clubbing. Clinical judgment must be exercised in determining the extent of further evaluation for underlying disease when these values exceed 180 degrees and 1.0, respectively.

Evaluating clinical teachers: does the learning environment matter?

Teaching evaluations are an important part of promotion reviews. This study of the effect of learning environment on evaluations found ratings from students in ambulatory settings were higher than were those from inpatient settings.