Community Pharmacist-Centered training program improves confidence in delivering epilepsy care.

RATIONALE: Incorporating pharmacists into interdisciplinary healthcare teams can improve patient outcomes across disease states; however, there is little evidence describing pharmacists' contributions to epilepsy care. Previous research from our group revealed that community pharmacists are well positioned to serve as patient advocates, monitor medications, and provide education for people living with epilepsy. However, pharmacists would like to receive additional training in epilepsy management. Advanced training in neurology is not a practical approach for community pharmacists who engage daily with patients having a variety of conditions and medications. OBJECTIVE: To develop and evaluate a flexible, community pharmacist-centered training program to improve both confidence and competence in delivering epilepsy care. METHODS: The training program consisted of five 1-hour, self-paced online modules and two 90-minute synchronous virtual sessions. Topics included the classification of the epilepsies, comorbid conditions, antiseizure medicine (ASM) therapy, special populations (pregnancy, people of childbearing potential, older adults), seizure emergencies, and sudden unexpected death in epilepsy (SUDEP), as well as social determinants of health. The training program was delivered over 6 weeks to pharmacists located at two community pharmacies in Washington State. Learning was assessed using a pre- and post-training questionnaire containing questions that evaluated knowledge and confidence in the training material. RESULTS: The training program did not significantly change pharmacists' mastery of the material. However, the pharmacists' confidence in delivering the material significantly improved in 14 of the 16 areas that were evaluated. Pharmacists' mastery and confidence were strongest in areas around ASM management, SUDEP and seizure emergencies, people of child-bearing potential and older adults with epilepsy, and comorbidities, whereas social health disparities in epilepsy care remained an area that required further training. CONCLUSION: Our findings support the idea that community pharmacists are well positioned with the knowledge to play an important role in epilepsy care. However, dedicated training tailored to community pharmacists' needs may improve their confidence in providing such care.

Assessing different cross-validation schemes for predicting novel traits using sensor data: an application to dry matter intake and residual feed intake using milk spectral data.

Feed efficiency is important for economic profitability of dairy farms; however, recording daily dry matter intakes (DMI) is expensive. Our objective was to investigate the potential use of milk mid-infrared (MIR) spectral data to predict proxy phenotypes for DMI based on different cross-validation schemes. We were specifically interested in comparisons between a model that included only MIR data (Model M1), a model that incorporated different energy sink predictors, such as body weight, body weight change, and milk energy (Model M2), and an extended model that incorporated both energy sinks and MIR data (Model M3). Models M2 and M3 also included various cow level variables (stage of lactation, age at calving, parity) such that any improvement in model performance from M2 to M3, whether through a smaller root mean squared error (RMSE) or a greater squared predictive correlation (R2), could indicate a potential benefit of MIR to predict residual feed intake. The data used in our study originated from a multi-institutional project on the genetics of feed efficiency in US Holsteins. Analyses were conducted on 2 different trait definitions based on different period lengths: averaged across weeks vs. averaged across 28-d. Specifically, there were 19,942 weekly records on 1,812 cows across 46 experiments or cohorts and 3,724 28-d records on 1,700 cows across 43 different cohorts. The cross-validation analyses involved 3 different k-fold schemes. First, a 10-fold cow-independent cross-validation was conducted whereby all records from any one cow were kept together in either training or test sets. Similarly, a 10-fold experiment-independent cross-validation kept entire experiments together whereas a 4-fold herd-independent cross-validation kept entire herds together in either training or test sets. Based on cow-independent cross-validation for both weekly and 28-d DMI, adding MIR predictors to energy sinks (Models M3 vs M2) significantly (P < 10-10) reduced average RMSE to 1.59 kg and increased average R2 to 0.89. However, adding MIR to energy sinks (M3) to predict DMI either within an experiment-independent or herd-independent cross-validation scheme seemed to demonstrate no merit (P > 0.05) compared with an energy sink model (M2) for either R2 or RMSE (respectively, 0.68 and 2.55 kg for M2 in herd-independent scheme). We further noted that with broader cross-validation schemes, i.e., from cow-independent to experiment-independent to herd-independent schemes, the mean and slope bias increased. Given that proxy DMI phenotypes for cows would need to be almost entirely generated in herds having no DMI or training data of their own, herd-independent cross-validation assessments of predictive performance should be emphasized. Hence, more research on predictive algorithms suitable for broader cross-validation schemes and a more earnest effort on calibration of spectrophotometers against each other should be considered.

Development of a novel dosing paradigm to model diazepam rescue therapy in preclinical seizure and epilepsy models.

Diazepam is a cornerstone immediate-use antiseizure rescue therapy that may extend the duration between seizure clusters in people living with epilepsy. However, our mechanistic understanding of intermittent rescue therapy on disease progression is limited by the lack of suitable preclinical models. Specifically, the pharmacokinetics of diazepam varies widely between humans and laboratory animals. Here, we developed a novel repeat rescue therapy dosing paradigm in rats to maintain prolonged therapeutic concentrations seen in humans. Rats received three diazepam doses separated by 1 h (0.75, 1.5, or 3 mg/kg, intraperitoneal); plasma and brains were collected at 10 min and 1, 3, or 6 h following the last dose. Plasma and brain concentrations followed a dose-dependent increase with peak concentrations following the repeat 3 mg/kg paradigm (180 ng/mL) being equivalent to plasma levels observed in human studies with diazepam nasal spray. Increased brain-to-plasma ratios in this paradigm indicate that diazepam accumulation in the brain may be long-acting at the site of action. Overall, our repeat diazepam dosing paradigm mimics drug concentrations and accumulation seen in humans, offering a preclinical tool to study the impact of benzodiazepine rescue therapy on seizure-cluster biology in rodent models of epilepsy. PLAIN LANGUAGE SUMMARY: There is more to learn about how diazepam works in the brains of people who use it only when they have two or more seizures in 24 h (this is called a seizure cluster). Ethical studies in animals can be used to learn more about medicines in the body. In this study, we showed that three doses of diazepam in rats give about the same amount of the drug as one dose for a person. We can now test rats with epilepsy to see how the drug might work in people who take it when needed for seizure clusters.

Diet composition and sterilization modifies intestinal microbiome diversity and burden of Theiler's virus infection-induced acute seizures.

OBJECTIVE: Brain infection with Theiler's murine encephalomyelitis virus (TMEV) in C57BL/6J mice can induce acquired epileptogenesis. Diet alters acute seizure incidence in TMEV-infected mice; yet it is unclear whether intestinal dysbiosis may also impact acute or chronic behavioral comorbidities. This study thus assessed the impact of diet formulation and sterilization on acute seizure presentation, gut microbiome composition, and epilepsy-related chronic behavioral comorbidities. METHODS: Baseline fecal samples were collected from male C57BL/6J mice (4- to 5-weeks-old; Jackson Labs) upon facility arrival. Mice were randomized to either autoclaved (AC) or irradiated diet (IR) (Prolab RMH 3000) or IR (Picolab 5053). Three days later, mice underwent intracerebral TMEV or phosphate-buffered saline (PBS) injection. Fecal samples were collected from a subset of mice at infection (Day 0) and Day 7 post-infection. Epilepsy-related working memory deficits and seizure threshold were assessed 6 weeks post-infection. Gut microbiome diversity was determined by 16S rRNA amplicon sequencing of fecal samples. RESULTS: TMEV-infected mice displayed acute handling-induced seizures, regardless of diet: 28 of 57 IR Picolab 5053 (49.1%), 30 of 41 IR Prolab RMH 3000 (73.2%), and 47 of 77 AC Prolab RMH 3000 (61%) mice displayed seizures. The number of observed seizures differed significantly by diet: IR Picolab 5053 diet-fed mice had 2.2 ± 2.8 seizures (mean ± standard deviation), IR Prolab RMH 3000 diet-fed mice had 3.5 ± 2.9 seizures, and AC Prolab RMH 3000 diet-fed mice had 4.4 ± 3.8 seizures during the 7-day monitoring period. Gut microbiome composition differed significantly in TMEV-infected mice fed the AC Prolab RMH 3000 diet, with measured differences in gram-positive bacteria. These mice also displayed worsened long-term working memory deficits. SIGNIFICANCE: Diet-induced differences in intestinal dysbiosis in the TMEV model are associated with marked changes in acute seizure presentation, symptomatic recovery, and onset of chronic behavioral comorbidities of epilepsy. Our study reveals a novel disease-modifying impact of dietary manipulation on intestinal bacterial species after TMEV-induced acute seizures.

Effects of feeding rumen-protected lysine during the postpartum period on performance and amino acid profile in dairy cows: A meta-analysis.

Lysine is one of the limiting AA in the diets of dairy cows and is typically fed as rumen-protected Lys (RPL). We hypothesized that supplementation of RPL during the postpartum period would improve the productive performance in dairy cows. Objectives were to use meta-analytic methods to explore the effects of feeding RPL on performance and blood AA profile in lactating dairy cows. An additional objective was to identify an optimal concentration (%) of Lys in MP (LYSMP) and determine if responses to LYSMP were associated with the concentration (%) of Met in MP (METMP). The literature was systematically reviewed, and 13 experiments, comprising 40 treatment means and 594 lactating cows, were included in the meta-analysis. All experiments had a nonsupplemental control (CON; n = 17 treatment means), or a group supplemented with RPL (n = 23 treatment means). Cows supplemented with RPL were supplied additionally with a mean (±standard deviation) 19.3 ± 10.3 g/d metabolizable Lys (5.1-40.6 g/d). Meta-analytical statistics were used to estimate the weighted mean difference in STATA. Mixed models were fitted to the data to investigate the linear and quadratic effects of LYSMP, METMP, and interactions between LYSMP and METMP. All models included the random effect of experiment and weighting by the inverse of the SE of the means squared. Cows that began receiving RPL in early lactation (≤90 DIM) or for an extended duration (≥70 DIM) produced 1.51 kg/d more milk compared with CON cows. Increasing digestible LYSMP from 6.5% to 8.5% linearly increased yields of milk, FCM, ECM, and milk fat by 1.8, 2.5, 2.4, and 0.10 kg/d, respectively, and tended to increase milk protein yield and body weight gain by 0.07 and 0.09 kg/d, respectively, without a concurrent increase in DMI. Interactions between the linear effects of LYSMP and METMP were observed for FCM/DMI or ECM/DMI. In a diet with low METMP (e.g., 1.82% of MP), a digestible supply of 7.40% LYSMP would result in 1.46 and 1.47 kg/kg FCM/DMI or ECM/DMI, respectively; however, with high digestible METMP (e.g., 2.91% of MP), supplying 7.40% of digestible LYSMP would result in 1.68 and 1.62 kg/kg FCM/DMI or ECM/DMI, respectively. Increasing digestible LYSMP from 6.5% to 8.5% linearly increased blood concentrations of Lys by 16.6 µM, whereas blood concentrations of Met and Ala decreased by 4.6 and 6.0 µM, respectively. Nevertheless, an interaction was also observed between LYSMP and METMP for blood concentrations of total EAA because as METMP increased, the positive response to LYSMP on total EAA was also increased, suggesting a competitive mobilization of AA and their utilization in various body tissues. Only 4 out of the 13 experiments in this meta-analysis involved primiparous cows; thus, insufficient data were available to understand the role of supplemental RPL in primiparous cows. Collectively, feeding RPL improved productive performance, and the increments were maximized up to 9.25% of LYSMP in multiparous dairy cows.

Using design thinking to strengthen the community pharmacist's role in epilepsy care.

OBJECTIVE: To use design thinking to develop a community pharmacist-led intervention for people living with epilepsy (PWE) with desirable, feasible, and viable features. METHODS: This study used design thinking. Three patient personas were created based on previous research: a newly diagnosed PWE, a well-controlled PWE, and a complex PWE with uncontrolled seizures. An intervention prototype was developed for each of the three personas. Structured interviews were conducted with pharmacists, pharmacy students, patients with diagnosed epilepsy, and caregivers to elicit feedback on which features of each intervention prototype were desirable, feasible, and viable. Interviews were analyzed using rapid content analysis. A multidisciplinary advisory group and the research team prioritized features of the prototypes to include in the final intervention. RESULTS: The following four features were identified as desirable, feasible, and viable for a pharmacist-led intervention for PWE: (1) pharmacist-patient consultations, (2) care plan development, (3) regular check-ins, and (4) care coordination with other health care providers. SIGNIFICANCE: This study identified evidence-based features for a community pharmacist intervention to support epilepsy care using design thinking. A pilot study to evaluate this intervention on the quality of life (QoL), health outcomes and satisfaction of PWE can inform the implementation and feasibility of such patient services.

Temporal relationship between levetiracetam nonadherence and breakthrough seizures in a preclinical model of temporal lobe epilepsy.

OBJECTIVE: Poor medication adherence remains a concern for individuals managing their epilepsy with antiseizure medicines (ASMs); however, ethical concerns around withholding medication make it impossible to study the causal relationship between missed doses and seizures in patients. Previous preclinical studies from our group suggest that mechanistically distinct ASMs have varying degrees of forgiveness when a dose is missed. However, with only a few ASMs studied in the context of nonadherence, we sought to expand on previous work to understand the relationship between levetiracetam (LEV) nonadherence and breakthrough seizures. METHODS: Chronic oral dosing was initiated in rats with established epilepsy via our automated medication-in-food delivery system coupled to 24/7 video-electroencephalographic recording. Baseline seizure burden was established for 4 weeks before enrolling subjects into a 4-week treatment period with LEV in a 100% fully adherent (75 mg/kg four times daily) or 50% variably adherent paradigm. The temporal relationship between missed doses and breakthrough seizures was correlated with LEV plasma and brain concentrations in separate cohorts of animals. RESULTS: Full adherence to LEV significantly improved seizure control by 50% in half of the animals. Poor adherence worsened seizure frequency by 85%, with most rats having more severe seizures that formed in clusters following missed doses. LEV concentrations remained below therapeutic levels (<10 µg/mL) in nonadherent animals, with brain and plasma levels directly correlating with the degree of adherence in a 24-h period. Missed doses of LEV immediately increased the risk of breakthrough seizures; however, this risk was significantly reduced with improved adherence in a 24-h period. SIGNIFICANCE: These findings enhance our understanding of ASM nonadherence in preclinical models, highlighting that the timing of missed doses and their impact on seizures may vary between different ASMs. Notably, LEV demonstrates a robust pharmacokinetic reliance on missed doses leading to breakthrough seizures.

Estimation of genetic parameters for feed efficiency traits using random regression models in dairy cattle.

Feed efficiency has become an increasingly important research topic in recent years. As feed costs rise and the environmental impacts of agriculture become more apparent, improving the efficiency with which dairy cows convert feed to milk is increasingly important. However, feed intake is expensive to measure accurately on large populations, making the inclusion of this trait in breeding programs difficult. Understanding how the genetic parameters of feed efficiency and traits related to feed efficiency vary throughout the lactation period is valuable to gain understanding into the genetic nature of feed efficiency. This study used 121,226 dry matter intake (DMI) records, 120,500 energy-corrected milk (ECM) records, and 98,975 metabolic body weight (MBW) records, collected on 7,440 first-lactation Holstein cows from 6 countries (Canada, Denmark, Germany, Spain, Switzerland, and the United States), from January 2003 to February 2022. Genetic parameters were estimated using a multiple-trait random regression model with a fourth-order Legendre polynomial for all traits. Weekly phenotypes for DMI were re-parameterized using linear regressions of DMI on ECM and MBW, creating a measure of feed efficiency that was genetically corrected for ECM and MBW, referred to as genomic residual feed intake (gRFI). Heritability (SE) estimates varied from 0.15 (0.03) to 0.29 (0.02) for DMI, 0.24 (0.01) to 0.29 (0.03) for ECM, 0.55 (0.03) to 0.83 (0.05) for MBW, and 0.12 (0.03) to 0.22 (0.06) for gRFI. In general, heritability estimates were lower in the first stage of lactation compared with the later stages of lactation. Additive genetic correlations between weeks of lactation varied, with stronger correlations between weeks of lactation that were close together. The results of this study contribute to a better understanding of the change in genetic parameters across the first lactation, providing insight into potential selection strategies to include feed efficiency in breeding programs.

The gut microbiota in adults with cystic fibrosis compared to colorectal cancer.

BACKGROUND: Gut dysbiosis is implicated in colorectal cancer (CRC) pathogenesis. Cystic fibrosis (CF) is associated with both gut dysbiosis and increased CRC risk. We therefore compared the faecal microbiota from individuals with CF to CRC and screening samples. We also assessed changes in CRC-associated taxa before and after triple CF transmembrane conductance regulator (CFTR) modulator therapy. METHODS: Bacterial DNA amplification comprising V4 16S rRNA analysis was conducted on 84 baseline and 53 matched follow-up stool samples from adults with CF. These data were compared to an existing cohort of 430 CRC and 491 control gFOBT samples from the NHS Bowel Cancer Screening Programme. Data were also compared to 26 previously identified CRC-associated taxa from a published meta-analysis. RESULTS: Faecal CF samples had a lower alpha diversity and clustered distinctly from both CRC and control samples, with no clear clinical variables explaining the variation. Compared to controls, CF samples had an increased relative abundance in 6 of the 20 enriched CRC-associated taxa and depletion of 2 of the 6 taxa which have been reported as reduced in CRC. Commencing triple modulator therapy had subtle influence on the relative abundance of CRC-associated microbiota (n = 23 paired CF samples). CONCLUSIONS: CF stool samples were clearly dysbiotic, clustering distinctly from both CRC and control samples. Several bacterial shifts in CF samples resembled those observed in CRC. Studies assessing the impact of dietary or other interventions and the longer-term use of CFTR modulators on reducing this potentially pro-oncogenic milieu are needed.

Diet composition and sterilization modifies intestinal microbiome diversity and burden of Theiler's virus infection-induced acute seizures.

Objective: Central nervous system infection with Theiler's murine encephalomyelitis virus (TMEV) in C57BL/6J mice can model acquired epileptogenesis. Diet alters the acute seizure incidence in TMEV-infected mice; yet it is unclear whether intestinal dysbiosis may also impact acute or chronic behavioral comorbidities. This study thus assessed the impact of diet sterilization in a specific pathogen-free vivarium on acute seizure presentation, the composition of the gut microbiome, and chronic behavioral comorbidities of epilepsy. Methods: Baseline fecal samples were collected from male C57BL/6J mice (4-5 weeks-old; Jackson Labs) upon arrival. Mice were randomized to either autoclaved (AC) or irradiated (IR) diet (Prolab RMH 3000 - UU diets) or IR (Picolab 5053 - UW IR diet). Mice then underwent intracerebral TMEV or PBS injection three days later. Fecal samples were collected from a subset of mice at infection (Day 0) and Day 7 post-infection. Epilepsy-related working memory deficits and seizure threshold were assessed 6 weeks post-infection. Gut microbiome diversity was determined by 16S rRNA amplicon sequencing of fecal samples. Results: TMEV-infected mice displayed acute handling-induced seizures, regardless of diet: 28/57 UW IR (49.1%), 30/41 UU IR (73.2%), and 47/77 UU AC (61%) mice displayed seizures. The number of observed seizures significantly differed: UW IR mice had 2.2±2.8 seizures (mean±standard deviation), UU IR mice had 3.5±2.9 seizures, and UU AC mice had 4.4±3.8 seizures during the 7-day monitoring period. The composition of the gut microbiome significantly differed in TMEV-infected mice fed the UU AC diet, with most measured differences occurring in Gram-positive bacteria. TMEV-infected mice fed the UU AC diet displayed worsened chronic working memory. Significance: Intestinal dysbiosis evokes stark differences in acute seizure presentation in the TMEV model and vastly influences the trajectory of post-TMEV infection-induced behavioral comorbidities of epilepsy. Our study reveals a novel disease-modifying contribution of intestinal bacterial species after TMEV-induced acute seizures.

Fatty acid challenge shifts cellular energy metabolism in a substrate-specific manner in primary bovine neonatal hepatocytes.

Adipose tissue mobilization increases circulating fatty acid (FA) concentrations, leads to increased hepatic FA uptake, and influences hepatic metabolism. Our objective was to trace carbon flux through metabolic pathways in primary bovine neonatal hepatocytes challenged with FA, and to examine the effect of FA challenge on oxidative stress. Primary bovine neonatal hepatocytes were isolated from 4 Holstein bull calves and maintained for 24 h before treatment with either 0 or 1 mM FA cocktail. After 21 h, either [1-14C]C16:0 or [2-14C]sodium pyruvate was added to measure complete and incomplete oxidation and cellular glycogen. Cellular and media triglyceride (TG), and glucose and ß-hydroxybutyrate (BHB) export were quantified, as well as reactive oxygen species and cellular glutathione (GSH/GSSH). Fatty acid treatment increased cellular, but not media TG, and although complete oxidation of [1-14C]C16:0 was not affected by FA, BHB export was increased. Reactive oxygen species were increased with FA treatment and GSSH was marginally increased such that the ratio of GSH:GSSG was marginally decreased. Glucose export increased, and cellular glycogen marginally increased with FA treatment while [2-14C]sodium pyruvate oxidation was decreased. These data suggest that FA treatment shifts cellular energy metabolism in a substrate-specific manner, spares pyruvate carbon from oxidation, and stimulates glucose synthesis.

Novel genetic parameters for genetic residual feed intake in dairy cattle using time series data from multiple parities and countries in North America and Europe.

Residual feed intake is viewed as an important trait in breeding programs that could be used to enhance genetic progress in feed efficiency. In particular, improving feed efficiency could improve both economic and environmental sustainability in the dairy cattle industry. However, data remain sparse, limiting the development of reliable genomic evaluations across lactation and parity for residual feed intake. Here, we estimated novel genetic parameters for genetic residual feed intake (gRFI) across the first, second, and third parity, using a random regression model. Research data on the measured feed intake, milk production, and body weight of 7,379 cows (271,080 records) from 6 countries in 2 continents were shared through the Horizon 2020 project Genomic Management Tools to Optimise Resilience and Efficiency, and the Resilient Dairy Genome Project. The countries included Canada (1,053 cows with 47,130 weekly records), Denmark (1,045 cows with 72,760 weekly records), France (329 cows with 16,888 weekly records), Germany (938 cows with 32,614 weekly records), the Netherlands (2,051 cows with 57,830 weekly records), and United States (1,963 cows with 43,858 weekly records). Each trait had variance components estimated from first to third parity, using a random regression model across countries. Genetic residual feed intake was found to be heritable in all 3 parities, with first parity being predominant (range: 22-34%). Genetic residual feed intake was highly correlated across parities for mid- to late lactation; however, genetic correlation across parities was lower during early lactation, especially when comparing first and third parity. We estimated a genetic correlation of 0.77 ± 0.37 between North America and Europe for dry matter intake at first parity. Published literature on genetic correlations between high input countries/continents for dry matter intake support a high genetic correlation for dry matter intake. In conclusion, our results demonstrate the feasibility of estimating variance components for gRFI across parities, and the value of sharing data on scarce phenotypes across countries. These results can potentially be implemented in genetic evaluations for gRFI in dairy cattle.

Perampanel's forgiveness factor in a variable medication adherence paradigm in a rat model of chronic epilepsy.

BACKGROUND: Poor medication adherence contributes to increased morbidity and mortality in patients with epilepsy and may be under-addressed in clinical practice. Ethical concerns make it impossible to study the impact of medication nonadherence in clinical trials, but our previous work emphasizes the importance of using preclinical approaches to address these questions. With over 30 clinically available antiseizure medicines (ASM's), it remains an important question to understand the relationship between poor adherence and seizure incidence across mechanistically distinct ASM's, including the broad-spectrum ASM, perampanel (PER). METHODS: We formulated PER into chow pellets to deliver to rats in a 100% fully adherent or 50% variable nonadherent paradigm via our novel automated medication-in-food delivery system. Chronic oral dosing was initiated in male rats with chronic epilepsy while monitoring 24/7 for videoEEG evidence of seizures during a 4-week placebo baseline and 4-week treatment phase. PER concentrations were monitored in plasma at 1-week intervals and correlated with degree of seizure control. The relationship between missed doses and extended patterns of nonadherence were correlated with breakthrough seizures. RESULTS: Fully adherent rats demonstrated a median reduction in seizure frequency of 50%, whereas nonadherent rats had a median increase of 54%. Plasma concentrations of PER were stable over the 4-week treatment period in both fully adherent and nonadherent groups, with levels being twice as high in fully adherent animals. There was no correlation between a single missed dose or series of missed doses and the incidence of breakthrough seizures. However, those animals in the nonadherent group that received PER for every meal during a 24-h period had a reduced likelihood of seizure incidence. CONCLUSIONS: If our preclinical data is supported in the clinic, PER's favorable pharmacokinetic profile in humans, combined with a lowered risk of breakthrough seizures suggests that it may provide a certain forgiveness factor if a dose is missed within a 24-h window.

New GABA-Targeting Therapies for the Treatment of Seizures and Epilepsy: II. Treatments in Clinical Development.

The inhibitory neurotransmitter γ-aminobutyric acid (GABA) plays an important role in the modulation of neuronal excitability, and a disruption of GABAergic transmission contributes to the pathogenesis of some seizure disorders. Although many currently available antiseizure medications do act at least in part by potentiating GABAergic transmission, there is an opportunity for further research aimed at developing more innovative GABA-targeting therapies. The present article summarises available evidence on a number of such treatments in clinical development. These can be broadly divided into three groups. The first group consists of positive allosteric modulators of GABAA receptors and includes Staccato® alprazolam (an already marketed benzodiazepine being repurposed in epilepsy as a potential rescue inhalation treatment for prolonged and repetitive seizures), the α2/3/5 subtype-selective agents darigabat and ENX-101, and the orally active neurosteroids ETX155 and LPCN 2101. A second group comprises two drugs already marketed for non-neurological indications, which could be repurposed as treatments for seizure disorders. These include bumetanide, a diuretic agent that has undergone clinical trials in phenobarbital-resistant neonatal seizures and for which the rationale for further development in this indication is under debate, and ivermectin, an antiparasitic drug currently investigated in a randomised double-blind trial in focal epilepsy. The last group comprises a series of highly innovative therapies, namely GABAergic interneurons (NRTX-001) delivered via stereotactic cerebral implantation as a treatment for mesial temporal lobe epilepsy, an antisense oligonucleotide (STK-001) aimed at upregulating NaV1.1 currents and restoring the function of GABAergic interneurons, currently tested in a trial in patients with Dravet syndrome, and an adenoviral vector-based gene therapy (ETX-101) scheduled for investigation in Dravet syndrome. Another agent, a subcutaneously administered neuroactive peptide (NRP2945) that reportedly upregulates the expression of GABAA receptor α and ß subunits is being investigated, with Lennox-Gastaut syndrome and other epilepsies as proposed indications. The diversity of the current pipeline underscores a strong interest in the GABA system as a target for new treatment development in epilepsy. To date, limited clinical data are available for these investigational treatments and further studies are required to assess their potential value in addressing unmet needs in epilepsy management.

New GABA-Targeting Therapies for the Treatment of Seizures and Epilepsy: I. Role of GABA as a Modulator of Seizure Activity and Recently Approved Medications Acting on the GABA System.

γ-Aminobutyric acid (GABA) is the most prevalent inhibitory neurotransmitter in the mammalian brain and has been found to play an important role in the pathogenesis or the expression of many neurological diseases, including epilepsy. Although GABA can act on different receptor subtypes, the component of the GABA system that is most critical to modulation of seizure activity is the GABAA-receptor-chloride (Cl-) channel complex, which controls the movement of Cl- ions across the neuronal membrane. In the mature brain, binding of GABA to GABAA receptors evokes a hyperpolarising (anticonvulsant) response, which is mediated by influx of Cl- into the cell driven by its concentration gradient between extracellular and intracellular fluid. However, in the immature brain and under certain pathological conditions, GABA can exert a paradoxical depolarising (proconvulsant) effect as a result of an efflux of chloride from high intracellular to lower extracellular Cl- levels. Extensive preclinical and clinical evidence indicates that alterations in GABAergic inhibition caused by drugs, toxins, gene defects or other disease states (including seizures themselves) play a causative or contributing role in facilitating or maintaning seizure activity. Conversely, enhancement of GABAergic transmission through pharmacological modulation of the GABA system is a major mechanism by which different antiseizure medications exert their therapeutic effect. In this article, we review the pharmacology and function of the GABA system and its perturbation in seizure disorders, and highlight how improved understanding of this system offers opportunities to develop more efficacious and better tolerated antiseizure medications. We also review the available data for the two most recently approved antiseizure medications that act, at least in part, through GABAergic mechanisms, namely cenobamate and ganaxolone. Differences in the mode of drug discovery, pharmacological profile, pharmacokinetic properties, drug-drug interaction potential, and clinical efficacy and tolerability of these agents are discussed.

Body mass index and nutritional intake following Elexacaftor/Tezacaftor/Ivacaftor modulator therapy in adults with cystic fibrosis.

BACKGROUND: Elexacaftor/Tezacaftor/Ivacaftor (ETI) modulator therapy is often associated with increased body mass index (BMI) in people with cystic fibrosis (CF). This is thought to reflect improved clinical stability and increased appetite and nutritional intake. We explored the change in BMI and nutritional intake following ETI modulator therapy in adults with CF. METHODS: Dietary intake, measured with myfood24®, and BMI were collected from adults with CF at baseline and follow-up as part of an observational study. Changes in BMI and nutritional intake in participants who commenced ETI therapy between time points were assessed. To contextualize findings, we also assessed changes in BMI and nutritional intake between study points in a group on no modulators. RESULTS: In the pre and post ETI threapy group (n = 40), BMI significantly increased from 23.0 kg/m2 (IQR 21.4, 25.3) at baseline to 24.6 kg/m2 (IQR 23.0, 26.7) at follow-up (p<0.001), with a median of 68 weeks between time points (range 20-94 weeks) and median duration of ETI therapy was 23 weeks (range 7-72 weeks). There was a significant decrease in energy intake from 2551 kcal/day (IQR 2107, 3115) to 2153 kcal/day (IQR 1648, 2606), p<0.001. In the no modulator group (n = 10), BMI and energy intake did not significantly change between time points (p>0.05), a median of 28 weeks apart (range 20-76 weeks). CONCLUSIONS: These findings tentatively suggest that the increase in BMI with ETI therapy may not simply be attributable to an increase in oral intake. Further exploration into the underlying aetiology of weight gain with ETI therapy is needed.

Increasing the prepartum dose of rumen-protected choline: Effects of maternal choline supplementation on growth, feed efficiency, and metabolism in Holstein and Holstein × Angus calves.

Feeding pregnant cows rumen-protected choline (RPC) may have the potential to affect the growth and health of offspring, but little is known about the optimal dose, or the potential mechanisms of action. The objectives of this experiment were to 1) determine if increasing RPC supplementation during late gestation in multiparous Holstein cows would improve calf growth and 2) determine if maternal choline supplementation alters global DNA methylation patterns. Pregnant multiparous Holstein cows (n = 116) were randomly assigned to diets targeting 0g choline ion (0.0 ± 0.000 choline ion, %DM, control; CTL), 15g of choline ion (recommended dose; RD) from an established RPC product (0.10 ± 0.004 choline ion, %DM, RPC1RD; ReaShure, Balchem Corp.; positive control), or 15g (0.09 ± 0.004 choline ion, %DM, RPC2RD) or 22g (0.13 ± 0.005 choline ion, %DM, high dose; RPC2HD) of choline ion from a concentrated RPC prototype (RPC2; Balchem Corp.). Treatments were mixed into a total mixed ration and cows had ad libitum access via a roughage intake control system (Hokofarm Group, Marknesse, Netherlands). All female Holstein (n = 49) and Holstein × Angus calves (male, n = 18; female, n = 30) were enrolled and fed colostrum from a cow within the same treatment. Holstein calves and Holstein × Angus calves were fed an accelerated and traditional milk replacer program, respectively, and offered ad libitum access to calf starter. Jugular vein blood samples were collected, and body weight was measured at 7, 14, 28, 42, and 56 d of age. Categorical treatment and continuous effects of actual prepartum maternal choline ion intake were analyzed using mixed effect models. An interaction of treatment with sex, nested within breed, resulted in any choline treatment increasing the proportion of methylated whole blood DNA in male, but not female calves. Although 37% of Holstein calves across all treatments experienced abomasal bloat, no evidence for differences in health measurements (signs of respiratory disease and fecal consistency) were observed across treatments. During the first 2 wk of life in Holstein calves, RPC2HD tended to increase average daily gain (ADG) and feed efficiency (FE) compared with CTL and increasing maternal choline ion intake linearly increased ADG and FE. Maternal choline supplementation increased plasma glucose compared with CTL, while increasing serum insulin-like growth factor-1 and decreasing serum lipopolysaccharide binding protein at 7 d of age in Holstein calves. In Holstein × Angus calves, the effect of treatment on ADG tended to interact with sex: in males, RPC2HD increased ADG after 2 wk of life compared with CTL, without evidence of a treatment effect in female calves. Increasing maternal choline ion intake linearly increased ADG after 2 wk of age in male Holstein × Angus calves, while quadratically increasing FE in both sexes. Altered global DNA methylation patterns in male Holstein × Angus calves, and changes in blood metabolites in Holstein calves, provide 2 potential mechanisms for observed improvements in calf growth. Continuous treatment models demonstrated that the effects of maternal choline supplementation are sensitive to the amount of maternal choline ion intake, with greater benefit to calves observed at higher maternal intakes.

Drug resistance in epilepsy.

Drug resistance is estimated to affect about a third of individuals with epilepsy, but its prevalence differs in relation to the epilepsy syndrome, the cause of epilepsy, and other factors such as age of seizure onset and presence of associated neurological deficits. Although drug-resistant epilepsy is not synonymous with unresponsiveness to any drug treatment, the probability of achieving seizure freedom on a newly tried medication decreases with increasing number of previously failed treatments. After two appropriately used antiseizure medications have failed to control seizures, individuals should be referred whenever possible to a comprehensive epilepsy centre for diagnostic re-evaluation and targeted management. The feasibility of epilepsy surgery and other treatments, including those targeting the cause of epilepsy, should be considered early after diagnosis. Substantial evidence indicates that a delay in identifying an effective treatment can adversely affect ultimate outcome and carry an increased risk of cognitive disability, other comorbidities, and premature mortality. Research on mechanisms of drug resistance and novel therapeutics is progressing rapidly, and potentially improved treatments, including those targeting disease modification, are on the horizon.

Increasing the prepartum dose of rumen-protected choline: Effects on milk production and metabolism in high-producing Holstein dairy cows.

Peripartum rumen-protected choline (RPC) supplementation is beneficial for cow health and production, yet the optimal dose is unknown. In vivo and in vitro supplementation of choline modulates hepatic lipid, glucose, and methyl donor metabolism. The objective of this experiment was to determine the effects of increasing the dose of prepartum RPC supplementation on milk production and blood biomarkers. Pregnant multiparous Holstein cows (n = 116) were randomly assigned to one of 4 prepartum choline treatments that were fed from -21 d relative to calving (DRTC) until calving. From calving until +21 DRTC, cows were fed diets targeting 0 g/d choline ion (control, CTL) or the recommended dose (15 g/d choline ion; RD) of the same RPC product that they were fed prepartum. The resulting treatments targeted: (1) 0 g/d pre- and postpartum [0.0 ± 0.000 choline ion, percent of dry matter (%DM); CTL]; (2) 15 g/d pre- and postpartum of choline ion from an established product (prepartum: 0.10 ± 0.004 choline ion, %DM; postpartum: 0.05 ± 0.004 choline ion, %DM; ReaShure, Balchem Corp.; RPC1RD▸RD); (3) 15 g/d pre- and postpartum of choline ion from a concentrated RPC prototype (prepartum: 0.09 ± 0.004 choline ion, %DM; postpartum: 0.05 ± 0.003 choline ion, %DM; RPC2, Balchem Corp.; RPC2RD▸RD); or (4) 22 g/d prepartum and 15 g/d postpartum from RPC2 [prepartum: 0.13 ± 0.005 choline ion, %DM; postpartum: 0.05 ± 0.003 choline ion, %DM; high prepartum dose (HD), RPC2HD▸RD]. Treatments were mixed into a total mixed ration, and cows had ad libitum access via a roughage intake control system (Hokofarm Group). From calving to +21 DRTC, all cows were fed a common base diet and treatments were mixed into the total mixed ration (supplementation period, SP). Thereafter, all cows were fed a common diet (0 g/d choline ion) until +100 DRTC (postsupplementation period, postSP). Milk yield was recorded daily and composition analyzed weekly. Blood samples were obtained via tail vessel upon enrollment, approximately every other day from -7 to +21 DRTC, and at +56 and +100 DRTC. Feeding any RPC treatment reduced prepartum dry matter intake compared with CTL. During the SP, no evidence for a treatment effect on energy-corrected milk (ECM) yield was found, but during the postSP, RPC1RD▸RD and RPC2RD▸RD treatments tended to increase ECM, protein, and fat yields. During the postSP, the RPC1RD▸RD and RPC2RD▸RD treatments tended to increase, and RPC2HD▸RD increased, the de novo proportion of total milk fatty acids. During the early lactation SP, RPC2HD▸RD tended to increase plasma fatty acids and ß-hydroxybutyrate concentrations, and RPC1RD▸RD and RPC2RD▸RD reduced blood urea nitrogen concentrations compared with CTL. The RPC2HD▸RD treatment reduced early lactation serum lipopolysaccharide binding protein compared with CTL. Overall, peripartum RPC supplementation at the recommended dose tended to increase ECM yield postSP, but no evidence was seen of an additional benefit on milk production with an increased prepartum dose of choline ion. The effects of RPC on metabolic and inflammatory biomarkers support the potential for RPC supplementation to affect transition cow metabolism and health and may support the production gains observed.

Animal Models of Drug-Resistant Epilepsy as Tools for Deciphering the Cellular and Molecular Mechanisms of Pharmacoresistance and Discovering More Effective Treatments.

In the last 30 years, over 20 new anti-seizure medicines (ASMs) have been introduced into the market for the treatment of epilepsy using well-established preclinical seizure and epilepsy models. Despite this success, approximately 20-30% of patients with epilepsy have drug-resistant epilepsy (DRE). The current approach to ASM discovery for DRE relies largely on drug testing in various preclinical model systems that display varying degrees of ASM drug resistance. In recent years, attempts have been made to include more etiologically relevant models in the preclinical evaluation of a new investigational drug. Such models have played an important role in advancing a greater understanding of DRE at a mechanistic level and for hypothesis testing as new experimental evidence becomes available. This review provides a critical discussion of the pharmacology of models of adult focal epilepsy that allow for the selection of ASM responders and nonresponders and those models that display a pharmacoresistance per se to two or more ASMs. In addition, the pharmacology of animal models of major genetic epilepsies is discussed. Importantly, in addition to testing chemical compounds, several of the models discussed here can be used to evaluate other potential therapies for epilepsy such as neurostimulation, dietary treatments, gene therapy, or cell transplantation. This review also discusses the challenges associated with identifying novel therapies in the absence of a greater understanding of the mechanisms that contribute to DRE. Finally, this review discusses the lessons learned from the profile of the recently approved highly efficacious and broad-spectrum ASM cenobamate.