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In recent decades, neurologists have been directing more of their research efforts to exploring the sources of health disparities in medical and surgical treatment of epilepsy. Many studies reveal that racial and ethnic minority patients continue to receive suboptimal care, which has some dire repercussions on their physical and mental health, as well as their social well-being because epilepsy is a chronic disease that tends to affect multiple aspects of the patient’s life. Although the earliest landmark studies emphasized the importance of mixed methodology research, the studies that followed tended to rely heavily on quantitative methods to unravel patterns of disparities with sparse use of qualitative methods to give voice to the patients concerned. In this work, I present a mixed methodology framework that is particularly suitable to investigating health disparities in epilepsy care, which affirms the complementary nature of quantitative and qualitative methods. I explore some of the challenges that clinicians face to utilizing qualitative methods, and introduce some of the validity criteria and techniques of qualitative research that make it a valuable methodology to understand disparities. I highlight some of the ethical concerns with recent studies in health disparities in epilepsy care which adopt only quantitative or qualitative methodology, and contribute very little to eliminating disparities compared to the potential contribution of mixed methodology research. This will be supported by various examples from research led by clinicians, public health professionals, and social scientists. / Urban Bioethics

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Connexins are transmembrane proteins that form hemichannels allowing the exchange of molecules between the extracellular space and the cell interior. Two hemichannels from adjacent cells dock and form a continuous gap junction pore, thereby permitting direct intercellular communication. Connexin 36 (Cx36), expressed primarily in neurons, is involved in the synchronous activity of neurons and may play a role in aberrant synchronous firing, as seen in seizures. To understand the reciprocal interactions between Cx36 and seizure-like neural activity, we examined three questions: a) does Cx36 deficiency affect seizure susceptibility, b) does seizure-like activity affect Cx36 expression patterns, and c) does acute blockade of Cx36 conductance increase seizure susceptibility. We utilize the zebrafish pentylenetetrazol (PTZ; a GABA(A) receptor antagonist) induced seizure model, taking advantage of the compact size and optical translucency of the larval zebrafish brain to assess how PTZ affects brain-wide neuronal activity and Cx36 protein expression. We exposed wild-type and genetic Cx36-deficient (cx35.5-/-) zebrafish larvae to PTZ and subsequently mapped neuronal activity across the whole brain, using phosphorylated extracellular-signal-regulated kinase (pERK) as a proxy for neuronal activity. We found that cx35.5-/- fish exhibited region-specific susceptibility and resistance to PTZ-induced hyperactivity compared to wild-type controls, suggesting that genetic Cx36 deficiency may affect seizure susceptibility in a region-specific manner. Regions that showed increased PTZ sensitivity include the dorsal telencephalon, which is implicated in human epilepsy, and the lateral hypothalamus, which has been underexplored. We also found that PTZ-induced neuronal hyperactivity resulted in a rapid reduction of Cx36 protein levels within. 30 minutes and one-hour exposure to 20 mM PTZ significantly reduced the expression of Cx36. This Cx36 reduction persists after one-hour of recovery but recovered after 3-6 hours. This acute downregulation of Cx36 by PTZ is likely maladaptive, as acute pharmacological blockade of Cx36 by mefloquine results in increased susceptibility to PTZ-induced neuronal hyperactivity. Together, these results demonstrate a reciprocal relationship between Cx36 and seizure-associated neuronal hyperactivity: Cx36 deficiency contributes region-specific susceptibility to neuronal hyperactivity, while neuronal hyperactivity-induced downregulation of Cx36 may increase the risk of future epileptic events. / Doctor of Philosophy / Within the brain, cells (neurons) communicate with each other to pass along information. This communication is important for normal functions of the brain such as learning and memory, muscle movement, etc. Epilepsy is a disease of the brain that is caused by rapid over synchronized communication between cells. This leads to seizures which can include convulsions, loss of attention, and much more. Currently, 30% of patients suffering from epilepsy do not have a treatment option that works for them, it is, therefore, imperative to investigate new targets for treatment in this disease. Connexin36 is a protein in the brain that directly connects cells so they can pass information quickly between them. Connexin36, therefore, might make a good target for treatment. Previous work has aimed to understand this relationship but has been limited in their ability to look at the entire brain at any one time. The goal of this study was to understand the relationship between connexin 36 and brain hyperactivity across the whole brain simultaneously. To understand this relationship, we first determined what happened to brain activity if the protein was missing entirely after exposure to a seizure causing drug. We were asking: How does connexin 36 affect hyperactivity. We found that different regions of the brain responded differently without the connexin 36 protein. This suggests that one size does not fit all, and one must look at the whole brain to understand the effects of the connexin 36 protein. Next, we asked a similar question, but in the opposite direction, how does hyperactivity affect connexin 36? We found, in the short-term, hyperactivity reduced the amount of connexin 36 present in certain regions of the brain. This continued until 3 hours following exposure to the seizure causing drug Pentylenetetrazol (PTZ). Lastly, to determine if this short-term reduction in connexin 36 meant that an individual was more likely to experience hyperactivity. To do this, we used a connexin 36 blocking drug, then introduced the seizure causing drug at different concentrations. We found, at all concentrations, the connexin 36 blocking drug caused significant changes in neuronal activity, depending on the brain regions. Overall, our results showed that connexin 36 plays an important role in hyperactivity and that a short-term reduction in connexin 36 is detrimental, and may contribute to an increase in the possibility of subsequent hyperactivity.

Epilepsy is one of the most common neurological disorders worldwide. This neurological disorder is characterized by spontaneous recurrent seizures and impacts about 65 million people globally. As there is no cure for epilepsy, the treatment goal for patients is seizure management, and ultimately seizure freedom. The first line of defense in seizure management is anti-epileptic drugs, which aim to restore the excitatory and inhibitory balance in the brain. Unfortunately, about 30% of people with epilepsy are drug resistant, a number which has remained unchanged despite the increasing amount of anti-epileptic drugs. This leads patients to seek alternative treatments, which include surgery, vagus nerve stimulation, or diet alterations such as the ketogenic diet. Due to the invasiveness of surgeries, difficulty to maintain specialty diets, or lack of effectiveness of these treatments in some patients, additional therapies are needed. The gut-brain axis is a bidirectional communication network connecting the central and enteric nervous systems. Part of this network includes communication via the gut microbiota. The gut microbiota consists of all the microorganisms living in the gut, including bacteria, viruses, and fungi. It is involved in aiding nutrient absorption, promoting the maturation of immune cells and functions, and protection against pathogens. There is growing interest in the role of the gut microbiome in human health and disease. Studies have shown that patients with epilepsy have altered gut microbiomes compared to healthy controls, and that gut microbiome alteration can impact seizure frequencies. These exciting findings have ignited research on the potential therapeutic role of the gut microbiome in epilepsy. Although studies have explored the impact of alterations in the gut microbiome on seizure activity, they have not studied how anti-epileptic drugs may contribute to this relationship. Thus, this dissertation explores the role of the commonly prescribed anti-epileptic drug topiramate on the gut microbiome. Fecal samples of mice treated with topiramate were analyzed using 16S ribosomal RNA gene sequencing. Analysis revealed that topiramate ingestion increased the probiotic bacteria Lactobacillus johnsonii in the gut microbiome. In addition, cotreatment of topiramate and Lactobacillus johnsonii reduced seizure susceptibility in a pentylenetetrazol-kindling seizure model. Moreover, cotreatment increased the butyrate producing family Lachnospiraceae and subsequently increased the neuroprotective SCFA, butyrate in the gut microbiome. Importantly, cotreatment also resulted in an increased GABA/glutamate ratio in the cortex of mice that underwent pentylenetetrazol-kindling. These results are the first to demonstrate that the anti-seizure effect of topiramate may be facilitated by the modulation of the gut microbiota via increasing butyrate and altering the GABA/glutamate ratio in the cortex. Lastly, this work highlights the potential for probiotics as an adjuvant therapy in seizure management. / Doctor of Philosophy / Epilepsy is one of the most common neurological disorders worldwide. This neurological disorder is characterized by spontaneous recurrent seizures and impacts about 65 million people globally. As there is no cure for epilepsy, the treatment goal for patients is seizure management, and ultimately seizure freedom. The first line of defense in seizure management is anti-epileptic drugs, which aim to restore the excitatory and inhibitory balance in the brain. Unfortunately, about 30% of people with epilepsy are drug resistant, a number which has remained unchanged despite the increasing amount of anti-epileptic drugs. Due to this unmet need, epilepsy patients utilize alternative treatments, which include surgery, vagus nerve stimulation, or diet modifications such as the ketogenic diet. Due to the invasiveness of surgeries, difficulty to maintain specialty diets, or lack of effectiveness of these treatments in some patients, additional therapies are needed. The gut microbiota consists of all the microorganisms living in the gut, including bacteria, viruses, and fungi, which can be both harmful and helpful. In healthy individuals, the gut microbiota coexists in a balance that prevents diseases and helps the host, however, disruptions in this balance can lead to susceptibility to several diseases. As a result, researchers are increasingly interested in the role of the gut microbiota in human health and disease. In epilepsy, the gut microbiome is altered compared to healthy individuals, and gut microbiome alterations can impact seizure activity. This has led researchers to investigate the potential therapeutic role of the gut microbiome in epilepsy. Although studies have explored the impact of alterations in the gut microbiome on seizure activity, they have not studied how anti-epileptic drugs may contribute to this relationship. Thus, this dissertation explores the role of the commonly prescribed anti-epileptic drug topiramate on the gut microbiome. The results demonstrate that topiramate increases probiotic bacteria in the gut microbiome of mice. Moreover, this probiotic bacterium facilitates topiramate in reducing the susceptibility to seizures in a mouse model by resulting in a beneficial gut microbiome and restoring excitatory and inhibitory balance to the brain. These results are the first to demonstrate that the anti-seizure effect of topiramate may be facilitated by the gut microbiome. Lastly, this work highlights the potential for probiotics as an adjuvant therapy in seizure management.

The study herein described represents a continuation of the work on 5-(2-thienyl)-5-substituted hydantoins which has been in progress in the laboratories of the North Texas State College for the past several years. It has for its purpose the study of the effect of lengthening the carbon chain connecting a cyclohexyl radical to 5-(2-thienyl)hydantoin in the 5- position.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第25162号 / 医博第5048号 / 新制||医||1070(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 林 康紀, 教授 髙橋 良輔, 教授 井上 治久 / 学位規則第4条第1項該当 / Doctor of Agricultural Science / Kyoto University / DFAM

Thesis (MSc)--Stellenbosch University, 2000. / ENGLISH ABSTRACT: Please see fulltext for abstract / AFRIKAANSE OPSOMMING: Sien asb volteks vir opsomming

Thesis (DMed (Medicine. Internal Medicine))--University of Stellenbosch, 2009. / ENGLISH ABSTRACT: Progressive Myoclonic Epilepsies (PME) are characterized by progressive neurological impairment with myoclonus, seizures and dementia. In contradistinction, Familial Adult Myoclonic Epilepsy (FAME) is characterized by a benign course with rare seizures and cortical tremor. Both conditions have neurophysiological features suggestive of a cortical origin for their myoclonus. This dissertation reports on a novel form of PME. Many of those who were affected had no or minimal progression of their illness, low seizure frequency and were cognitively intact, suggestive of non-progressive disorders linked to the FAME loci. The majority of patients had features of cortical myoclonus, with generalized spike and wave discharges on electroencephalography, enlarged evoked potentials, enhanced C reflexes, and evidence of cortical excitability with magnetic stimulation. However, there was evidence of cerebellar dysfunction both pathologically and on imaging. With regard to similar conditions, dentatorubral pallidoluysian atrophy and Unverricht-Lundborg syndrome were excluded by linkage analysis. Similarly, linkage was not present for either the FAME 1 or FAME 2 loci. This syndrome is both clinically and genetically novel, and has a nosology which is difficult to characterize, in which the condition appears to lie on the spectrum between FAME and PME. The dissociation between the pathological and radiological findings which suggest subcortical dysfunction, and the neurophysiological findings of cortical myoclonus is striking. Review of the literature associated with the neurophysiology of related conditions associated with PME and FAME suggests that: 1. The assumption that generalized forms of myoclonic disorders represent multifocal forms of focal cortical discharges is an oversimplification. 2. The dissociation between initial and later components of the evoked potential is less robust than is generally supposed, and that subcortical inputs may affect later components of the evoked potential. 3. In a high proportion of cases the latency from cortical spike discharge to myoclonic jerk obtained with jerk locked averaging is incompatible with a cortical origin for the spike discharge. 4. The proposal that myoclonus is a form of long latency reflex and that myoclonus represents a reflex arising from subclinical sensory input, is unproven. / AFRIKAANSE OPSOMMING: Progressiewe Miokloniese Epilepsie (PME) word gekenmerk deur progressiewe neurologiese agteruitgang met mioklonus, konvulsies en demensie. Daarenteen word Familiële Volwasse Miokloniese Epilepsie (FAME) gekenmerk deur 'n benigne verloop met ongereelde konvulsies en kortikale tremor. Beide entiteite het neurofisiologiese kenmerke suggestief van 'n kortikale oorsprong vir die mioklonus. Hierdie manuskrip beskryf 'n nuwe vorm van PME. Baie van die aangetaste persone toon geen of min agteruitgang van die siekte oor tyd nie, met 'n lae frekwensie van konvulsies en is kognitief intak, wat suggestief is van 'n nie-progressiewe siekte gekoppel aan die FAME loci. Die oorgrote meerderheid van pasiente het kenmerke van kortikale mioklonus gehad, met algemene spits en boog ontladings op elektroensefalografie, hoë amplitude ontlokte potensiale, versterkte C-reflekse, en tekens van kortikale eksiteerbaarheid met magnetiese stimulasie. Met neurobeelding en patologie was daar egter bewyse van serebellêre disfunksie. Soortgelyke toestande, naamlik dentatorubro-pallidoluysiese atrofie en Unverricht-Lundborg sindroom is uitgeskakel deur middel van koppelingsanalise. Koppeling met die FAME1 of FAME2 loci kon ook nie aangetoon word nie. Die sindroom is beide klinies sowel as geneties nuut en het 'n nosologie wat moeilik gekaraktiseer kan word. Dit wil voorkom of die siekte op 'n spektrum lê tussen FAME en PME. Die dissosiasie tussen die patologiese en radiologiese bevindinge, wat suggestief is van subkortikale disfunksie, en die neurofisiologiese bevindinge van kortikale mioklonus is opmerklik. ’n Oorsig van die literatuur in verband met die neurofisiologie van toestande geassosieer met PME en FAME suggesteer die volgende: 1. Die aanname dat algemene vorme van miokloniese toestande multifokale vorme van fokale kortikale ontladings verteenwoordig, is ’n oorvereenvoudiging. 2. Die dissosiasie tussen inisiële en latere komponente van die ontlokte potensiaal is minder robuust as wat algemeen aanvaar word, en subkortikale invoer mag latere komponente van die ontlokte potensiaal beïnvloed. 3. In ’n groot proporsie van gevalle is die latensie van kortikale spits ontlading tot miokloniese ruk, verkry deur “jerk locked averaging”, nie verenigbaar met met ’n kortikale oorsprong vir die spits ontlading nie. 4. Geen bewyse bestaan vir die teorie dat mioklonus ’n vorm van ’n lang latensie refleks is en dat mioklonus ’n refleks is wat ontstaan uit subkliniese sensoriese invoer nie.