Mapping the gene for autosomal dominant restless legs syndrome in an Irish family

Restless Legs Syndrome (RLS) is a common neurological disorder affecting nearly 15% of the general population. Ironically, RLS can be described as the most common condition one has never heard of. It is usually characterised by uncomfortable, unpleasant sensations in the lower limbs inducing an uncontrollable desire to move the legs. RLS exhibits a circadian pattern with symptoms present predominantly in the evening or at night, thus leading to sleep disruption and daytime somnolence. RLS is generally classified into primary (idiopathic) and secondary (symptomatic) forms. Primary RLS includes sporadic and familial cases of which the age of onset is usually less than 45 years and progresses slowly with a female to male ratio of 2:1. Secondary forms often occur as a complication of another health condition, such as iron deficiency or thyroid dysfunction. The age of onset is usually over 45 years, with an equal male to female ratio and more rapid progression. Ekbom described the familial component of the disorder in 1945 and since then many studies have been published on the familial forms of the disorder. Molecular genetic studies have so far identified ten loci (5q, 12q, 14p, 9p, 20p, 16p, 19p, 4q, 17p). No specific gene within these loci has been identified thus far. Association mapping has highlighted a further five areas of interest. RLS6 has been found to be associated with SNPs in the BTBD9 gene. Four other variants were found within intronic and intergenic regions of MEIS1, MAP2K5/LBXCOR1, PTPRD and NOS1. The pathophysiology of RLS is complex and remains to be fully elucidated. Conditions associated with secondary RLS, such as pregnancy or end-stage renal disease, are characterised by iron deficiency, which suggests that disturbed iron homeostasis plays a role. Dopaminergic dysfunction in subcortical systems also appears to play a central role. An ongoing study within the Department of Pathology (University College Cork) is investigating the genetic characteristics of RLS in Irish families. A three generation RLS pedigree RLS3002 consisting of 11 affected and 7 unaffected living family members was recruited. The family had been examined for four of the known loci (5q, 12q, 14p and 9p) (Abdulrahim 2008). The aim of this study was to continue examining this Irish RLS pedigree for possible linkage to the previously described loci and associated regions. Using informative microsatellite markers linkage was excluded to the loci on 5q, 12q, 14p, 9p, 20p, 16p, 19p, 4q, 17p and also within the regions reported to be associated with RLS. This suggested the presence of a new unidentified locus. A genome-wide scan was performed using two microsatellite marker screening sets (Research Genetics Inc. Mapping set and the Applied Biosystems Linkage mapping set version 2.5). Linkage analysis was conducted under an autosomal dominant model with a penetrance of 95% and an allele frequency of 0.01. A maximum LOD score of 3.59 at θ=0.00 for marker D19S878 indicated significant linkage on chromosome 19p. Haplotype analysis defined a genetic region of 6.57 cM on chromosome 19p13.3, corresponding to 2.5 Mb. There are approximately 100 genes annotated within the critical region. Sequencing of two candidate genes, KLF16 and GAMT, selected on the assumed pathophysiology of RLS, did not identify any sequence variant. This study provides evidence of a novel RLS locus in an Irish pedigree, thus supporting the picture of RLS as a genetically heterogeneous trait.

Artefact detection and removal algorithms for EEG diagnostic systems

The electroencephalogram (EEG) is a medical technology that is used in the monitoring of the brain and in the diagnosis of many neurological illnesses. Although coarse in its precision, the EEG is a non-invasive tool that requires minimal set-up times, and is suitably unobtrusive and mobile to allow continuous monitoring of the patient, either in clinical or domestic environments. Consequently, the EEG is the current tool-of-choice with which to continuously monitor the brain where temporal resolution, ease-of- use and mobility are important. Traditionally, EEG data are examined by a trained clinician who identifies neurological events of interest. However, recent advances in signal processing and machine learning techniques have allowed the automated detection of neurological events for many medical applications. In doing so, the burden of work on the clinician has been significantly reduced, improving the response time to illness, and allowing the relevant medical treatment to be administered within minutes rather than hours. However, as typical EEG signals are of the order of microvolts (μV ), contamination by signals arising from sources other than the brain is frequent. These extra-cerebral sources, known as artefacts, can significantly distort the EEG signal, making its interpretation difficult, and can dramatically disimprove automatic neurological event detection classification performance. This thesis therefore, contributes to the further improvement of auto- mated neurological event detection systems, by identifying some of the major obstacles in deploying these EEG systems in ambulatory and clinical environments so that the EEG technologies can emerge from the laboratory towards real-world settings, where they can have a real-impact on the lives of patients. In this context, the thesis tackles three major problems in EEG monitoring, namely: (i) the problem of head-movement artefacts in ambulatory EEG, (ii) the high numbers of false detections in state-of-the-art, automated, epileptiform activity detection systems and (iii) false detections in state-of-the-art, automated neonatal seizure detection systems. To accomplish this, the thesis employs a wide range of statistical, signal processing and machine learning techniques drawn from mathematics, engineering and computer science. The first body of work outlined in this thesis proposes a system to automatically detect head-movement artefacts in ambulatory EEG and utilises supervised machine learning classifiers to do so. The resulting head-movement artefact detection system is the first of its kind and offers accurate detection of head-movement artefacts in ambulatory EEG. Subsequently, addtional physiological signals, in the form of gyroscopes, are used to detect head-movements and in doing so, bring additional information to the head- movement artefact detection task. A framework for combining EEG and gyroscope signals is then developed, offering improved head-movement arte- fact detection. The artefact detection methods developed for ambulatory EEG are subsequently adapted for use in an automated epileptiform activity detection system. Information from support vector machines classifiers used to detect epileptiform activity is fused with information from artefact-specific detection classifiers in order to significantly reduce the number of false detections in the epileptiform activity detection system. By this means, epileptiform activity detection which compares favourably with other state-of-the-art systems is achieved. Finally, the problem of false detections in automated neonatal seizure detection is approached in an alternative manner; blind source separation techniques, complimented with information from additional physiological signals are used to remove respiration artefact from the EEG. In utilising these methods, some encouraging advances have been made in detecting and removing respiration artefacts from the neonatal EEG, and in doing so, the performance of the underlying diagnostic technology is improved, bringing its deployment in the real-world, clinical domain one step closer.

Early biomarkers to predict grade of encephalopathy following hypoxic ischaemic injury

The standard early markers for identifying and grading HIE severity, are not sufficient to ensure all children who would benefit from treatment are identified in a timely fashion. The aim of this thesis was to explore potential early biomarkers of HIE. Methods: To achieve this a cohort of infants with perinatal depression was prospectively recruited. All infants had cord blood samples drawn and biobanked, and were assessed with standardised neurological examination, and early continuous multi-channel EEG. Cord samples from a control cohort of healthy infants were used for comparison. Biomarkers studied included; multiple inflammatory proteins using multiplex assay; the metabolomics profile using LC/MS; and the miRNA profile using microarray. Results: Eighty five infants with perinatal depression were recruited. Analysis of inflammatory proteins consisted of exploratory analysis of 37 analytes conducted in a sub-population, followed by validation of all significantly altered analytes in the remaining population. IL-6 and IL-6 differed significantly in infants with a moderate/severely abnormal vs. a normal-mildly abnormal EEG in both cohorts (Exploratory: p=0.016, p=0.005: Validation: p=0.024, p=0.039; respectively). Metabolomic analysis demonstrated a perturbation in 29 metabolites. A Cross- validated Partial Least Square Discriminant Analysis model was developed, which accurately predicted HIE with an AUC of 0.92 (95% CI: 0.84-0.97). Analysis of the miRNA profile found 70 miRNA significantly altered between moderate/severely encephalopathic infants and controls. miRNA target prediction databases identified potential targets for the altered miRNA in pathways involved in cellular metabolism, cell cycle and apoptosis, cell signaling, and the inflammatory cascade. Conclusion: This thesis has demonstrated that the recruitment of a large cohortof asphyxiated infants, with cord blood carefully biobanked, and detailed early neurophysiological and clinical assessment recorded, is feasible. Additionally the results described, provide potential alternate and novel blood based biomarkers for the identification and assessment of HIE.

Early nutrition and eczema in infancy

Eczema prevalence rates among Irish infants are unreported, despite eczema being the most common inflammatory condition of infancy. Maternal and infant nutritional status including vitamin D and other fat-soluble vitamins as well as early infant feeding have been linked with eczema initiation and development. Therefore, early nutrition could be a potential modifiable risk factor. The objective of this thesis was to prospectively describe early infant feeding and complementary feeding practices, to evaluate infant vitamin D supplementation practice, to quantify cord serum 25-hydroxyvitamin D [25(OH)D] and propose reference intervals for vitamin D metabolites, to report eczema prevalence and explore the potential role of infant nutrition and eczema. These research needs were investigated through the Cork BASELINE (Babies After SCOPE: Evaluating the Longitudinal Impact with Neurological and Nutritional Endpoints) Birth Cohort Study (n 2137). This thesis was the first comprehensive report from the birth cohort, therefore it was important to describe the cohort sociodemographic profile. Although socio-demographic characteristics compared well with national data, there was an over-representation of educated mothers which may limit the generalizability of the results. From August 2008 through November 2011, comprehensive postnatal assessments were completed at day 2 and at 2, 6, 12 and 24 months. Breastfeeding rates were low, while complementary feeding practices were broadly compliant with national guidelines. The implementation of a national infant vitamin D supplementation policy had a major impact on supplementation practice. Low levels of serum 25(OH)D were universal among Irish neonates. Eczema is a complex and multifaceted disease, which is increasing globally. This was the first report of eczema prevalence data among Irish infants which compared with international reports. Given the high prevalence and considerable burden eczema has on the lives of sufferers, intensive research efforts to identify a cause and therapeutic strategies to prevent/reduce eczema was re-emphasized in this thesis.

Physical function, psychosocial adaptation, and hardiness post stroke

Introduction: Stroke is a chronic condition that significantly impacts on morbidity and mortality (Balanda et al. 2010). Globally, the complexity of stroke is well documented and more recently, in Ireland, as part of the National Survey of Stroke Survivors (Horgan et al. 2014). There are a number of factors that are known to influence adaptation post stroke. However, there is a lack of research to explain the variability in how survivors adapt post stroke. Hardiness is a broad personality trait that leads to better outcome. This study investigated the influence of hardiness and physical function on psychosocial adaptation post stroke. Methods: A quantitative cross-sectional, correlational, exploratory study was conducted between April and November 2013. The sample consisted of stroke survivors (n=100) who were recruited from three hospital outpatient departments and completed a questionnaire package. Results: The mean age of participants was 76 years (range 70-80), over half (56%) of the participants achieved the maximum score of 20 on the Barthel Index indicating independence in activities of daily living. The median number of days since stroke onset was 91 days (range 74-128). The total mean score and standard deviation for hardiness was 1.89 (0.4) as measured by the Dispositional Resilience Scale, indicating medium hardiness (possible range 0-3). Psychosocial adaptation was measured using the Psychosocial Adjustment to Illness Scale, the total weighted mean and standard deviation was 0.54 (0.3) indicating a satisfactory level of psychosocial adaptation (possible range 0-3). A hierarchical multiple linear regression was performed which contained 6 independent variables (hardiness, living arrangement, and length of hospital stay, number of days since stroke onset, physical function and self-rated recovery). Findings demonstrated that physical function (p<0.001) and hardiness (p=0.008) were significantly related to psychosocial adaptation. Altogether, 65% of the variation in psychosocial adaptation can be explained by the combined effect of the independent variables. Physical functioning had the highest unique contribution (11%) to explain the variance in psychosocial adaptation while self-rated recovery, hardiness, and living arrangements contributed 3% each. Conclusion: This research provides important information regarding factors that influence psychosocial adaptation post stroke at 3 months. Physical function significantly contributed to psychosocial adaptation post stroke. The personality trait of hardiness provides insight into how behaviour influenced adaptation post stroke. While hardiness also had a strong relationship with psychosocial adaptation, further research is necessary to fully comprehend this process.

Caregiver burden and resilience among Malaysian caregivers of individuals with severe mental illness

Little research has focused on caregiver burden experienced by Malaysian caregivers of individuals with mental illness, despite the fact that data in the Asian region shows almost threequarter of patients with mental illness live with family members. The aim of this research was to examine the levels of caregiver burden and resilience of caregivers of individuals with severe mental illness and to determine the influencing factors on caregiver burden. A quantitative, cross sectional, correlational design was used to measure burden and resilience and to explore the relationship between demographic variables, caregiver stressors, resilience and caregiver burden. This study was guided by the model of Carer Stress and Burden. Data collection was conducted over two months in summer 2014. A self-administered questionnaire that consisted of four sections measuring demographic data, primary stressors, caregiver burden and resilience was used to collect data. Two hundred and one caregivers of individuals with mental illness attending Psychiatric Outpatient Clinics in Malaysia were recruited. Samples were selected using non-probability, consecutive sampling. Factors that were found to be significantly associated with caregiver burden were caregivers’ age, gender, ethnic group, employment status, having a medical condition and current health status. The primary stressors found to be significantly associated with caregiver burden include the time spent for caregiving tasks, unavailability of support with caregiving tasks, lack of emotional support and patients’ behavioural disturbances. In addition, it was found that caregivers who were less resilient reported a higher level of caregiver burden. Findings from hierarchical multiple regression indicated that caregivers’ marital status, current health status, time spent for caregiving and resilience predicted caregiver burden. This research provides insight into caregiver burden among caregivers of individuals with mental illness in Malaysia. It highlights the important factors associated with caregiver burden and the significant role of resilience in reducing caregiver burden.

Nutrition, growth and body composition in infancy

This thesis is presented in two parts. Data for this research is from the Cork BASELINE (Babies after SCOPE, Evaluating Longitudinal Impact using Neurological and Nutritional Endpoints) Birth Cohort Study (n = 2137). In this prospective birth cohort study, pediatric follow-up with in-person appointments were repeated from the time of birth through to 2, 6 and 12 months, and at 2 years. Body composition was measured by air displacement plethysmography at birth and at 2 months using the PEA POD Infant Body Composition Tracking System. This thesis provides the first extensive report on the study’s 2 year assessment. In part one, the aims were to investigate potential early-life risk factors for childhood overweight and obesity, including rapid growth and body composition in infancy and umbilical cord concentrations of leptin and high molecular weight (HMW) adiponectin. This research is the first to describe rapid growth in early infancy in terms of changes in direct measures of body composition. These are also the first data to examine associations between umbilical cord leptin and HMW adiponectin concentrations and changes in fat and lean mass in early infancy. These data provide additional insight into characterising the growth trajectory in infancy and into the role of perinatal factors in determining infant growth and subsequent overweight/obesity risk. In part two of this thesis, the aims were to quantify vitamin D intake and status at 2 years and to investigate whether 25-hydroxyvitamin D [25(OH)D] concentrations in early pregnancy and in umbilical cord blood are associated with infant growth and body composition. There was a low prevalence of vitamin D deficiency among Irish 2 year olds (n = 742) despite a high prevalence of inadequate intakes and high latitude (51°N). Maternal 25(OH)D concentrations at 15 weeks gestation and cord 25(OH)D concentrations at delivery were not associated with infant growth or adiposity.