clinical practice

Clinical Trial Readiness of MEG Biomarkers in Children Across the Autism Spectrum

PROJECT SUMMARY Biological and phenotypic heterogeneity of autism spectrum disorder (ASD) poses a major challenge for clinically focused research and interventions. Brain electrophysiological phenotyping holds promise for parsing this heterogeneity. Using magnetoencephalography (MEG), findings of diminished and delayed auditory evoked responses (e.g. the ~50ms component, M50 and, specifically, its latency: M50L) have reproducibly been shown in ASD, with correlation to behavior. Additionally, abnormal resting state activity and network functional connectivity has been identified as an electrophysiological hallmark. Such passively-acquired signatures may serve as objective biomarkers in subtyping autistic individuals, including stratifying patients for inclusion in clinical trials according to biology, rather than behavior alone. However, despite their abundant promise, these measures are not yet permeating clinical trial design, nor being utilized in clinical practice, in part because of their lack of standardized implementation and analysis. This proposal seeks to remedy this by using rigorous and standardized, scalable and sharable methods with two leading MEG measures to determine their measurement- reliability as well as their sensitivity to inter-individual differences in clinically-relevant aspects of autism features, general cognitive ability and language and communication. Specifically adopting a 12-week repeated scanning design, mimicking the duration of a typical pharmaceutical trial or behavioral intervention, we will acquire each of these two MEG metrics at baseline and 12-week follow-up to assess interval change. Additionally, we will evaluate test-retest variability with an intermediate measurement point 4-weeks after baseline. As such we will characterize both intra-subject variability (measurement precision) and inter-subject variability which will be correlated with dimension axes of autism features, general cognitive ability and language skills, as well as major co-occurring condition confounds. These studies will recruit a broad range of 240 autistic children, paralleling the CDC’s prevalence data on intellectual ability and encompassing the group considered as having “profound autism”. This is enabled by our adoption of MEG-PLAN, a strategy developed over the last decade in our group and demonstrated to enhance inclusive participation in MEG scanning studies, even in non-verbal participants. Data will be compared to a control group of age-matched typically-developing peers. The two MEG measures will also be assessed for their ability to identify clusters of less heterogeneous neurophysiological phenotype as a novel basis for stratification or subtyping of the heterogeneous autism population. In culmination, this study addresses key “clinical readiness” aspects of utilization of MEG biomarkers for ASD including profound autism, for both stratification (inclusion/trial selection) and monitoring of response to intervention, and will, ultimately, pave the way for the adoption of such biomarkers as adjunctive tests in increasingly-routine clinical practice.

Improving Disease-Modifying Therapy Uptake among Patients with Multiple Sclerosis

Project Summary/Abstract Recent advances in the epidemiology of multiple sclerosis (MS) indicate that its prevalence is similar among White (238 per 100,000) and Black (226 per 100,000) populations. These data challenge historic assumptions about individuals with northern European heritage having higher risk and prevalence of MS. Evidence also suggests that MS incidence may be higher than previously recognized in the United States and increasing over time with more individuals identified and diagnosed year over year. MS continues to impose significant and growing burden on patients, healthcare systems and society. These health differences in the diagnosis, treatment and symptom management of MS in light of the increasing prevalence of MS in the US are an important public health issue that requires broader urgent research and policy attention to reduce the overall disease burden. In this study, we will use real-world data derived from the electronic health records (EHR) from four large academic medical centers (University of Kentucky, University of Virginia, Virginia Commonwealth University, and University of Southern California). Extracted EHR data from these four medical centers will be deidentified, combined, and harmonized. We will use this combined data set to examine (1) whether there are any differences in the timely treatment of disease modifying therapy (DMT) among different MS populations, (2) any disparities in the management of symptoms and comorbidities, (3) how non-medical factors of health such as income, education, and health insurance status (patientlevel), linguistically appropriate care provision (provider-level), and neighborhood factors (system-level) affect these outcomes and influence disparities across populations, and (4) assess whether disparities exist in the risks of cardiovascular disease CVD and mortality in MS subgroups and examine if these disparities can be reduced with improved treatment of MS and vascular comorbidities. In pursuing these objectives, we will identify clinical solutions (e.g., optimal DMT sequences) and non-medical factors such as neighborhood factors such as poverty, educational achievement, crime rates, civic participation, and housing quality, access to care factors, and cultural and linguistic match between providers and patients that substantially contribute to health disparities. For actionable solutions, we will rank-order these factors by their relative importance in addressing disparities, which will guide decision-making at the policy, system, and provider level. Our long-term objective is to develop public health strategies and scalable solutions to reduce overall burden in the management of MS. This project is expected to help policy makers and health system administrators in prioritizing interventions and to have implications for clinical practice in improving care of all patients with MS in neurology clinics, at the healthcare system level, and for national health policy.

Development of an at-home weight-shifting balance game with musical biofeedback for older adults

Reducing fall risk is a dire societal need that requires interventions that over-prepare individuals to perform maneuvers important to daily mobility. Falling is often caused by improper weight shifting, and interventions that focus on developing weight-shifting abilities have shown improvements in clinical balance outcomes, including reduced fall incidence. Interventions that combine challenges to the cognitive and motor systems may be necessary to reduce fall-risk. Our central hypothesis is that leveraging gamification and “musical biofeedback” will improve balance abilities through practicing weight-shifting skills with increased cognitive and physical demands. Musical biofeedback conveys biological sensor data from the participant through specific musical sound parameters in real-time. Of particular interest in the proposal is the applicability to use musical biofeedback to train weight-shifting skills in a musical game. The goal is to develop a wearable sensor system that can be used at-home to practice and develop balance skills, while supporting cognitive engagement and motivation to adhere to exercise goals. To start, we are focusing on older adult end-users who typically have home exercise programs focused on weight-shifting. However, in the future, many other populations can benefit from this technology. In this Trailblazer award, the PI is leveraging her background in studying complex human maneuvers, developing musical biofeedback for older adults, and in algorithm development for mHealth sensors. The transdisciplinary team includes expertise in engineering, gamified rehabilitation technologies, home exercise programs, psychology of aging, and music. In the proposed research, our goals are to evaluate responses to the musical biofeedback game (Aim 1), validate the mHealth sensor system (Aim 2), and phenotype the gameplay behavior of fallers vs. non-fallers (Aim 3), relative to their baseline characteristics (Sub-Aim 3). Our long-term goal is for a variety of people to improve their balance control patterns while supporting and building their self-efficacy. We envision users, including older adults, training with musical biofeedback to safely (and enjoyably) prepare themselves to ambulate in their community – improving and preserving their mobility. The proposed research will pioneer using an emerging clinical technology – musical biofeedback – to train balance during weight-shifting tasks. The proposed research innovates how musical biofeedback, gamification, and focusing on weight-shifting and turns in balance training can be leveraged to challenge cognitive and physical body systems in fall-risk populations. By developing new therapy options and better understanding responses relative to baseline characteristics, this research improves clinical practices to reduce fall risk and deepens our understanding of dynamic balance control. Finally, the results of the proposed research will have translational impacts to help other fall-risk groups.

Beyond Homogeneity: Characterizing Brain Disorder Heterogeneity through EEG and Normative Modeling

Electroencephalography (EEG) has been thoroughly studied for decades in psychiatry research. Yet its integration into clinical practice as a diagnostic/prognostic tool remains unachieved. We hypothesize that a key reason is the underlying patient's heterogeneity, overlooked in psychiatric EEG research relying on a case-control approach. We combine HD-EEG with normative modeling to quantify this heterogeneity using two well-established and extensively investigated EEG characteristics -spectral power and functional connectivity- across a cohort of 1674 patients with attention-deficit/hyperactivity disorder, autism spectrum disorder, learning disorder, or anxiety, and 560 matched controls. Normative models showed that deviations from population norms among patients were highly heterogeneous and frequency-dependent. Deviation spatial overlap across patients did not exceed 40% and 24% for spectral and connectivity, respectively. Considering individual deviations in patients has significantly enhanced comparative analysis, and the identification of patient-specific markers has demonstrated a correlation with clinical assessments, representing a crucial step towards attaining precision psychiatry through EEG.

Influence of the context of administration in the antidepressant-like effects of the psychedelic 5-MeO-DMT

Psychedelics like psilocybin have shown rapid and long-lasting efficacy on depressive and anxiety symptoms. Other psychedelics with shorter half-lives, such as DMT and 5-MeO-DMT, have also shown promising preliminary outcomes in major depression, making them interesting candidates for clinical practice. Despite several promising clinical studies, the influence of the context on therapeutic responses or adverse effects remains poorly documented. To address this, we conducted preclinical studies evaluating the psychopharmacological profile of 5-MeO-DMT in contexts previously validated in mice as either pleasant (positive setting) or aversive (negative setting). Healthy C57BL/6J male mice received a single intraperitoneal (i.p.) injection of 5-MeO-DMT at doses of 0.5, 5, and 10 mg/kg, with assessments at 2 hours, 24 hours, and one week post-administration. In a corticosterone (CORT) mouse model of depression, 5-MeO-DMT was administered in different settings, and behavioral tests mimicking core symptoms of depression and anxiety were conducted. In CORT-exposed mice, an acute dose of 0.5 mg/kg administered in a neutral setting produced antidepressant-like effects at 24 hours, as observed by reduced immobility time in the Tail Suspension Test (TST). In a positive setting, the drug also reduced latency to first immobility and total immobility time in the TST. However, these beneficial effects were negated in a negative setting, where 5-MeO-DMT failed to produce antidepressant-like effects and instead elicited an anxiogenic response in the Elevated Plus Maze (EPM).Our results indicate a strong influence of setting on the psychopharmacological profile of 5-MeO-DMT. Future experiments will examine cortical markers of pre- and post-synaptic density to correlate neuroplasticity changes with the behavioral effects of 5-MeO-DMT in different settings.

Post-traumatic headache

Concussion (mild traumatic brain injury) affects approximately 50 million people annually. Headache is the most common symptom after concussion and persists in up to 50% of those affected for at least one-year. The biological underpinnings of and the efficacy and tolerability of treatments for post-traumatic headache has historically received little attention. While treatment in clinical practice is mostly directly at the underlying phenotype of the headache, persistent post-traumatic headache is considered to be less responsive to treatments used to treat migraine or tension-type headache. Over the past several years, significant pre-clinical research has begun to elucidate the mechanism(s) involved in the development of post-traumatic headache, and a concerted effort to evaluate the efficacy of selected treatments for persistent post-traumatic headache has begun. This presentation will review the epidemiology, pathophysiology, and emerging data on the prevention and treatment of post-traumatic headache.

Epilepsy Genetics – From Family Studies to Polygenic Risk Scores

Whilst epilepsy may be a consequence of an acquired insult including trauma, stroke, and brain tumours, the genetic component to epilepsies has been greatly under-estimated. Considerable progress has recently occurred in the understanding of epilepsy genetics, both at a clinical genetic level and in the basic science of epilepsies. The clinical evidence for genetic components will be first briefly discussed including data from population studies, twin analyses and multiplex family studies. Initial molecular discoveries occurred via classical methods of linkage and gene identification. Recent large-scale hypothesis-free whole exome studies searching for rare variants and genome-wide association studies detecting common variants have been very rewarding. These discoveries have now impacted on clinical practice, especially in severe childhood epilepsies but increasingly so in adult patients. The “genetic background” of patients has long been posited as part of the reason that some patients have epilepsy, or perhaps why some have more severe epilepsy. This has been unmeasurable but now, with the development of polygenic risk scores, the “background” is now in the research foreground. The current and future impact of polygenic risk scores will be explored.

Adaptive Deep Brain Stimulation: Investigational System Development at the Edge of Clinical Brain Computer Interfacing

Over the last few decades, the use of deep brain stimulation (DBS) to improve the treatment of those with neurological movement disorders represents a critical success story in the development of invasive neurotechnology and the promise of brain-computer interfaces (BCI) to improve the lives of those suffering from incurable neurological disorders. In the last decade, investigational devices capable of recording and streaming neural activity from chronically implanted therapeutic electrodes has supercharged research into clinical applications of BCI, enabling in-human studies investigating the use of adaptive stimulation algorithms to further enhance therapeutic outcomes and improve future device performance. In this talk, Dr. Herron will review ongoing clinical research efforts in the field of adaptive DBS systems and algorithms. This will include an overview of DBS in current clinical practice, the development of bidirectional clinical-use research platforms, ongoing algorithm evaluation efforts, a discussion of current adoption barriers to be addressed in future work.

AI-guided solutions for early detection of neurodegenerative disorders

Despite the importance of early diagnosis of dementia for prognosis and personalised interventions, we still lack robust tools for predicting individual progression to dementia. We propose a trajectory modelling approach that mines multimodal data from patients at early dementia stages to derive individualised prognostic scores of cognitive decline Our approach has potential to facilitate effective stratification of individuals based on prognostic disease trajectories, reducing patient misclassification with important implications for clinical practice.

Blood phosphorylated tau as biomarkers for Alzheimer’s disease

Alzheimer's disease (AD) is the most common cause of dementia, and its health and socioeconomic burdens are of major concern. Presently, a definite diagnosis of AD is established by examining brain tissue after death. These examinations focus on two major pathological hallmarks of AD in the brain: (i) amyloid plaques consisting of aggregated amyloid beta (Aβ) peptides and (ii) neurofibrillary tangles made of abnormally phosphorylated tau protein. In living individuals, AD diagnosis relies on two main approaches: (i) brain imaging of tau tangles and Aβ plaques using a technique called positron emission tomography (PET) and (ii) measuring biochemical changes in tau (including phosphorylated tau at threonine-181 [p-tau181]) and the Aβ42 peptide metabolized into CSF. Unlike Aβ42, CSF p-tau181 is highly specific for AD but its usability is restricted by the need of a lumbar puncture. Moreover, PET imaging is expensive and only available in specialised medical centres. Due to these shortcomings, a simple blood test that can detect disease-related changes in the brain is a high priority for AD research, clinical care and therapy testing. In this webinar, I will discuss the discovery of p-tau biomarkers in blood and the biochemistry of how these markers differ from those found in CSF. Furthermore, I will critically review the performance of blood p-tau biomarkers across the AD pathological process and how they associate with and predict Aβ and tau pathophysiological and neuropathological changes. Furthermore, I will evaluate the potential advantages, challenges and context of use of blood p-tau in clinical practice, therapeutic trials and population screening.

Clinical practice recommendations for physical therapy for Huntington’s disease