A Pacinian hyperplasia of the foot

A case of Pacinian hyperplasia of the right great toe is reported. Pacinian hyperplasia is a rare benign and recently recognized painful lesion composed of an excess of well formed or hyperplastic Pacinian corpuscules, normaly involved in sensory innervation. This lesion that is usually observed in the hand, must be distinguished from nerve tumors harboring onion-bulb structure which are not true well formed Pacinian corpuscules and from Morton neuroma. Pacinian hyperplasia is considered a reactive lesion and not a true neoplasm. To our knowledge, this case is the first described in the foot.

Radiotherapy of the Neuroaxis for Palliative Treatment of Leptomeningeal Carcinomatosis

BACKGROUND

Leptomeningeal carcinomatosis occurs in about 5% of solid tumors and may seriously compromise quality of life. Aim of the present study was to evaluate the feasibility of craniospinal irradiation with and without intrathecal chemotherapy and its efficacy with regard to symptom palliation and survival.

PATIENTS AND METHODS

16 patients (mean age 46 years; nine breast cancers, five lung cancers, one renal cell cancer, one tumor of unknown primary site) with leptomeningeal carcinomatosis occurring after a median interval from primary tumor diagnosis of 5 months (0-300 months) received craniospinal irradiation between October 1995 and May 2000. The median total dose was 36 Gy (à 1.6-2.0 Gy). Ten patients were additionally treated with intrathecal methotrexate (15 mg per cycle, 2-8 cycles).

RESULTS

Median survival was 12 weeks, 8 weeks after radiotherapy alone, 16 weeks after combined modality treatment. 14 patients died from disease. Eleven patients (68%) experienced regression of their neurological symptoms during or soon after completion of radiotherapy. Seven patients regained their ability to walk, six had pain reduction, three regression of bladder and bowel incontinence. In three patients symptom progression and in two patients no change occurred. Side effects were: myelosuppression (CTC) Grade I: n = 2, Grade II: n = 4, Grade III: n = 4 patients and Grade IV: n = 1. Nine patients had dysphagia, seven mucositis, three suffered from nausea. No late toxicity was observed.

CONCLUSION

Craniospinal radiotherapy is feasible and effective for palliative treatment of leptomeningeal carcinomatosis. As far as the small patient number permits any definite conclusions, combined modality treatment seems superior to irradiation alone.

The impact of epilepsy from the patient's perspective I. Descriptions and subjective perceptions

This study surveyed the perceptions about and subjective experience of 1023 people with epilepsy in two community-based samples: one from a national postal survey; the other callers to the Epilepsy Foundation. Response to a mail survey was 49%. In comparison with US Census Bureau norms, respondents had received less education, were less likely to be employed or married, and came from lower income households. Complex partial seizures were the most prevalent seizure type, but a convulsion had occurred in 61%. Fifty percent of respondents reported incomplete control of their seizure disorder, although 25% of these had a seizure in the prior year. Thirteen percent had a longest inter-seizure interval of a year or greater, 37% of 3 months, 22% of 1 month, 10% of 1 week and 4% of 1 day. Respondents listed uncertainty and fear of having a seizure as the worst thing about having epilepsy. Lifestyle, school, driving, and employment limits were also listed as major problems. When asked to rank a list of potential problems, cognitive impairment was ranked highest. These data indicate that ongoing medical and psychosocial problems continue for those with epilepsy in the view of those questioned and their families, even in a sample where the majority report good control of their epilepsy.

The impact of epilepsy from the patient's perspective II: views about therapy and health care

A national survey of 1023 people with epilepsy in the US assessed their attitudes about their therapies. Subjects were drawn from responders to a previous national survey of US households or from those who phoned the Epilepsy Foundation. Overall response rate was 49%. Approximately 90% of the respondents were taking medications for their epilepsy. Only 56% were on monotherapy, while 26% were taking two, 6% three, and 2% four medications. Only 68% of respondents were very satisfied with their current seizure medications. When asked to rank five areas of importance regarding their seizure medication, the rank order (highest to lowest) was seizure control, fewer side effects, convenient dosing regimens and cost. Adverse medication events were listed in descending rank order as problems with cognition, energy level, school performance, childbearing, coordination, and sexual function. Inter-individual differences in side effects of concern were listed, suggesting medication choices should be individualized according to potential side effects. Twenty percent of 920 respondents adjusted their medications on their own, by adjusting amount (62%), dosing schedule (31%), or both (3%). Eighty percent of respondents were satisfied with their medical care systems. In this group, 82% had health insurance that covered epilepsy. The large majority (94%) of respondents had seen a neurologist. Subjects expressed dissatisfaction about time limits and lack of accessible information about epilepsy. People with epilepsy are generally satisfied with efforts to treat their disorder, but adverse events are of concern. Many patients requested more information about epilepsy.

Repetitive transcranial magnetic stimulation induces active coping strategies and attenuates the neuroendocrine stress response in rats

The effects of repetitive transcranial magnetic stimulation (rTMS) on various brain functions were investigated in adult male Wistar rats. The stimulation parameters were adjusted according to the results of accurate computer-assisted, magnetic resonance imaging-based reconstructions of the current density distributions induced by rTMS in the rat and human brain, ensuring comparable stimulation patterns in both cases. The animals were subjected to daily rTMS-treatment (three trains of 20 Hz; 2.5 s) for 8 weeks from the age of 4 weeks on. In the forced swim test these rats showed a more active stress coping strategy than the control rats. This was accompanied by a significantly attenuated stress-induced elevation of plasma ACTH concentrations. Pituitary changes accounting for the attenuation were ruled out by the corticotropin-releasing hormone test. Baseline concentrations of ACTH and corticosterone were indistinguishable in the two groups. No changes were found in the anxiety-related behavior of the rats on the elevated plus-maze or in behavior during the social interaction test. Accordingly, the binding characteristics of the benzodiazepine agonist [(3)H]flunitrazepam at the benzodiazepine/gamma-aminobutyric acid type A receptor complex were similar in the rTMS and control groups. In summary, chronic rTMS treatment of frontal brain regions in rats resulted in a change in coping strategy that was accompanied by an attenuated neuroendocrine response to stress, thus revealing parallels to the effects of antidepressant drug treatment.

Pharmacological characterisation of cortical gamma-aminobutyric acid type A (GABAA) receptors in two Wistar rat lines selectively bred for high and low anxiety-related behaviour

Two Wistar rat lines that have been selectively bred for high-anxiety-related behaviour (HAB) and low-anxiety-related behaviour (LAB) in the elevated plusmaze test may be considered as a genetically prone animal model to study the neurochemical correlates of anxiety-related behaviour. Because there are pronounced differences between the two lines both in baseline levels of open-arm exploration in the elevated plus-maze test and in sensitivity to the anxiolytic effects of 1 mg/kg diazepam, we used these lines to investigate the pharmacology of the benzodiazepine binding site and the GABA binding site of cortical GABAA receptors. No difference in characteristics of flunitrazepam, zolpidem or muscimol binding to cortical GABAA receptors could be detected between the two lines. Although there was an increase in the brain concentration of the anxiolytic neuroactive steroid allopregnanolone, a potent positive allosteric modulator of GABAA receptors, both in HAB and LAB animals after a forced swim stress, allopregnanolone concentrations did not differ between the two lines. Moreover, plasma dehydroepiandrosterone (DHEA) concentrations were similar in HAB and LAB animals. We conclude that anxiety-related behaviour and benzodiazepine sensitivity in these rat lines are likely to be independent of the pharmacology of cortical GABAA receptors.

Left anterior lobectomy and category-specific naming

Damasio and colleagues (1996) have proposed that the left anterior temporal region supports knowledge pertaining to living objects, whereas more posterior temporal regions play a critical role in naming nonliving things. Accordingly, one might expect that left-sided anterior temporal lobectomy should have a more profound effect on the naming of living as opposed to nonliving things. As part of a multicenter collaborative project, seventy-nine patients (all left-hemisphere speech dominant) were tested pre- and post-left-temporal lobectomy on a task that required naming of living and nonliving items equated for name frequency, familiarity, and visual complexity. Consistent with the proposals of Damasio et al. (1996), left temporal lobectomy impaired naming ability, particularly for living things. When individual outcomes were considered, twice as many patients showed a relative decline in naming living as opposed to nonliving things.

Fluoxetine decreases concentrations of 3 alpha, 5 alpha-tetrahydrodeoxycorticosterone (THDOC) in major depression

There is evidence for a differential alteration in the concentrations of 3 alpha-reduced neuroactive steroids in major depression. Because it has been suggested that fluoxetine may shift the activity of the 3 alpha-hydroxysteroid oxidoreductase towards the reductive direction, treatment of major depression may be accompanied by a further increase in plasma 3 alpha, 5 alpha-tetrahydrodeoxycorticosterone (THDOC) concentration. We studied eight male depressed patients before and after treatment with fluoxetine and compared them to healthy age-matched control subjects. Blood samples were quantified for 3 alpha, 5 alpha-tetrahydroprogesterone, 3 alpha,5 beta-tetrahydroprogesterone (THP) and THDOC by means of a highly sensitive combined gas chromatography/mass spectrometry analysis. Compared to control subjects, concentrations of THDOC were higher in depressed patients and decreased after fluoxetine treatment. In contrast, THP concentrations were lower in depressed patients and increased after fluoxetine treatment. Our results give further evidence for a disequilibrium of 3 alpha-reduced neuroactive steroids in major depression, which is normalized by treatment with fluoxetine.

Neuropsychological and behavioral status of children with complex partial seizures

Neuropsychological and behavioral status were examined in 57 children aged 7 to 16 years with complex partial seizures (CPS) and compared with 27 sibling control children of the same age. Epilepsy had a significant effect on both cognitive and behavioral adjustment measures. Children with CPS had significant impairment across all seven cognitive domains assessed, reflective of a profile of relatively diffuse and generalized cognitive dysfunction. Age at onset of recurrent seizures was the strongest and most consistent predictor of adequacy of cognitive functioning; earlier age at onset was associated with poorer cognitive status. Children with CPS also had more problems compared with sibling control children on measures of social and school competence and internalizing behavior problems, but not externalizing behaviors. Further, frequency of seizure activity in the past year, rather than age at seizure onset, emerged as the strongest predictor of these behavioral difficulties. These findings are discussed in the context of understanding the impact of CPS on cognition and behavioral adjustment, and identifying the contribution of various aspects of the neurodevelopmental course of CPS to these issues.

Co-morbid psychiatric disorder in chronic epilepsy: recognition and etiology of depression

This article briefly presents one approach to conceptualizing known and suspected risk factors for co-morbid psychiatric disorder in epilepsy. The utility of this model is then reviewed by examining selected neurobiologic, psychosocial, and iatrogenic risk factors for a common co-morbid psychiatric disorder, interictal depression. Finally, data are presented concerning the rates of current and lifetime mood disorders among a sample of 76 patients with chronic complex partial seizures, the degree to which co-morbid depression has been recognized and treated in chronic epilepsy, and the health-related quality of life status associated with current and past mood disorders. Finally, these findings are related to the larger literature concerned with the recognition and treatment of depression.

Visual confrontation naming outcome after standard left anterior temporal lobectomy with sparing versus resection of the superior temporal gyrus: a randomized prospective clinical trial

PURPOSE

Intraoperative mapping of eloquent cortex during left (speech dominant) anterior temporal lobectomy has shown a significant proportion of patients to have sites on the anterior superior temporal gyrus at which visual confrontation naming can be disrupted by electrical stimulation. The purpose of this investigation was to conduct a randomized clinical trial to determine whether sparing versus resection of the superior temporal gyrus affected visual confrontation naming outcome after standard left anterior temporal lobectomy. Also examined was the degree to which inherent patient characteristics were associated with language outcome regardless of surgical technique.

METHODS

Thirty patients with intractable left temporal lobe epilepsy undergoing standard anterior temporal lobectomy were randomized in regard to whether the superior temporal gyrus was resected or spared. Patients were tested preoperatively and 6-8 months postoperatively by using two conventional tests of visual confrontation naming ability.

RESULTS

No significant differences were found between the groups in either confrontation naming or surgical outcome. Postoperative decline in nominal speech was most closely associated with later age at onset of epilepsy/absence of hippocampal sclerosis.

CONCLUSIONS

It appears that specific types of localization-related temporal lobe epilepsy are more closely associated with the risk of adverse language outcome after anterior temporal lobectomy than with the surgical variations investigated in this study.

Po gene expression is modulated by androgens in the sciatic nerve of adult male rats

The present results show that androgens are able to modulate the Po gene expression in different models. In particular, we have shown that: (1) the messenger for the androgen receptor (AR) is present in the rat sciatic nerve but not in cultured Schwann cells; (2) castration induces a decrease of Po mRNA levels in the sciatic nerve of male rats, which is counteract by the subsequent treatment with dihydrotestosterone (DHT), the 5alpha-reduced metabolite of testosterone; (3) castration is also able to significantly decrease in the sciatic nerve the activity of the enzyme 5alpha-reductase (which converts testosterone into DHT); and (4) DHT is able to stimulate Po gene expression in cultured Schwann cells. These observations seem to indicate that androgens may exert their effect on Po gene expression via indirect mechanisms; modulation of neuronal influences reaching the Schwann cells through the binding of the androgen to the AR present in neurons may be postulated. However, alternative mechanisms may also be taken in consideration. The data presented suggest indeed that androgens might act on Schwann cells via the progesterone receptor (PR) rather than the AR. It has been observed that: (1) the messenger for PR is present in Schwann cells; (2) DHT may activate the transcriptional activity of a PR-responsive gene by binding to the PR; and (3) putative steroid responsive elements have been described in this paper to be present in the Po promoter region.

DNA preservation: a microsatellite-DNA study on ancient skeletal remains

To determine the effect of environmental factors on the preservation of DNA, archeological teeth of approximately similar age but greatly differing site milieu were examined for DNA content. The complex relational system of locational milieu of the samples was reduced to its essential and, at the same time, easily measurable factors. These are temperature, humidity, pH value, the geochemical properties of the soil, the amount of postmortal organic substances and the general degree of microbial infestation in the respective soil. The relative DNA content in the samples was established by determining the rate of successful polymerase chain reaction (PCR) amplifications. Differences in quantity and quality of the results are attributed to the respective prevailing environmental factor or to the respective storage conditions. Dryness, low temperature and absence of microorganisms favors the preservation of DNA. The bioapatite of bones and teeth, like the DNA, are preserved under neutral or slightly alkaline conditions. Brief storage at room temperature does not affect the amount of amplifiable DNA but does affect the reproducibility of the results. Long storage outside a lab freezer reduces the amount and the reproducibility of DNA amplifications in ancient specimens.

Concentrations of 3 alpha-reduced neuroactive steroids and their precursors in plasma of patients with major depression and after clinical recovery

BACKGROUND

There is preclinical and clinical evidence that plasma concentrations of 3 alpha-hydroxy-5 alpha-pregnan-20-one (3 alpha,5 alpha-tetrahydroprogesterone; 3 alpha,5 alpha-THP), a neuroactive steroid that is a positive allosteric modulator of the GABAA receptor, are altered in depression and normalize as a result of antidepressant treatment. However, no data are available on the concentrations of 3 alpha,21-dihydroxy-5 alpha-pregnan-20-one (3 alpha,5 alpha-tetrahydrodeoxycorticosterone; 3 alpha,5 alpha-THDOC), another GABA ergic neuroactive steroid, in depression.

METHODS

We studied nine depressed patients before and after treatment with various antidepressants and compared them to healthy matched control subjects. Blood samples were quantified by means of a highly sensitive combined gas chromatography/mass spectrometry analysis.

RESULTS

Compared to control subjects, plasma concentrations of 3 alpha,5 alpha-THDOC and its precursor 5 alpha-dihydrodeoxycorticosterone (5 alpha-DHDOC) were increased in depressed patients and were not significantly influenced by antidepressant treatment. However, 3 alpha,5 alpha-THP plasma concentrations were decreased in depression and clinically effective antidepressant treatment was accompanied by an increase of 3 alpha,5 alpha-THP concentrations in these patients.

CONCLUSIONS

Our results provide the first evidence for a differential alteration in the plasma concentrations of the 3 alpha-reduced neuroactive steroids 3 alpha,5 alpha-THDOC and 3 alpha,5 alpha-THP in major depression, which is only partially reversed by successful antidepressant treatment.

The interferon-gamma gene as a positional and functional candidate gene for inflammatory bowel disease

Epidemiological and genome-wide linkage analyses have provided firm evidence for a genetic component in the pathogenesis of inflammatory bowel disease. The linkage regions on chromosomes 12 and 16 have been replicated in several independent samples. These represent the best positional evidence in the search for inflammatory bowel disease susceptibility genes. While systematic association and physical mapping studies in these regions are under way, the direct analysis of immunologically relevant genes as positional and functional candidates may provide a shortcut in this process. The interferon-gamma gene resides in the chromosome 12 linkage region near the marker D12S83. Interferon-gamma is an important proinflammatory cytokine in the interleukin-12 cascade and has been implicated in the pathogenesis of mucosal inflammation. We tested this gene for evidence of linkage and association in 133 German multiplex families and 506 single patients with their parents. An intragenic, highly informative CA-repeat marker in intron 1 of the gene was typed using fluorescence-labeled polymerase chain reaction and analysis on an automated sequencer. In the nonparametric linkage analysis using GENEHUNTER, a nonsignificant maximum LOD score of 0.67 was obtained. The transmission disequilibrium test for association was negative (P > or = 0.22) for Crohn's disease, ulcerative colitis, and the combined inflammatory bowel disease phenotype. In summary, the findings make interferon-gamma a very unlikely candidate for the major susceptibility gene in the chromosome 12 linkage interval. Future efforts can concentrate on other transcripts in the region.

Neuroactive steroid concentrations following metyrapone administration in depressed patients and healthy volunteers

BACKGROUND

There is evidence that treatment with the 11 beta-hydroxylase inhibitor metyrapone may represent an alternative treatment strategy in major depression. As a consequence of inhibition of cortisol synthesis the overdrive of corticotropin leads to an accumulation of precursor steroids. However, the effects of metyrapone on the concentrations of endogenous neuroactive steroids that modulate ion channels, e.g., the GABAA receptor, have not yet been studied systematically.

METHODS

Therefore, we quantified the concentrations of an array of neuroactive steroids following administration of 1.5 g metyrapone before and after pretreatment with 1 mg dexamethasone in 19 patients suffering from severe depression in comparison to 13 healthy controls by means of a highly sensitive gas chromatography/mass spectrometry analysis.

RESULTS

The administration of metyrapone induced a pronounced increase in all neuroactive steroids studied both in patients and controls that was prevented by dexamethasone pretreatment.

CONCLUSIONS

Thus, the psychotropic properties of endogenous neuroactive steroids may contribute to the antidepressant properties of metyrapone in the treatment of major depression.

Functional antagonism of gonadal steroids at the 5-hydroxytryptamine type 3 receptor

Steroid hormone action involves binding to cognate intracellular receptors that, in turn, bind to respective response elements and thus modulate gene expression. The present study shows that the gonadal steroids, 17beta-estradiol and progesterone, may also act as functional antagonists at the 5-hydroxytryptamine type 3 (5-HT3) receptor in whole-cell voltage-clamp recordings of HEK 293 cells stably expressing the 5-HT3 receptor. Functional antagonistic properties at this ligand-gated ion channel could also be shown for 17alpha-estradiol, 17alpha-ethinyl-17beta-estradiol, mestranol, R 5020, testosterone, and allopregnanolone but not for pregnenolone sulfate and cholesterol. An antagonism at the 5-HT3 receptor could further be observed with the aromatic alcohol 4-dodecylphenol but not with phenol or ethanol. Thus, the modulation of 5-HT3 receptor function by steroids or alcohols is dependent on their respective molecule structure. The antagonistic action of steroids at the 5-HT3 receptor is not mediated via the serotonin binding site because the steroids did not alter the binding affinity of [3H]GR65630 to the 5-HT3 receptor, and kinetic experiments revealed a quite different response pattern to 17beta-estradiol when compared with the competitive antagonist metoclopramide. BSA-conjugated gonadal steroids labeled with fluorescein isothiocyanate bound to membranes of HEK 293 cells expressing the 5-HT3 receptor in contrast to native HEK 293 cells. However, there was no dose-dependent displacement of the binding of gonadal steroids to membranes of cells expressing the 5-HT3 receptor in binding experiments or fluorescence studies. Thus, gonadal steroids probably interact allosterically with the 5-HT3 receptor at the receptor-membrane interface. The functional antagonism of gonadal steroids at the 5-HT3 receptor may play a role for the development and course of nausea during pregnancy and of psychiatric disorders.

Neuropsychological outcome following anterior temporal lobectomy in patients with and without the syndrome of mesial temporal lobe epilepsy

The nature, pattern, and degree of neuropsychological change following anterior temporal lobectomy (ATL) were examined as a function of the presence or absence of the syndrome of mesial temporal lobe epilepsy (MTLE). Fifty-four patients exhibited the syndrome of MTLE, while 34 patients were without the syndrome (non-MTLE). The test-retest performance of a group of 40 epilepsy patients who did not undergo surgery was used to derive regression-based estimates of test-retest change. Overall, the MTLE group did not show significant cognitive decline following ATL. In contrast, the left non-MTLE group showed significant declines on verbal memory, confrontation naming, and verbal conceptual ability. Further, verbal memory was the most substantial area of decline, and was independent of seizure outcome. Clinical and theoretical implications of these findings are discussed.

Effects of antidepressant treatment on neuroactive steroids in major depression

OBJECTIVE

There is evidence from animal studies that fluoxetine may enhance the concentrations of neuroactive steroids. Therefore, the authors investigated whether clinically effective treatment with antidepressants may alter the concentrations of neuroactive steroids in patients suffering from a major depressive episode.

METHOD

In the first study, eight drug-naive outpatients with major depression were studied during treatment with fluoxetine. In a complementary study, 11 inpatients with major depression were studied during a severe depressive episode and after recovery following treatment with different antidepressants. Plasma samples were quantified for neuroactive steroids by means of a highly sensitive and specific combined gas chromatography/mass spectrometry analysis.

RESULTS

During depression, there was a significant decrease in 3 alpha, 5 alpha-tetrahydroprogesterone (3 alpha, 5 alpha-THP) and 3 alpha, 5 beta-THP concentrations, both of which are positive modulators of the gamma-aminobutyric acidA receptor, and a concomitant increase in 3 beta, 5 alpha-THP levels. This dysequilibrium of neuroactive steroids could be corrected by treatment with different antidepressants.

CONCLUSIONS

These results provide the first clinical evidence of a possible role of neuroactive steroids in successful antidepressant therapy.

Psychiatric outcome of temporal lobectomy for epilepsy: incidence and treatment of psychiatric complications

PURPOSE

To determine the incidence of psychiatric disorders before and after surgical treatment for partial epilepsy and to document the effectiveness of their treatment.

METHODS

Fifty consecutive patients treated surgically for focal epilepsy (44 temporal and six frontal) were evaluated by established neuropsychiatric methods before surgery and over a mean period of 2 years after surgery. The patients with interictal dysphoric disorders, with or without psychotic episodes, were treated with tricyclic antidepressant medication alone or combined with serotonin selective reuptake inhibitors and, if necessary, with the addition of risperidone.

RESULTS

Before surgery, 25 (57%) of the 44 patients with temporal lobe epilepsy had dysphoric disorders. After surgery, 17 (39%) of the 44 patients experienced either de novo psychiatric complications (six psychotic episodes, six dysphoric disorders, and two depressive episodes) or exacerbation of preoperative dysphoric disorder (three patients). Eight previously intact patients of the 19 (42%) developed dysphoric disorders after surgery that were significantly related to recurrence of seizures. All psychiatric complications occurred in the first 2 months after surgery, except for the six patients intact before surgery, who had a recurrence of seizures. A significant predictor of ultimate excellent psychiatric outcome was complete absence of seizures after surgery. All postoperative psychiatric complications remitted on treatment with psychotropic medication in the compliant patients.

CONCLUSIONS

An exceptional psychiatric morbidity is associated with the months after temporal lobectomy. Possible pathogenetic mechanisms are discussed. Antidepressant drugs are very effective in treating the psychiatric disorders of chronic epilepsy; their use in conjunction with the surgical treatment of epilepsy appears to be crucial for the overall positive outcome of a significant number of patients.

Neuropsychological outcome following anterior temporal lobectomy in patients with and without the syndrome of mesial temporal lobe epilepsy

The nature, pattern, and degree of neuropsychological change following anterior temporal lobectomy (ATL) were examined as a function of the presence or absence of the syndrome of mesial temporal lobe epilepsy (MTLE). Fifty-four patients exhibited the syndrome of MTLE, while 34 patients were without the syndrome (non-MTLE). The test-retest performance of a group of 40 epilepsy patients who did not undergo surgery was used to derive regression-based estimates of test-retest change. Overall, the MTLE group did not show significant cognitive decline following ATL. In contrast, the left non-MTLE group showed significant declines on verbal memory, confrontation naming, and verbal conceptual ability. Further, verbal memory was the most substantial area of decline, and was independent of seizure outcome. Clinical and theoretical implications of these findings are discussed.

Development and cross-cultural translations of a 31-item quality of life in epilepsy inventory

PURPOSE

We report the development of a questionnaire to assess health-related quality-of-life (HRQOL) in people with epilepsy and the process of cross-cultural translations of the questionnaire.

METHODS

A sample of 304 adults with epilepsy from 25 seizure clinics in the United States was used to derive an abbreviated questionnaire focusing on epilepsy-related issues from a longer, 89-item instrument (QOLIE-89). A rigorous forward-backward-forward system was used for cross-cultural translation.

RESULTS

A 31-item questionnaire (QOLIE-31, version 1.0) resulted, comprising seven subscales covering general and epilepsy-specific domains. Subscale and total scores can be calculated. The subscales were grouped into two factors: Emotional/Psychological Effects (seizure worry, overall QOL, emotional well-being, energy/fatigue subscales) and Medical/Social Effects (medication effects, work-driving-social limits, cognitive function subscales). Cross-cultural translations were made from U.S.-English into Danish, Dutch, German, Canadian French, French, Italian, Spanish, Swedish, and U.K. English Versions 1.1.

CONCLUSIONS

Our results support the reliability and validity of the QOLIE-31 (U.S.-English version 1.0) as a measure of HRQOLIE. Cross-cultural translations into nine other languages make it feasible to use the QOLIE-31 (version 1.1) in multinational clinical trials after validation in each population or concurrent with the clinical trial.

Role of the hippocampus in sex differences in verbal memory: memory outcome following left anterior temporal lobectomy

The authors examined the neural and cognitive bases for sex differences in verbal memory in 57 patients who underwent left anterior temporal lobectomy (ATL) for the treatment of intractable seizures. On the California Verbal Learning Test (D. C. Delis, J. H. Kramer, E. Kaplan, & B. A. Ober, 1987), women recalled more words than men both before and after surgery, regardless of the extent of hippocampal damage. Extent of hippocampal sclerosis was related to memory loss in both men and women. Women's superiority in verbal memory appears to result in part from their use of an efficient encoding strategy. Women were more likely than men to use semantic clustering both before and after ATL, and sex differences in word recall were attenuated after scores were adjusted for semantic clustering. There was no effect of ATL on semantic clustering. Taken together, these results suggest that sex differences in verbal memory are not due to differences in the integrity of the left hippocampus.

Role of the hippocampus in sex differences in verbal memory: memory outcome following left anterior temporal lobectomy

The authors examined the neural and cognitive bases for sex differences in verbal memory in 57 patients who underwent left anterior temporal lobectomy (ATL) for the treatment of intractable seizures. On the California Verbal Learning Test (D. C. Delis, J. H. Kramer, E. Kaplan, & B. A. Ober, 1987), women recalled more words than men both before and after surgery, regardless of the extent of hippocampal damage. Extent of hippocampal sclerosis was related to memory loss in both men and women. Women's superiority in verbal memory appears to result in part from their use of an efficient encoding strategy. Women were more likely than men to use semantic clustering both before and after ATL, and sex differences in word recall were attenuated after scores were adjusted for semantic clustering. There was no effect of ATL on semantic clustering. Taken together, these results suggest that sex differences in verbal memory are not due to differences in the integrity of the left hippocampus.

Leukosialin (CD43) is proteolytically cleaved from stimulated HMC-1 cells

Leukosialin (CD43), the major sialoprotein on circulating leukocytes, has been previously described to be down-regulated on neutrophils following activation with phorbol myristate acetate (PMA). The other single cells previously examined, blood lymphocytes, do not down-regulate CD43 when stimulated by PMA. Recently, we have characterized leukosialin on the human mast cell line HMC-1 and observed that leukosialin is down-regulated after stimulation with PMA. In the present study, we have investigated the mechanism of PMA-mediated down-regulation of CD43 on HMC-1 cells (subclone 5C6). PMA caused the release of soluble leukosialin (123 kD) during HMC-1 cell activation. The molecular weight of soluble leukosialin was nearly identical to that of the cell-membrane bound molecule, suggesting a cleavage proximal from the cell membrane. Inhibitors of serine proteases, like phenylmethylsulphonyl fluoride (PMSF), benzamidine and 3, 4-dichloroisocoumarin, blocked the PMA-mediated cleavage of CD43. In all experiments, the inhibition of CD43-down-regulation was dependent on the concentration of protease inhibitors. Treatment of HMC-1 cells with various proteases (trypsin, alpha-chymotrypsin, elastase, papain, nagarse) substantially decreased anti-CD43 binding capacity and caused the release of soluble leukosialin (116 kD) or its fragments into the supernatant. Pretreatment of HMC-1 cells with neuraminidases from Vibrio cholerae or Arthrobacter ureafaciens resulted in an increased sensitivity of CD43 against proteases, whereas the effects of PMA were not influenced. In conclusion, proteolytic cleavage of CD43 is described for the first time in a cell other than neutrophils, namely HMC-1 cells. Our results suggest that serine proteases are involved in the PMA-mediated down-regulation of leukosialin on HMC-1 cells.

Two-point discrimination of vibratory perception on the sole of the human foot

The capability for discrimination of vibratory stimuli of the sole of the foot was tested on 12 subjects (6 men, 6 women). Two vibratory stimuli (sinusoidal impulse: frequency, 200 Hz; amplitude, 0.1 mm; duration, 2 sec) were applied at different sites to the sole of the foot. Subjects were asked whether they detected one or two vibratory sensations. The discrimination threshold was defined as the shortest distance at which two vibrations can be differentiated at repeated trials. In addition, the absolute threshold was measured by one plunger (sinusoidal vibration: frequency, 200 Hz; variable amplitude). The values of the absolute threshold (average value, 1.2 microns) were in accordance with the results of other authors. A decrease of discrimination capability was observed along the longitudinal axis of the foot from distal to proximal parts and was about 15 mm at the big toe and 34 mm at the heel. Discrimination at the medial longitudinal arch was inferior to that at the lateral longitudinal arch. This was also true for inverse vibration in which all subjects showed lower thresholds. No relationship was found with respect to thickness of the skin (measured by ultrasound), side of foot, or gender. Determining factors for vibratory threshold might be the density of the Pacinian corpuscles per cm2 as well as their peripheral and central representation. Anatomical or physical factors (e.g., thickness of the skin, impedance of the deeper tissue) can probably be disregarded.

Functional antagonistic properties of clozapine at the 5-HT3 receptor

The atypical neuroleptic clozapine is thought to exert its psychopharmacological actions through a variety of neurotransmitter receptors. It binds preferentially to D4 and 5-HT2 receptors; however, little is known on it's interaction with the 5-HT3 receptor. Using a cell line stably expressing the 5-HT3 receptor, whole-cell voltage-clamp analysis revealed functional antagonistic properties of clozapine at low nanomolar concentrations in view of a binding affinity in the upper nanomolar range. Because the concentration of clozapine required for an interaction with the 5-HT3 receptor can be achieved with therapeutical doses, functional antagonistic properties at this ligand-gated ion channel may contribute to its unique psychopharmacological profile.

[Value of anamnesis and clinical examination in degenerative impingement syndrome in comparison with surgical findings--a prospective study]

50 patients with a degenerative shoulder-syndrome with impingement are evaluated by questioning and 17 clinical tests. Also taking in account findings of plain x-rays they are classified preoperatively as "rotator cuff tear" or "no tear". Only 4 of the maneuvers are positive in more than 66% of cases. Jobe test and Eppendorf test are especially useful in diagnosing an impingement syndrome. A painful are is found in only 48.9%. In the rupture group 9.7 maneuvers are positive while in the non rupture group it is 7.7 in the mean (not significant). Because no significant differences are noticed between groups for any of the tests a cuff tear can not be ruled out by a single sign. The overall rate of positive tests of both authors is similar (41.1%, 45.8%) but in detail differences are found in 21.2%. Useful (significant, p < 0.05) data for diagnosing a tear are older age (56.1 years vs. 47.7 years. in the non rupture group), previous (minor) trauma and radiological findings on plain films suggesting periarticular degenerative lesions. A calcifying tendinitis is consistent with pure impingement. The correct diagnosis confirmed by operation is made in 90% (sensitivity 91.3%, specificity 88.9%). This can be achieved only by an experienced clinician who takes into account all anamnestic and clinical findings, especially details that cannot be classified as just positive or negative and thus cannot be computerized.

Executive system dysfunction in temporal lobe epilepsy: effects of nociferous cortex versus hippocampal pathology

This investigation contrasted two hypotheses regarding executive system dysfunction in temporal lobe epilepsy. The nociferous cortex hypothesis posits that epileptogenic cortex adversely affects the extratemporal regions that mediate executive system abilities, thereby resulting in performance deficits. The hippocampal hypothesis suggests that such impairments are due to the fact that the human hippocampi are directly involved in the mediation of some executive system functions and performance deficits are therefore directly attributable to hippocampal pathology. Seventy-four patients who underwent anterior temporal lobectomy were administered the Wisconsin Card Sorting Test preoperatively and approximately 6 months postoperatively. Presence or absence of hippocampal sclerosis was determined by histopathological analysis. Three specific and contrasting predictions were tested and in each instance the findings supported the nociferous cortex hypothesis.

Predicting cognitive impairment in epilepsy: findings from the Bozeman epilepsy consortium

We examined the contribution of age of seizure onset, seizure duration, seizure laterality, seizure location, gender, handedness, and cerebral speech representation to cognitive attainment in 1,141 patients with medically refractory seizures. The combined influence of the predictor variables was modest. Age of seizure onset was the best single indicator of Full Scale IQ (partial r = .23) and General Memory (partial r = .20). Laterality and location of dysfunction, and cerebral speech dominance were also relevant and independent indicators of aspects of cognition. Except for age of onset of seizures (early onset was associated with poorer cognitive attainment), however, the magnitude of the effects was limited.

Development of the quality of life in epilepsy inventory

We developed an instrument to measure health-related quality of life (HRQOL) in epilepsy. A 99-item inventory was constructed from the RAND 36-Item Health Survey (generic core), with 9 additional generic items, 48 epilepsy-targeted items, and 6 other items concerning attitudes toward epilepsy and self-esteem. We administered the 99-item inventory to 304 adults with epilepsy at 25 epilepsy centers. Patients and patient-designated proxies completed the inventory and were retested 1-91 days later. A multitrait scaling analysis of these data led to retention of 86 items distributed in 17 multiitem scales (Cronbach's alpha ranged from 0.78 to 0.92). Factor analysis of the 17 multiitem scales yielded four underlying dimensions of health: an epilepsy-targeted dimension, a cognitive factor, mental health, and physical health. Construct validity was supported by significant patient-proxy correlations for all scales and correlations between neuropsychologic tests and self-reported emotional and cognitive function (all p values < 0.05). There were significant negative correlations between the four factor scores derived from the HRQOL scales and neurotoxicity, systemic toxicity, and health care utilization (except for the correlation between mental health factor and health care utilization; all p values < 0.05). Patients who were seizure-free in the preceding year reported better HRQOL for the overall score, three of the four factor scores, and 8 of the 17 scale scores than did patients with a high frequency of seizures. Relative validity analysis showed that the epilepsy-targeted factor and three of its four component scales were more sensitive to categorization of patients by severity of seizure frequency and type than scales tapping physical health, mental health, or cognitive function. These cross-sectional data support the reliability and validity of this measure of HRQOL in epilepsy. The addition of an epilepsy-targeted supplement to the generic core improved the sensitivity to severity of epilepsy. The 86 items included in the field testing were supplemented by three additional items to form the Quality of Life in Epilepsy (QOLIE-89) inventory.

[Form and structure of the metatarsal head arch in adults. Ultrasonographic and podometric studies]

Ultrasonic measurements (n = 172) and plantar pressure investigations (n = 119) are performed on the forefeet of healthy adults, in order to constitute a correlation between shape and function of the anterior metatarsal arch. The thickness of the sole of the foot has its maximum beneath the 2nd metatarsal head and its minimum beneath the 1st and 5th ray. The highest pressure values are found at the 2nd and 3rd metatarsal head. It is concluded that despite the arch like configuration of the forefoot there is no structural arch function. The biological principle of adequate padding of pressure points results-depending on the load-in a different thickness of the soft tissues of the sole of the foot. The higher pressure under the central metatarsal heads is accompanied by thicker soft tissue pads and a more dorsal position of these rays.

Psychiatric morbidity in seizure patients on a neurodiagnostic monitoring unit

This study aimed to clarify prevalence and type of psychiatric disorders among 97 consecutive patients with seizures who were admitted for neurodiagnostic monitoring. Of the 97 patients, 33 (34%) had an atypical mood disorder, 21 (22%) had pseudoseizures, and 9 (9%) had other psychiatric disorders, for a total of 63 (65%) in need of psychiatric treatment. Patients with the atypical mood disorder had predominantly depressive symptoms, which occurred intermittently, were associated with episodes of irritability, and alternated with briefer euphoric moods. Anxiety and phobic symptoms occurred less often. The existence of an epilepsy-specific mood disorder is suggested.

Long-term subdural strip electrocorticographic monitoring of ictal déjà vu

We report a series of 8 patients with ictal déjà vu. Subdural strip electrocorticographic (ECoG) monitoring localized the ictal epileptogenic focus as follows: right (n = 6) and left (n = 2) mesiotemporal lobe. In all 8 patients, the left hemisphere was dominant for language function based on intracarotid amytal testing. In 6 right-handed patients, ictal déjà vu was associated with a right temporal lobe focus. However, in the 2 left-handed patients, the ictal focus was left temporal lobe. Although ictal déjà vu localizes the epileptic focus to temporal lobe, this experimental phenomenon appears to lateralize to the hemisphere nondominant for handedness.

[Injuries in field hockey]

Frequency and mechanisms of injuries in field hockey are evaluated in a retrospective study of 322 players. Each athlete sustains 0.6 (female) respectively 1.0 (male) injuries per season on the average, mostly minor lesions. Severe injuries are mostly due to the playing surface; especially astroturf seems to be dangerous. The risk during match exceeds the risk during practice by a factor of 10.36% are typical field hockey injuries as they are caused by ball or stick. 62% of the lesions are related to the lower limb, 19% to the upper limb (mainly hand and fingers), and 19% to head and trunk. The data allow to draw conclusions concerning preventive measures.

Verbal recognition memory performance in unilateral temporal lobe epilepsy

Recognition memory performance of 91 left and right unilateral temporal lobe epilepsy (TLE) patients was examined prior to and post anterior temporal lobectomy. The left TLE group showed more impaired response discrimination ability than the right TLE group; however, their false positive rate varied as a function of distractor type. Prior to temporal lobe resection, false positives were higher for semantically related distractors (novel or from an interference list) than for semantically unrelated items from an interference list, phonemic distractors, or unrelated errors. Following temporal lobe resection, only novel semantically related distractors in the left TLE group showed a significant increase in false positives, and they were also significantly higher than all other error types. The results of this study suggest that the left TLE patients have impaired individual item recollection in the context of intact information about basic semantic attributes.

[Diagnosis and clinical aspects of Yersinia arthritis]

Clinical and serological criteria of Yersinia arthritis are presented by a review of the literature and case studies. Characteristic findings are preceding abdominal symptoms followed by oligoarthritis of the lower extremities. 80% of patients are HLA-B 27 positive, rheumatoid factors are negative. Detection of Yersinia in stool cultures is a rare proof. The most important serological indicator is IgA for identification of Yersinia antibodies. Yersinia arthritis will resolve without sequelae under symptomatic and antibiotic (chemotherapeutic) medication within 6 months.

Psychopathology in epilepsy. The role of psychology in altering paradigms of research, treatment, and prevention

This article offers a brief review of the literature examining epilepsy and abnormal behavior. The generally accepted concept of epilepsy as a high psychiatric risk disorder is reexamined in light of research that has investigated the influence of selection bias. A conceptual model that organizes the known or postulated risk variables (neurological, psychosocial, and medication) is presented, with emphasis on psychology's potential contribution.

[Tarsal tunnel syndrome after fibular ligament repair. A rare complication of surgical therapy of chronic instability of the ankle joint ligament]

A case of tarsal tunnel syndrome following a reconstructive procedure with repair of chronic ankle instability using periosteal flap is reported. Two pathogenetic factors have to be discussed as possible causes for this complication. Dissection of the medial retinaculum was performed. With this procedure the patient is complaints could be removed.

Psychopathology in epilepsy: The role of psychology in altering paradigms of research, treatment, and prevention

This article offers a brief review of the literature examining epilepsy and abnormal behavior. The generally accepted concept of epilepsy as a high psychiatric risk disorder is reexamined in light of research that has investigated the influence of selection bias. A conceptual model that organizes the known or postulated risk variables (neurological, psychosocial, and medication) is presented, with emphasis on psychology's potential contribution.

[Development of loss-of-limb coverage in private accident insurance]

The oldest known private accident insurance is recorded in the maritime law of Wisby of 1541. Defoe is the first to propose a compensation scale for loss of limbs in the 17th century. It is taken over in a modified character by all insurance companies being founded in Europe and North America since 1850. The structure of the present insurance conditions originates in the conditions of 1920. Since then the loss of the right and left upper limb is rated equally. The compensation scale is changed again in 1961, the loss of extremities is valued higher and the loss of sense of smelling and tasting is considered.

[Etiology, diagnosis and therapy of tarsal tunnel syndrome--results of a retrospective study]

Tarsal tunnel syndrome is a rare entrapment neuropathy of the posterior tibial nerve. The compression of the nerve behind the medial ankle should be distinguished from that of the more distal compression syndrome of the plantar nerves, because of different anatomic conditions and pathogenesis. The patient's history is of special diagnostic value. The most impressive clinical finding is tenderness of the nerve. Neurological deficits must be searched for. Decompression by cutting the flexor retinaculum and neurolysis is advised. 77% of the 30 patients having undergone this operation were satisfied with the results.

[Gibbous hand deformity--carpe bossu]

Fiolle (10) was the first to describe a bony protuberance of a carpometacarpal joint and named it carpe bossu. This anomalous anatomical condition occasionally becomes a--widely unknown--common clinical entity. The reasons are discussed. The clinical diagnosis can be confirmed by a lateral tangential radiograph. Discomfort and pain are rare and can be treated usually by conservative means, surgery is seldom indicated.

[Surgical therapy and results in rupture of the rotator cuff]

Follow up evaluations of 57 patients with surgically treated rotator cuff tears are presented and valued with regard to the literature. A short anterior exposure and cuff anchorage to the humerus is the method of choice. Anterior acromioplasty should not be a routine. Attention should be paid to adhesions of the sub-coracoidal space, they should be separated if necessary. Patients being of older age, with a short history and a long time interval between operation and final evaluation do have the best results.

[Clear cell chondrosarcoma--clinico-pathological report of an additional case]

On account of the rarity and its histologic features, the clear-cell chondrosarcoma is a particular entity. Up to the present, 98 cases have been reported in the literature. In the present report one case located in the proximal femur will be discussed. Approximately 60% of these tumors are situated in the mentioned region. Including one referred case, which will not be described in detail, 100 cases have been recognized. Clear-cell chondrosarcoma is radiographically indistinguishable from benign lesions or chondroblastoma. Therefore the histologic examination is crucial for the diagnosis. The histologic characteristics preclude the diagnosis of chondroblastoma. Clear-cell chondrosarcoma is characterized by regions of chondroid matrix and areas of closely packed, glycogen-rich large tumor cells with distinct boundaries. The centrally located nuclei are large with marked polymorphism, surrounded by abundant clear PAS positive cytoplasm. The chondroid matrix is lacking. Osteoid formation and multinucleated giant cells are present in clear-cell areas. In spite of the low malignancy there is still a metastatic potential. Therefore the type of surgical treatment is very important. En bloc excision with wide margins is the treatment of choice. The knowledge about this tumor is crucial for adequate surgical therapy.

[Chronic impingement syndrome of the shoulder]

The most common manifestation of periarthritis of the shoulder is the chronic impingement syndrome, which represents an "entrapment situation". When the arm is raised, the supraspinatus tendon that forms part of the rotator cuff, comes into contact with the coracoacromial arch. The complains can often be improved by conservative treatment. If, however, the problem persists--in about 10 to 20% of the cases--surgical decompression of the coracoacromial arch by resecting the coracoacromial ligament and the subacromial bursa is indicated. This limited intervention carries only a low risk and, as studies have shown, has such a high rate of success that, in the individual case, the indication for surgery can be established earlier than has so far been assumed.

[Topography of the upper biceps tendon segment]

26 shoulders are studied by polariscopic and histologic examination. It can be confirmed that the origin of the long biceps tendon is not only at the supraglenoid tubercle, but also y-shaped in the glenoid labrum. This finding can be explained by phylogenetic means. Further details are found during the course of the tendon through the bicipital groove. A mesotenonium is seen regularly. This is fixed either to the roof or the ground of the sulcus by a band of connective tissue. It is shown also, that the roof of the groove is not a ligament (ligamentum transversum humeri) but consists of collagen fibers continuing from the subscapularis and capsular attachment at the lesser tubercle.

Arterial supply of the human long biceps tendon

The present study deals with the question whether an insufficient vascular supply of certain areas can be made responsible for ruptures in the biceps tendon. The macroscopic and microscopic examination shows that the blood supply of the tendon in the part most prone to ruptures, that is in the bicipital groove, is guaranteed even in older individuals. It is at least much better than in the intra-articular portion where ruptures are seldom observed. This means that mechanical components such as friction are dominant. The vascular factors seem to play a minor part.