Traitement d’une dépression résistante par substitution du Dépamide® par la Dépakine® chez une patiente avec résection du grêle

Valpromide (VPD) is an antiepileptic drug, derivative of Valproic acid (VPA), used as a mood-stabilizer in bipolar disorder for 25 years in several European countries. VPD is also used as an augmentation strategy in refractory depression. Despite chemical similarity between VPA and VPD, the pharmacokinetics of the 2 drugs in humans are quite distinct. We report a case of a patient, suffering from a bipolar treatment resistant depression, who dramatically improved after substituting VPD to VPA in association with fluoxetine. Mme X, 68 years old, has been hospitalized in March 2001 for the treatment of a resistant depression (TRD). She was suffering from removal of small intestine with chronic diarrhoea after a suicidal attempt two years ago. She had a bipolar disorder treated with VPD (1,200 mg/d) since 1 year. She presented a major depressive episode according to DSM IV with various symptoms like depressed mood, hypersomnia and difficulty initiating sleep, diminished ability to concentrate and to think, markedly diminished pleasure in all activities and major anxiety. Mme X fulfilled TRD diagnosis after resistance to two adequate antidepressants trials from different classes (clomipramine 175 mg/day and venlafaxine 300 mg/day). The antidepressant treatment (venlafaxine) was interrupted and she has been receiving a SSRI (fluoxetine 20 mg/day) for 4 weeks. After four weeks, she had a partial remission with persistent sleep problems, mood lability and anxiety. The VPA blood concentration was very low: 27 mg/L (normal range: 50 to 100 mg/L) in spite of a high dosage: 1,200 mg/day. Pharmacokinetic analysis of VPD shown that VPD transformation to VPA usually done in the intestine, was reduced because of the removal of hail intestine. We substituted VPD by VPA. Valproate blood concentration returned to normal range, induced dramatic improvement of depression within three days. VPD is an amide derivative of valproic acid (valproate), biotransformed by hydrolysis to its corresponding valproic acid. VPD is a prodrug of VPA. VPD is absorbed after transformation in gastro-intestinal mucous membrane. The adequate dosage of VPD (Depamide, 300 mg) is 4 to 6 tablets in acute manic phases, 2 to 4 tablets in long term treatment, 1 to 3 tablets in depressive episode. The biodisponibility of VPD is around 100% 75 and 90% of VPD is linked with protein albumin. The daily dosage determined the blood concentration of the active form (VPA), but this relation isn't linear. The optimal blood concentration of VPA (Depakine) ranges between 50 and 100 mg/L. the free form of VPA is influenced by protein disorders such as of hypoalbuminemia and by presence of fat acids in food. This case report demonstrates at a clinical level that VPD and VPA are not equivalent for treating bipolar depression. This case also suggests that a deep investigation of the pharmacokinetic of psychotropic drugs can help clinicians to resolve clinical problems of treatment of depression.

Distributed self in episodic memory: neural correlates of successful retrieval of self-encoded positive and negative personality traits

Words processed with reference to the self are generally better remembered than words processed in semantic terms. An account of this phenomenon, labeled the Self Reference Effect (SRE), is that the self promotes elaboration and organization of encoded information. Although a few neuroimaging studies associated self-referential encoding with activations of the medial prefrontal cortex, no previous study has investigated the neural correlates of remembering emotional words encoded in an SRE paradigm. The main goal of this study was to define with fMRI the neural correlates of the successful retrieval of negative and positive personality traits encoded in a self-referential mode. Functional MRI scans were acquired for 11 subjects as they recognized positive and negative emotional personality traits adjectives encoded in a self-referential condition, a semantic condition and in a phonemic condition. The correct recognition of self-encoded personality traits engaged dorso-medial prefrontal cortex and lateral prefrontal regions, premotor cortex, parietal and occipital cortex, caudate and cerebellum. The specific recognition of self-encoded negative personality traits involved greater neural activation in the right extra-striate region than the recognition of positive personality traits. Our fMRI findings suggest that specific processes may operate at both encoding and retrieval to subserve the SRE. Unlike self-encoding, the retrieval of personality traits is modulated by the valence of the stimuli with greater activation for negative words. Our results indicate that personally relevant words may signal important emotional clues and support the notion of a widely distributed set of brain regions involved in maintaining the concepts of self.

Verbal memory performance of patients with a first depressive episode and patients with unipolar and bipolar recurrent depression

Depression is usually associated with episodic memory impairment. The main clinical features of depression associated with that memory impairment are not clearly defined. The main goal of that study was to assess the role of the diagnostic subtypes and the number of depressive episodes on the memory performance of acute unipolar (UP) and bipolar (BP) depressed patients.Twenty-three patients with a first major depressive episode (FE), 28 patients meeting DSM-IV criteria for UP recurrent depression (UR) and 18 BP patients with recurrent depression were compared with 88 healthy subjects on a verbal episodic memory task. Patients suffering from a first depressive episode did not show verbal memory impairment as compared to normal controls. Unlike FE patients, UR and BP patients exhibited verbal memory deficits with impaired free recall and normal cued recall and recognition. The memory deficits of the UR and BP patients was present in the first free recall trial. Depressed patients improved their memory performance across the three trials of the task at the same rate than normal controls. Our results suggest that the number of depressive episodes has a negative influence on verbal memory performance of acute depressed patients. The effects of the repetition of the depressive episodes are not modulated by the subtypes of depression and may reflect sensitization to the cognitive impact of depression associated with increasing prefrontal dysfunction.

Personality influences limbic-cortical interactions during sad mood induction

The current study examined limbic-cortical activation under transient emotional stress as a function of personality style. A ventral cingulate (Cg25)-centred limbic-cortical network was identified using positron emission tomography (PET) measures of regional cerebral blood flow (rCBF) during a sad mood challenge that demonstrated differences for individuals selected for specific patterns of Negative and Positive emotional traits, indexed by the NEO Personality Inventory-Revised. Healthy subjects scoring both low on the dispositional Depression facet of Neuroticism (N3) and high on the Positive Emotions facet of Extraversion (E6) were compared to those scoring high on the Depression facet (N3) and low on Positive Emotions (E6), a combination of traits previously linked to normal variations in mood reactivity. Scan analyses were designed to further characterize known variations in Cg25 activity previously reported in studies of negative mood in both healthy subjects and depressed patients. A multivariate technique, partial least squares (PLS) demonstrated a divergent Cg25-mediated network that differentiated temperamentally negative (NAS) from temperamentally positive (PAS) subjects providing a potential neural link between these specific combinations of trait affective styles and vulnerability to depression.

In search of the emotional self: an fMRI study using positive and negative emotional words

OBJECTIVE

The authors used functional magnetic resonance imaging (fMRI) to define the neural regions mediating self-referential processing of emotional stimuli and to explore how these regions are influenced by the emotional valence of the stimulus.

METHOD

Ten healthy subjects were presented with words describing positive and negative personality traits during fMRI scanning in three different conditions. In the self-referential processing condition, subjects judged whether they thought each trait described them. In the other-referential processing condition, subjects judged whether the stimulus described a generally desirable trait. In the letter-recognition control condition, subjects indicated whether the word contained a specific target letter.

RESULTS

The self-referential condition induced bilateral activation in the dorsomedial prefrontal cortex, whereas the other-referential condition induced activation in lateral prefrontal areas. Activation in the right dorsomedial prefrontal cortex was unique to the self-referential condition regardless of the valence of the words, although positive words produced a more robust activation than did negative words. In the self-referential condition, differences between the processing of positive and negative words were seen in regions outside the medial frontal cortex, with reductions in the insula, temporal and occipital regions, and inferior parietal regions associated with negative words.

CONCLUSIONS

A widely distributed network of brain areas contributes to emotional processing. Among these regions, the right dorsomedial prefrontal cortex is one main area mediating self-reference. By providing a personal perspective in the evaluation of emotional stimuli, the right dorsomedial prefrontal cortex may mediate cognitive processes, such as those involved in psychotherapy, that guide self-regulation of emotional experience.

Implicit and Explicit Emotional Memory for Melodies in Alzheimer's Disease and Depression

The present study investigates the impact of emotional deficits on implicit and explicit memory for musical stimuli in patients with Alzheimer's disease and elderly depressed patients. Results showed that unlike Alzheimer's patients, depressed patients were unable to develop a positive affective bias of judgment for previously heard melodies.

Qualitative analysis of verbal fluency in depression

The aim of this study was to analyze qualitative aspects of verbal fluency in depression. Phonemic and semantic output was scored for word clustering and switching between clusters in depressed patients and normal control subjects. Depressed patients (n=25) and normal control subjects (n=19) were administered both phonemic and semantic fluency tasks. All patients were also evaluated with executive card sorting tests. Patients with depression produced fewer words on the semantic fluency task than controls and showed normal performance on the phonemic fluency tasks. The deficit on semantic fluency of depressed patients was related to a reduced number of switches with normal cluster sizes. The number of switches in depression was associated with a reduced ability to shift mental set on card sorting tests, suggesting that verbal fluency impairment reflects general executive problems in depression.

Antenatal diagnosis and management of a vallecular cyst

Vallecular cysts are rare. It is important to be aware of their presence as they can cause upper airway obstruction. We describe a case of congenital vallecular cyst diagnosed at 28 weeks of gestation. This early diagnosis enabled us to plan careful perinatal management. We believe that, in cases of suspected oropharyngeal tumors, elective delivery should be carried out in a tertiary referral center in which emergency ventilation and tracheostomy are possible.

[Prenatal diagnosis at 25 weeks gestation and neonatal management of a vallecular cyst]

Due to the anatomical location, vallecular cyst is a rare but well-recognized cause of upper airway obstruction and death in newborn. This cyst can be accurately diagnosed by echography in utero and by MR imaging. Prenatal diagnosis allows for early consultation with surgical specialist, so that the time and place of the delivery can be addressed for neonatal preoperative planning. We report the first prenatal diagnosis of a vallecular cyst at 25 weeks of gestation. At birth, the cyst was drained and then marsupialized. We believed that, in cases of oropharyngeal tumors discovered in utero, elective delivery should be realised in a tertiary referral center in which emergency ventilation and tracheostomy are possible.

The neural system that bridges reward and cognition in humans: an fMRI study

We test the hypothesis that motivational and cognitive processes are linked by a specific neural system to reach maximal efficiency. We studied six normal subjects performing a working memory paradigm (n-back tasks) associated with different levels of monetary reward during an fMRI session. The study showed specific brain activation in relation with changes in both the cognitive loading and the reward associated with task performance. First, the working memory tasks activated a network including the dorsolateral prefrontal cortex [Brodmann area (BA) 9/46] and, in addition, in the lateral frontopolar areas (BA 10), but only in the more demanding condition (3-back task). This result suggests that lateral prefrontal areas are organized in a caudo-rostral continuum in relation with the increase in executive requirement. Second, reward induces an increased activation in the areas already activated by working memory processing and in a supplementary region, the medial frontal pole (BA 10), regardless of the level of cognitive processing. It is postulated that the latter region plays a specific role in monitoring the reward value of ongoing cognitive processes. Third, we detected areas where the signal decreases (ventral-BA 11/47 and subgenual prefrontal cortices) in relation with both the increase of cognitive demand and the reward. The deactivation may represent an emotional gating aimed at inhibiting adverse emotional signals to maximize the level of performance. Taken together, these results suggest a balance between increasing activity in cortical cognitive areas and decreasing activity in the limbic and paralimbic structures during ongoing higher cognitive processing.

Influence of age and executive functioning on verbal memory of inpatients with depression

BACKGROUND

Despite many studies demonstrating memory and executive impairments in young and old depressed patients, the relationships between age, executive functioning and memory have not been evaluated in depression. The aim of this study was to investigate if older patients were more vulnerable than younger patients to the impact of depression on memory and if the differences between young and old depressed could be related to executive functioning.

METHODS

Forty-nine inpatients, with unipolar and bipolar depression, ranging in age from 19 to 72 years were compared with 70 controls on a verbal memory task. Age cut-off of 45 years was used as a categorical variable to divide subjects into subgroups. A subset of patients (n=41) was also evaluated with the modified version of the Wisconsin Card Sorting Test and separated into a non-dysexecutive group and a group of patients with mild-executive impairment.

RESULTS

Depressed patients exhibited memory deficits with a pattern of memory failure -- impaired free recall and normal cued recall and recognition -- interpreted as a retrieval problem. Both age and executive function influenced memory performance in depression, however neither group x age interaction nor age x executive status interaction were significant. Multiple regression analysis showed that free recall scores were related to age and psychomotor retardation in depressed patients.

CONCLUSION

Age and executive functioning have different influences on the memory performance of depressed patients. Our findings support an 'executive memory decline hypothesis' in young as well as old depressed patients. The memory deficits in depression may be associated with both trait and state factors and raise questions about the long-term cognitive functioning of patients with recurrent affective disorders.

[Executive functioning in unipolar depression: a review]

While several neuropsychological studies have demonstrated that cognitive deficits are seen across a broad range of cognitive domains, executive deficits associated with frontal lobe dysfunction may be prominent in depression. Executive function refers to cognitive processes that control and integrate other cognitive activities such as episodic memory. These executive functions involve a set of cognitive behaviors which include: dealing with novelty, selecting strategies, inhibiting incorrect responses, monitoring performance and using feedback to adjust future responding. The measurement of executive function relies mainly on the use of neuropsychological tests known to be sensitive to frontal lobe damage such as the Wisconsin and California Card Sorting Tests, verbal fluency tests, Stroop-test, Tower of London Task and Trail Making Test. The present review focuses on studies investigating executive functions in primary unipolar depression with these neuropsychological tasks. Unipolar depressed patients mainly exhibit cognitive inhibition deficits, problem-solving impairments and planning deficits. Cognitive inhibition deficits in depressed patients have been related to a reduction of cognitive resources and psychomotor retardation. Inhibition disturbance could lead depressed patients to process irrelevant information and consequently reduce their capacity to control transient mood changes. Several studies have found evidence of problem solving impairments in depressed patients. Depressed subjects show with card sorting tests difficulties in hypothesis testing with a loss of spontaneous and reactive cognitive flexibility. The cognitive rigidity and hypothesis-testing associated with dorsolateral prefrontal dysfunction in depression may prevent patients to cope with life events and lead to a perpetuation of depressed mood by a continuation of stress exposure. Planning tasks, such as the Tower of London Test, also demonstrate that depressed patients fail to use negative feedback as a motivational boost to improve their performance. Both trait and state factors influence the executive level of depressed patients. Executive deficits have been reported in more severely depressed subjects with melancholic or psychotic features. Executive functioning also might predict a poorer outcome in depression. Thus initiation and perseveration scores - a measure of cognitive flexibility - is associated with relapse and recurrence of depression and residual depressive symptoms. Brain imaging studies show that reduced blood flow, particularly in medial prefrontal cortex and dorsal anterior cingulate cortex subserve executive impairments in depression. However neuroimaging studies underscore the importance of mood-cognitive interactions in depression. A recent working model of depression (Mayberg et al., 1999) implicates failure of the coordinated interactions of distributed cortical-limbic pathways in the neuropsychopathology of depression. According to this model, neocortical (prefrontal and parietal regions) and superior limbic elements (dorsal anterior cingulate) are postulated to mediate impaired attention and executive function, whereas ventral limbic regions (ventral anterior cingulate, subcortical structures) are postulated to mediate circadian and vegetative aspects of depression. Further studies are needed to validate this model at the neuropsychological level as well as the brain level and to elucidate the complex interactions between mood, cognitive resources and executive function in depression.

Problem-solving abilities in unipolar depressed patients: comparison of performance on the modified version of the Wisconsin and the California sorting tests

Problem solving relies on such abilities as decision-making, planning, initiation and hypothesis testing. Although problem-solving deficits have been consistently reported in depression, the specific nature of these deficits is not fully elucidated. In order to assess and isolate cognitive processes underlying problem-solving impairments in depression, depressed patients and normal controls were evaluated with the modified version of the Wisconsin Card Sorting Test (WCST) and the California Card Sorting Test (CCST). The California Card Sorting Test, unlike the modified WCST, provides several different measures of concept generation, concept identification and concept execution. Compared with controls, depressed patients did not show any deficits on all the measures of the modified WCST. In contrast, depressed patients evidenced mild impairment on the CCST with a specific deficit on concept generation but no major problems in concept identification and concept execution. The deficit in concept generation may be rooted in multiple factors such as hypothesis-testing deficits, a loss of cognitive flexibility and a conservative style of response. Since a positive relation between problem-solving deficits and the mean duration of the depressive episode was observed, problem-solving abilities might be predictive of poorer outcome in patients with unipolar affective disorders.

Absence of cognitive impairment at long-term follow-up in adolescents treated with ECT for severe mood disorder

OBJECTIVE

Cognitive functions of adolescents treated with ECT for mood disorder were evaluated at long-term follow-up.

METHOD

At an average of 3.5 years (SD=1.7) after the last ECT, 10 subjects treated during adolescence with bilateral ECT for severe mood disorder completed a clinical and cognitive evaluation, including the California Verbal Learning Test and Squire's Subjective Memory Questionnaire. The same assessments were given to 10 psychiatric comparison subjects matched for sex, age, and diagnosis.

RESULTS

All cognitive test scores of the patients treated with ECT were similar to those of the comparison subjects and did not differ from norms from the community. Six of the 10 ECT-treated patients reported having had memory losses immediately after the ECT course, but only one complained of subjective memory impairment at follow-up.

CONCLUSIONS

The results suggest that adolescents given ECT for severe mood disorder do not suffer measurable cognitive impairment at long-term follow-up.

Executive functioning and verbal memory in young patients with unipolar depression and schizophrenia

Although neuropsychological studies have consistently reported executive deficits in schizophrenia, studies of executive functions in depression have produced equivocal results. The aim of this study was to examine the profile and the specificity of the executive impairment and its association with memory performance in young patients with unipolar depression. We compared patients with depression to normal control subjects and schizophrenics. Twenty young inpatients with unipolar depression, 14 schizophrenics and 20 age-, education- and IQ-matched control subjects were assessed with a neuropsychological battery including: (1) verbal memory task; (2) frontal tasks (WCST, Cognitive Estimate, Verbal fluency, verbal and visuo-spatial span) and a new complex sorting test (Delis test). Depressed patients and schizophrenics exhibited executive deficits. Unlike schizophrenics, depressed patients did not show memory impairment. Deficits in several 'higher-level' functions combined to produce executive impairments in patients with depression including complex integration for concept formation, spontaneous cognitive flexibility and initiation ability. Impaired functions in schizophrenia and in depressed patients were similar but were differently related to clinical variables. The pattern of memory failure in our schizophrenics is believed to reflect retrieval and encoding deficits. Our findings highlight the heterogeneity of skills grouped under the term 'executive functions' that are vulnerable in depression or schizophrenia.

[Epidural air after closed thoracic trauma]

We report a rare case of spontaneous pneumorachis (epidural air in the spinal canal) after benign chest trauma without rib fracture or pneumothorax.

[Dupuytren's contracture and diabetes mellitus]

The literature suggests that the frequency of Dupuytren's disease is ten times greater in diabetes than in the general population. We have studied 42 diabetic patients with a contracture of the palmar fascia. Dupuytren's contracture can be considered a complication of diabetes and of the local neurovascular changes since both are often associated. The contracture is usually not severe in diabetes, is nodular in form, and usually crushes the palmar surface of the long and ring fingers. It is usually well tolerated by the patients and surgery is rarely indicated, particularly in view of the advanced age of many patients. In caring for patients with Dupuytren's disease, surgeons should also rule out the presence of diabetes with appropriate test.

[Pituitary radiotherapy. Current data and future prospects]

Some technical improvements have allowed to minimize the frequency of severe complications following fractionated pituitary conventional radiotherapy, without altering its efficiency. "Conformational" radiotherapy is currently under development, aiming at the best fitting of the tumor borders to the irradiation zone, by the means of stereotactic imaging. More recently, radiosurgery has been proposed for pituitary adenomas. It consists in a single high radiation dose to the tumor, by the means of either cobalt minibeams (Gamma Unit) or photon beams from a linear particle accelerator. These techniques require the use of a stereotactic frame and precise 3D imaging in order to tightly superimpose the target volume to the reference isodose. They must not be viewed as an alternative to conventional radiotherapy. They can be applied only to small lesions (less than 20 mm in their maximal axis) which are distant (> 5 mm) from the optic chiasma and nerves. Their efficiency is similar to the one of fractionated conventional radiotherapy, with a shorter response time. In conclusion, radiotherapy can be used safely for pituitary adenomas. It remains however a second line treatment, when surgery has been incomplete and when a simple, effective and inexpensive medical treatment is not possible.

[Gonadotropic adenomas]

Since the advent of immunohistochemical and cell culture techniques, the role of gonadotroph adenomas in hypophyseal disorders appears more important than formerly. A large part of "nonfunctional" adenomas in fact correspond to gonadotroph adenomas in vitro. These adenomas raise many clinical and biological questions since their presentation is not univocal. In addition, diagnosis of these adenomas is important since their spontaneous development leads to neuro-opthalmological complications, which presently are still too often the revealing manifestations of these adenomas.

[Deficits in memory retrieval: an argument in favor of frontal subcortical dysfunction in depression]

While numerous studies have objective quantitative and qualitative deficits of memory in depressed patients, the mechanisms of these impairments are not well established. The study reported here was designed to assess encoding and retrieval processes in depression and to define the specific nature of memory failure associated with this disorder.

METHODS

Ten inpatients with major depression responding to DSM III-R criteria and ten normal controls were included in this study. All subjects were assessed with a neuropsychological battery including: a) subtests of Weschsler memory scale (digit span, logical memory); b) verbal fluency (letter); c) two tasks assessing executive functions (cognitive estimate, Nelson's test); d) two explicit tasks of verbal learning (California Verbal Learning Test and Grober & Buschke's procedure) which measure memory performance in various conditions of encoding (incidental vs controlled) and of recollection (free recall, cued recall and recognition). Severity of depression was assessed with the MADRS and the Retardation Rating Scale for Depression.

RESULTS

Although there was no difference between patients and controls on digit span and logical memory tasks, depressed patients exhibited a deficit in verbal learning with CVLT and Grober & Buschke's procedure. On California Verbal Learning Test, depressive subjects performed poorly in free recall and demonstrated poor consistency. Patients show free recall improvement across trials 1 or 5 and this learning effect didn't differ from controls. Score of patients and controls on cued recall and recognition were at the same level. Grober & Buschke's procedure confirmed these results. Despite a control of encoding processes during the initial presentation of the words, free recall measure revealed significant difference between groups. Like controls, patients recalled almost all items when semantic cues was provided and their recognition results showed a ceiling effect. Consistency indexes of free recall and cued recall differed significantly between groups. Verbal fluency and frontal tasks didn't allow to distinguish the depressive patients from controls.

DISCUSSION

Depressive subjects exhibited a deficit in free recall and poor consistency while cued recall and recognition were normal. Patient's results in free recall are characterized by difficulties in planning and in maintaining retrieval strategies. These findings suggest that memory failure in depression could reflect an impairment in retrieval processes depending on executive functions controlled by the subcortical structures.

Ovarian stromal hypertrophy in hyperandrogenic women

OBJECTIVE

By using vaginal endosonography, ovarian stromal hypertrophy has been shown to be a strong diagnostic feature of polycystic ovarian syndrome and related states. However, this sign is difficult to quantify and to correlate with other findings because of its subjectivity. We have evaluated the use of computer assisted analysis of ultrasound scans to provide more objective measurements of ovarian structure and size.

DESIGN

We used a computer assisted method for the reading of ultrasound scans. It allowed selective calculation of the stromal area by subtraction of the cyst area from the total ovarian area on a longitudinal ovarian section.

PATIENTS

A consecutive series of 57 patients with hyperandrogenism (group 1), 17 patients with hypothalamic anovulation (group 2) and 20 normal women (group 3).

RESULTS

By computerized measure, 75% patients from group 1 had a bilateral stromal area above the mean +2 SD (700 mm2) of women from group 3. All patients from group 2 were below this threshold. Serum LH level was above the normal range in 45% patients from group 1. The stromal area correlated positively with the serum delta 4-androstenedione (r = 0.47, P < 0.005) and 17 alpha-hydroxyprogesterone (r = 0.39, P < 0.005) levels, exclusively in group 1. It did not correlate with the basal serum testosterone, LH or insulin levels. The cyst area did not correlate with any hormonal parameter.

CONCLUSION

Ovarian stromal hypertrophy is a frequent and specific feature of hyperandrogenism. It correlates with the ovarian androgenic dysfunction. Its presence is not always linked with elevated serum immunoreactive LH levels. Further data are needed to elucidate the role of insulin and ovarian growth factors.

Pituitary microadenomas: experience with Gd-DOTA-enhanced MR imaging at 0.5 Telsa

PURPOSE

We report our experience with magnetic resonance imaging at 0.5 Tesla in the radiological diagnosis of pituitary adenomas.

METHODS

Over 2 years we performed a prospective study in 38 patients with pituitary microadenomas to assess the potential additional benefit of gadolinium in the detection of small intrasellar lesions. The protocol included three coronal T1-weighted sequences: precontrast, early postcontrast (obtained less than 2 min after injection) and late postcontrast (obtained 5 min after injection). For each sequence lesions were classified according to their visibility into three categories: definite lesion, probable lesion or absent lesion.

RESULTS

Lesions were classified as well-defined in 55% of patients on the precontrast study, 89.5% on the early postcontrast study and 60.5% on the late postcontrast study. Of nine microadenomas not detected on the precontrast scans, all were clearly seen on the early post contrast scans; only four were well-defined on the late postcontrast study. Only one lesion was not seen on the early postcontrast study but was well-defined on precontrast study as a spontaneous high-intensity focal area: it was a hemorrhagic microadenoma.

CONCLUSION

Our results suggest that the early postcontrast study is the most useful sequence for the detection of microadenomas. Precontrast image is necessary to detect hemorrhagic lesions; the late postcontrast sequence has a low additional diagnostic yield and seems unnecessary unless the other sequences are inconclusive.

Association of Lhermitte-Duclos and Cowden disease: report of a new case and review of the literature

Lhermitte-Duclos disease is a rare entity, and its pathological features are unique. Pathological findings are characteristic of the disease, with global hypertrophy of the cerebellum, coarse gyri, and the typical "inverted cortex" pattern. Several associated lesions were noted in many patients with Lhermitte-Duclos disease. It is only recently that an association between Lhermitte-Duclos disease and Cowden disease was reported. Cowden disease, or multiple hamartomas syndrome, is a familial disease associating breast cancer, cutaneomucous tricholemmomas, and various other tumoural and dysplasic conditions. A new case of Lhermitte-Duclos disease associated with Cowden disease is reported. A review of the literature found 72 cases of Lhermitte-Duclos disease; 26 had conditions suggesting Cowden disease and seven were definite cases of Cowden disease. The association of Lhermitte-Duclos disease and Cowden disease is probably underestimated. Cowden disease represents a new form of phakomatosis; Lhermitte-Duclos disease may occur as a sporadic disease, or as part of familial Cowden disease. The possibility of preneoplastic states in Cowden syndrome stresses the importance of a thorough screening when Lhermitte-Duclos disease is diagnosed.

Explicit memory, procedural learning and lexical priming in Alzheimer's disease

Different aspects of memory functions were studied in two groups of patients with Alzheimer's disease (AD) and in normal elderly controls. The tests included: explicit memory tests with free and cued recall, and recognition measures; learning of a motor skill; learning of a perceptual skill with verbal material; a priming task with the word stem completion paradigm. The data confirmed that, besides severe impairment for all measures of explicit memory, AD patients were able to learn and retain normally a motor skill in the rotor pursuit task, even across a long retention interval. Moreover, sparing of procedural learning was not restricted to motor tasks, since patients learned normally a mirror-reading task, demonstrating (a) rapid acquisition of the procedure, and (b) acquisition of item-specific information for repeated words. This last effect is accounted for in terms of repetition priming effects rather than of explicit memory strategies, since patients had also normal repetition effect in the word stem completion paradigm.

A step forward in enzymatic measurement of creatinine

We describe an improved enzymatic ultraviolet absorbance method for assaying creatinine in serum, plasma, and urine. Creatinine is hydrolyzed by creatinine iminohydrolase (EC 3.5.4.21) to ammonia and N-methylhydantoin. The ammonia produced combines with 2-oxoglutarate and NADPH in the presence of glutamate dehydrogenase to yield glutamate and NADP+. The consumption of NADPH, measured by a two-point fixed-time assay, is proportional to the amount of creatinine in the sample. The assay is carried out in two steps: The first step eliminates background absorbance in hyperlipemic samples and endogenous ammonia through a "clearing system" and an isocitrate dehydrogenase-based "ammonia scavenger system"; the second step starts creatinine measurement. The method affords a simple, rapid, and sensitive assay with good precision and extended linearity; it employs working solutions stable at least 4 months. Test results compare closely with those of the isotope dilution-mass spectrometry Definitive Method, the HPLC procedure, and the fuller's earth method. The proposed method is not subject to interference from several metabolites or from the 72 drugs tested. Because it is easily automated, the method is suitable for routine work in clinical laboratories.

A step forward in enzymatic measurement of creatinine

We describe an improved enzymatic ultraviolet absorbance method for assaying creatinine in serum, plasma, and urine. Creatinine is hydrolyzed by creatinine iminohydrolase (EC 3.5.4.21) to ammonia and N-methylhydantoin. The ammonia produced combines with 2-oxoglutarate and NADPH in the presence of glutamate dehydrogenase to yield glutamate and NADP+. The consumption of NADPH, measured by a two-point fixed-time assay, is proportional to the amount of creatinine in the sample. The assay is carried out in two steps: The first step eliminates background absorbance in hyperlipemic samples and endogenous ammonia through a "clearing system" and an isocitrate dehydrogenase-based "ammonia scavenger system"; the second step starts creatinine measurement. The method affords a simple, rapid, and sensitive assay with good precision and extended linearity; it employs working solutions stable at least 4 months. Test results compare closely with those of the isotope dilution-mass spectrometry Definitive Method, the HPLC procedure, and the fuller's earth method. The proposed method is not subject to interference from several metabolites or from the 72 drugs tested. Because it is easily automated, the method is suitable for routine work in clinical laboratories.

[Endocrine and metabolic consequences of massive obesity]

Massive obesity is always accompanied by insulin resistance with hyperinsulinaemia in proportion to the amount of visceral fat, which has repercussions on oxidative and non-oxidative glucose metabolism. The increase of free fatty acids in direct relation to the adipocytic mass reduces the hepatic insulin uptake; it increases the suprahepatic glucose flow and the production of very low density lipoproteins. The adipose tissue exerts a feminizing effect in men and a masculinizing effect in women. Women have disorders of ovulation and hirsutism, with increase of free testosterone and elevation of luteotropic hormone levels. Men have hypoandrism due to excessive aromatization of androgens and oestrogens. The adipose tissue accelerates the turnover of cortisol and facilitates cortisone production, which stimulates ACTH secretion and maintains stimulation of the adrenal cortex. Hyperinsulinism and resistance to insulin also intervene in hormonal regulation. They elevate the insulin-like growth factor 1 (IGF-1) which inhibits the production of growth hormone and reduces its plasma half-life; hyperinsulinism and IGF-1 facilitate ovarian androgen production; hypothalamic disturbances occur by diminution of sensitivity to hypoglycaemia, and there are abnormalities in monoaminergic and serotoninergic control. Bone tissue density is preserved for a long time, as it is in proportion to the fatty mass and to the oestrogen and IGF-1 levels, but it may be gradually reduced by secondary hyperparathyroidism. Thyroid function and thyrotropic regulations are unaffected.

Interrelationship between ultrasonography and biology in the diagnosis of polycystic ovarian syndrome

In order to compare the diagnostic significance of hormonal and ultrasonic criteria of polycystic ovarian syndrome (PCOS), the presence or the absence of ultrasonographic and hormonal features of PCOS were recorded in a heterogeneous population of 90 women presenting with hyperandrogenism and/or menstrual disorders. On clinical and hormonal grounds exclusively, these patients could be separated into five diagnostic subgroups: presumed cases of PCOS (n = 21), idiopathic hirsutism (IH) (n = 26), hypothalamic anovulation (HA) (n = 11), hyperprolactinemia (HPRL) (n = 9), and miscellaneous or undetermined diagnosis (n = 23). By the means of a computed automatic classification of patients (cluster analysis) using five hormonal and ultrasonic criteria of PCOS, four homogeneous clusters of patients were obtained. Cluster #1 (25 patients) had the most characteristic profile of PCOS. It included 15 cases of PCOS and 7 cases of IH. Cluster #4 (47 patients) had the less characteristic profile of PCOS. It included the majority of patients with HA and HPRL and the half of the patients with IH. Cluster #2 included only two hyperandrogenic patients, who were massively obese and in whom ultrasonography may have failed to detect PCOS. Cluster #3 (16 patients) included patients from each diagnostic group, who were gathered together because ultrasonographic and hormonal features were, respectively, present and absent in nearly all of them. With the same analysis, the criteria of PCOS could be graded according to their grouping potential. The presence of an abnormal ovarian stroma by ultrasonography appeared as the most potent criterion. Elevated serum testosterone and androstenedione levels and the polyfollicular pattern of ovaries gave intermediate results, while elevated basal LH level was a much weaker grouping parameter. In conclusion, the automatic classification of patients by cluster analysis using both hormonal and ultrasonographic criteria revealed that the classical diagnostic classification, relying upon hormonal data exclusively, may arbitrarily separate patients having the same disease; and that ultrasonography affords pertinent information that should help provide a better diagnostic definition of PCOS.

Is it still worthwhile to treat bone metastases from differentiated thyroid carcinoma with radioactive iodine?

From 1964 to 1989, bone metastases were found in 28 of 600 patients operated on for differentiated thyroid carcinoma. Bone metastasis was the presenting symptom in 15 (54%) patients, was detected from the initial symptom in 4 (14.5%) patients, and occurred subsequently in 9 (32%) patients, with an average lag time of 4.5 years after surgical treatment. Pathological pattern of the thyroid cancer was follicular in 26 (93%) patients and papillary in 2 (7%) patients. Bone metastatic involvement was multiple in 21 (75%) patients and associated with other synchronous or metachronous distant metastases in 13 (46%) patients, especially in the lung (10 patients) or the brain (3 patients). The primary treatment of thyroid carcinoma was total thyroidectomy in all 28 patients, with additional modified neck dissection in 8 patients. All 15 patients presenting with symptoms had bone metastases demonstrated by x-ray studies. Six of the bone metastases only took up radioactive iodine 6 weeks after total thyroidectomy, as did 2 of 4 bone metastases detected at initial observation and 4 of 9 metachronous bone metastases. All 12 patients with functioning bone metastases were given radioactive iodine therapy; 4 of the metastases were surgically resected. Only 2 patients with bone metastases showed a complete response after an ablative dose of I-131; none of the metastases had been demonstrated by x-ray studies. Radioactive iodine therapy cures no more than 17% of patients with bone metastases taking up radioactive iodine and 7% of all patients with bone metastases. All patients cured of bone metastases were given radioactive iodine, either alone, or combined with other treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Kinetic colorimetric assay of lipase in serum

We describe a kinetic colorimetric method for assaying lipase (EC 3.1.1.3) activity in serum by using a natural long-chain fatty acid 1,2-diglyceride. In the presence of colipase, deoxycholate, and calcium ions, pancreatic lipase hydrolyzes the clear substrate solution to produce a 2-monoglyceride, which in turn releases glycerol by the action of a 2-monoglyceride lipase. Glycerol is then assayed by a sequence of enzymatic actions (glycerol kinase, glycerol phosphate oxidase, and peroxidase) that produce a violet quinone monoimine dye with peak absorption at 550 nm. The method features zero-order reaction kinetics, provides a simple and rapid assay with an extended dynamic range, is specific and precise, gives results that correlate well (r greater than or equal to 0.99) with those of methods in which emulsified triolein is the substrate, and lends itself readily to automation. For all these reasons, the method seems highly suitable for routine use in clinical laboratories.

Polycystic ovarian disease: contribution of vaginal endosonography and reassessment of ultrasonic diagnosis

OBJECTIVE

We evaluated the superiority of vaginal ultrasonography (US) on the abdominal US for the diagnosis of polycystic ovarian disease (PCOD).

DESIGN

The US pattern of ovaries was prospectively investigated by abdominal US and, whenever possible, by vaginal US.

SETTING

Primary care, institutional.

PATIENTS

One hundred forty-four women in whom PCOD was suspected on endocrine grounds and 62 other patients presenting with primary hyperprolactinemia (n = 23) or hypothalamic anovulation (n = 39).

MAIN OUTCOME MEASURE

Vaginal US allowed a better analysis of the ovarian stroma.

RESULTS

The external ovarian features of PCOD were observed by both routes in less than one third of the 144 patients with PCOD. The internal ovarian features of PCOD were much more frequently observed by vaginal US than by abdominal US (polycystic pattern: 66.7% versus 38.1%, P less than 0.05; increased ovarian stroma: 57.1% versus 4.8%, P less than 0.001). In the 62 patients without PCOD, US features of PCOD were observed in less than 10% of them, except for the uterine width/ovarian length ratio less than 1 and the polycystic pattern (abdominal US: 17% and 34%; vaginal US: 11% and 50%, respectively).

CONCLUSIONS

An increased ovarian stroma seems to be the most sensitive and specific US sign of PCOD, providing that it can be investigated by vaginal US.

Heterozygous hypobetalipoproteinemia with fasting chylomicronemia

We describe a disorder in which low-density lipoprotein (LDL)-cholesterol and apolipoprotein B are in low concentration (0.47 mmol/L and 0.28 g/L, respectively) and chylomicrons are still present in plasma after an 18-h fast. The d less than 1.006 fraction was isolated by flotation ultracentrifugation and the apolipoproteins were analyzed by electrophoresis, immunoblotting with anti-apolipoprotein B-100 antiserum, and isoelectric focusing. In the d less than 1.006 fraction of the fasting serum, we found an apolipoprotein B form with the same apparent molecular mass as apolipoprotein B-48 and similar in amount to apolipoprotein B-100 (respective percentages, 46% and 54%). The monosialylated form of the apolipoprotein C-III was severely decreased. After an oral fat load, the repartition of the two species of apolipoprotein B did not change greatly (respective percentages, 60% and 40%), and the concentration of serum triglyceride increased only from 1.20 to 1.65 mmol/L.

Heterozygous hypobetalipoproteinemia with fasting chylomicronemia

We describe a disorder in which low-density lipoprotein (LDL)-cholesterol and apolipoprotein B are in low concentration (0.47 mmol/L and 0.28 g/L, respectively) and chylomicrons are still present in plasma after an 18-h fast. The d less than 1.006 fraction was isolated by flotation ultracentrifugation and the apolipoproteins were analyzed by electrophoresis, immunoblotting with anti-apolipoprotein B-100 antiserum, and isoelectric focusing. In the d less than 1.006 fraction of the fasting serum, we found an apolipoprotein B form with the same apparent molecular mass as apolipoprotein B-48 and similar in amount to apolipoprotein B-100 (respective percentages, 46% and 54%). The monosialylated form of the apolipoprotein C-III was severely decreased. After an oral fat load, the repartition of the two species of apolipoprotein B did not change greatly (respective percentages, 60% and 40%), and the concentration of serum triglyceride increased only from 1.20 to 1.65 mmol/L.

Enzymatic assay of magnesium through glucokinase activation

We describe an improved enzymatic method for assaying magnesium in serum, plasma, or urine. Magnesium participates as an Mg.ATP complex in a reaction catalyzed by glucokinase (EC 2.7.1.2) coupled to an NADP+-dependent glucose-6-phosphate dehydrogenase (EC 1.1.1.49) reaction. The increase of absorbance at 340 nm, due to the NADPH produced, is proportional to the amount of the activated glucokinase, which in turn is related to the concentration of magnesium in the sample. The method is characterized by a zero-order reaction kinetics, affording a simple and rapid assay with good sensitivity and linearity (up to 2.06 mmol/L) and by working solutions that are stable (refrigerated) for one month. The method is reliable, produces test results that compare closely with those of the atomic absorption spectrophotometry (r greater than or equal to 0.99), is suitable for routine work, and lends itself to automation.

Enzymatic assay of magnesium through glucokinase activation

We describe an improved enzymatic method for assaying magnesium in serum, plasma, or urine. Magnesium participates as an Mg.ATP complex in a reaction catalyzed by glucokinase (EC 2.7.1.2) coupled to an NADP+-dependent glucose-6-phosphate dehydrogenase (EC 1.1.1.49) reaction. The increase of absorbance at 340 nm, due to the NADPH produced, is proportional to the amount of the activated glucokinase, which in turn is related to the concentration of magnesium in the sample. The method is characterized by a zero-order reaction kinetics, affording a simple and rapid assay with good sensitivity and linearity (up to 2.06 mmol/L) and by working solutions that are stable (refrigerated) for one month. The method is reliable, produces test results that compare closely with those of the atomic absorption spectrophotometry (r greater than or equal to 0.99), is suitable for routine work, and lends itself to automation.

Adrenocorticotropin and cortisol responses to ovine corticotropin-releasing factor in alcohol dependence disorder. Preliminary report

A 100-micrograms bolus of synthetic ovine corticotropin-releasing factor was administered intravenously to 10 nondepressed inpatients suffering from an alcohol dependence disorder. The test was performed during withdrawal and after 4 weeks of abstinence. During withdrawal, the plasma cortisol responses of alcoholic patients and 7 control subjects were similar, except for an earlier decrease of cortisol in the former group. However, after 4 weeks of abstinence, the cortisol response was significantly lower in alcoholic patients than in controls. These abnormalities observed during discontinuance of alcohol consumption may reflect adaptive mechanisms of the hypothalamic-pituitary-adrenal activity which may be previously altered by chronic alcohol intoxication.

Experience of a six-month treatment with sandostatin at increasing doses in acromegaly

The French Sandostatin/Acromegaly Study Group performed a multicentric, prospective, open-label trial of incremental doses with the aim of obtaining the best antisecretory effect. Forty-two patients (24 women, 18 men) aged 22-71 years were involved, either after unsuccessful surgery and/or radiotherapy (30 patients), or as primary treatment (12 patients). Doses were increased from 3 x 100 to 3 x 500 micrograms/day, according to the results of hormonal investigations (GH profiles and Sm-C) performed each month and for each dose, and tolerability. Four patients dropped out because of major digestive troubles. Recurrent pain at the injection site and minor gastrointestinal disorders were noted in some patients. Asymptomatic gallstones appeared in 4 patients. Carbohydrate tolerance and insulin secretion (determined by diurnal plasma glucose and insulin profiles) were not significantly altered by the various SMS doses. Clinical improvement was determined by the scoring of the symptoms. Mean plasma GH concentrations were significantly reduced for each SMS dose, compared to pretreatment values. Fifteen patients obtained 75% of GH values less than or equal to 2 micrograms/l. In 9 patients the highest dose failed to bring GH below 10 micrograms/l. Sm-C normalized in 17/31 patients. After 6 months of treatment a tumor reduction of 20-50% was found in 7 patients and greater than 50% in 5 patients. We conclude that (1) the tolerability of SMS is compatible with long-term treatments; (2) clinical improvement and biological criteria of efficacy are obtained in 3/4 acromegalic patients treated by SMS, and that (3) some patients are resistant to SMS and the increase in the dose does not improve the result.

One-step protocol for assays of total and direct bilirubin with stable combined reagents

We describe an improved colorimetric method for assays of total and direct bilirubin in serum. Bilirubin reacts with diazotized sulfanilic acid in an acidic medium to form a blue azopigment. Total bilirubin is assayed in the presence of reaction accelerators (caffeine, urea, and citric acid), direct bilirubin in their absence. The azo compound so formed is read at the same wavelength (570 nm) in both assays. A sample blank is run in parallel. Standard curves are linear for total and direct bilirubin concentrations up to 513.0 and 256.5 mumol/L, respectively. The method is characterized by (a) use of the same protocol for both assays, i.e., a one-step procedure with short reaction time (5 min at room temperature), and (b) use of a single working solution, which, refrigerated, is stable for one month. The method is reliable, yields results that compare closely with those of the classical Jendrassik--Gróf method, is suitable for routine use, and lends itself to automation.

One-step protocol for assays of total and direct bilirubin with stable combined reagents

We describe an improved colorimetric method for assays of total and direct bilirubin in serum. Bilirubin reacts with diazotized sulfanilic acid in an acidic medium to form a blue azopigment. Total bilirubin is assayed in the presence of reaction accelerators (caffeine, urea, and citric acid), direct bilirubin in their absence. The azo compound so formed is read at the same wavelength (570 nm) in both assays. A sample blank is run in parallel. Standard curves are linear for total and direct bilirubin concentrations up to 513.0 and 256.5 mumol/L, respectively. The method is characterized by (a) use of the same protocol for both assays, i.e., a one-step procedure with short reaction time (5 min at room temperature), and (b) use of a single working solution, which, refrigerated, is stable for one month. The method is reliable, yields results that compare closely with those of the classical Jendrassik--Gróf method, is suitable for routine use, and lends itself to automation.

Screening heterozygotes for 21-hydroxylase deficiency among hirsute women: lack of utility of the adrenocorticotropin hormone test

Heterozygosity for 21-hydroxylase deficiency (21-OHD) was investigated in 174 adult hirsute women by using the sum of the incremental responses of serum 17 alpha-hydroxyprogesterone (17 alpha-OHP) and progesterone (P) (delta 17 alpha-OHP + P), 60 minutes after a 0.25 mg intravenous (IV) bolus of synthetic adrenocorticotropic hormone (ACTH). The distribution of 17 alpha-OHP + P in hirsute women was bimodal, allowing two subgroups to be distinguished. In one subgroup including 137 patients, the mode was similar to controls and all values were lower than 3 ng/ml. Thirty-seven (21%) patients constituted another subgroup with values higher than 3 ng/ml and could a priori have been considered as heterozygotes for 21-OHD. However, human leukocyte antigen genotyping provided no conclusive evidence that this subgroup included exclusively heterozygotes for the 21-OHD.

Enzymatic colorimetric method for the determination of inorganic phosphorus in serum and urine

The performance of an enzymatic colorimetric method for the determination of inorganic phosphorus in serum and urine is described. Phosphate ions react with inosine in the presence of purine nucleoside phosphorylase to form hypoxanthine; this is oxidized by xanthine oxidase to uric acid with production of hydrogen peroxide. The latter is determined with the aid of the chromogen system peroxidase/4-aminophenazone/N-ethyl-N-(3-methylphenyl)-N'-acetylethyl enediamine , the coloured product being measured at 555 nm. This series of reactions is completed in 5 min at 37 degrees C. The test is linear up to 240 mg/l. Analytical recovery in serum averaged 101.2 +/- 1.2% and in urine 101.9 +/- 3.2%. Within-run and between-run precision studies in serum and urine samples gave CVs less than or equal to 4.54% (at 22.0 mg/l). Results obtained by this method agree (r = greater than or equal to 0.983) with the molybdate UV and molybdenum blue methods. Interference by endogenous substances, including organic phosphate, was negligible.