Cytokines in agitated and non-agitated patients admitted to an acute psychiatric department: A cross-sectional study

BACKGROUND

Different psychiatric diagnostic groups have been reported to have cytokine levels deviating from healthy controls. In acute clinical settings however, the specific challenging symptoms and signs are more important than a diagnostic group. Thus, exploration of cytokines and immune activity and their role in specific symptoms is important. Reports in this field so far are sparse.

OBJECTIVE

In the present study, we aimed to examine the association between immune activity measured as levels of cytokines and agitation (independent of diagnostic group) in patients admitted to an acute psychiatric inpatient department.

METHODS

A total of 316 patients admitted to an acute psychiatric inpatient department were included. Thirty-nine patients with psychosis were subject to subgroup analyses. Agitation was assessed by the Positive and Negative Syndrome Scale, Excitement Component (PANSS-EC). Based on PANNS-EC patients were stratified into two groups: 67 agitated patients and 249 non-agitated patients. Serum concentrations of the following immune markers were measured: interleukin (IL) -1β, IL-4, IL-6, IL-10, tumor necrosis factor (TNF) -α, interferon (IFN) -γ and transforming growth factor (TGF) -β.

RESULTS

Serum levels of TNF-α were significantly higher in patients with agitation compared to those without, both when all patients were included in the analyses (p = 0.004) and in the psychosis group (p = 0.027). After correcting for multiple testing, only the findings in the total population remained significant.

CONCLUSIONS

Our findings suggest an association between TNF-α and agitation in an acute psychiatric population. A similar trend was reproduced to the psychosis subgroup. This suggests that agitation might be an independent entity associated with cytokines across different diagnostic groups.

High-frequency repetitive transcranial magnetic stimulation combined with cognitive training improves cognitive function and cortical metabolic ratios in Alzheimer's disease

Various studies report discordant results regarding the efficacy, parameters, and underlying mechanisms of repetitive transcranial magnetic stimulation (rTMS) combined with cognitive training (CT) on Alzheimer's disease (AD). The objective of the study was to assess the effect of rTMS-CT on cognition, the activities of daily life, neuropsychiatric behavioral symptoms, and metabolite levels beneath the stimulated areas of the brain in patients with AD and to investigate the correlation of metabolic changes (measured with proton magnetic resonance spectroscopy [¹H-MRS]) with clinical outcomes after treatment. Thirty consecutive patients with mild or moderate AD were enrolled and randomly divided into one of the two intervention groups: (1) real rTMS with CT (i.e., real group) and (2) sham rTMS with CT (i.e., sham group). 10 Hz rTMS was used to stimulate the left dorsolateral prefrontal cortex (DLPFC) and then to stimulate the left lateral temporal lobe (LTL) for 20 min each day for 4 weeks. Each patient underwent neuropsychological assessment at baseline (T0), immediately after treatment (T1), and 4 weeks after treatment (T2). The ratios of N-acetylaspartate/creatine (NAA/Cr), myoinositol/creatine (mI/Cr), and choline/creatine (Cho/Cr) in the stimulated cortex were measured using ¹H-MRS at T0 and T1. Twenty-eight patients were treated with rTMS-CT for 4 weeks. Two patients in the sham group withdrew after being treated several times. Compared with the sham group, the cognitive function and behavior in the real rTMS group improved significantly at T1 and T2. In the real group, compared with the sham group, the NAA/Cr ratio in the left DLPFC was significantly elevated (p = 0.045); however, in the left LTL, it only showed a tendency toward increase (p = 0.162). The change in the NAA/Cr ratio in the left DLPFC was negatively correlated with the change in the cognitive scales of the Alzheimer's Disease Assessment Scale (ADAS-cog). This study indicated a possible modest effect of rTMS-CT on preventing clinical and neuronal functional deterioration in the left DLPFC of patients with AD. The left DLPFC is a better candidate area than the left LTL.

The neurochemistry of agitation in Alzheimer's disease: a systematic review

OBJECTIVE

To provide an up-to-date systematic review of the characteristics, methodology and findings of studies that have investigated the neurochemistry of agitation in Alzheimer's disease (AD).

METHODS

Electronic databases were searched for published peer-reviewed articles which provided data on any neurotransmitter system in relation to agitation in AD. Screening of titles and abstracts and data extraction from full texts were conducted in duplicate.

RESULTS

Forty-five studies were included. Monoamines (serotonin, dopamine and noradrenaline) were most commonly investigated. A variety of methods were used to investigate the neurochemistry underlying agitation in AD and, although there were several conflicting findings, there was evidence of serotonergic deficit, relatively preserved dopaminergic function and compensatory overactivity of postsynaptic noradrenergic neurons in agitation in AD.

CONCLUSIONS

Disruption of the dynamic balance between multiple neurotransmitter systems could impair functional neural networks involved in affective regulation and executive function. Differences in study design and methodology may have contributed to conflicting findings. Future studies that overcome these limitations (e.g. using standardized criteria to define agitation) and employ neuroimaging methods such as MRI/PET to investigate specific neural networks are needed to clarify the role of neurotransmitter alterations in these patients.

Endocrine regulation of migratory departure from stopover: Evidence from a longitudinal migratory restlessness study on northern wheatears

Most migrating birds make stopovers to replenish fuel stores. The decision to resume migration from stopover to a large extent shapes the temporal organization of migration. This decision is known to be shaped by a suite of intrinsic and extrinsic factors such as the bird's fuel stores and current weather conditions. However, how departures from stopover are physiologically regulated is largely unknown. We here present data that strongly indicate that corticosterone, a hormone with a stimulatory effect on locomotion, acts as a mediator between fuel stores and departure from stopover. In migrating northern wheatears (Oenanthe oenanthe) temporarily caged at stopover, we observed a positive relationship between the change in fuel stores and the concurrent change in glucocorticoid metabolite (GCM) levels measured in the birds' droppings. We also found a positive relationship between the change in GCM levels and the change in the intensity of nocturnal migratory restlessness. As in northern wheatears nocturnal migratory restlessness is an accurate proxy for stopover departure likelihood, our results indicate that corticosterone mediates between fuel stores and the decision to resume migration. Our unique longitudinal study represents a considerable advance in our understanding of the endocrine regulation of avian migration.

Spontaneous Physical Activity Defends Against Obesity

PURPOSE OF REVIEW

Spontaneous physical activity (SPA) is a physical activity not motivated by a rewarding goal, such as that associated with food-seeking or wheel-running behavior. SPA is often thought of as only "fidgeting," but that is a mischaracterization, since fidgety behavior can be linked to stereotypies in neurodegenerative disease and other movement disorders. Instead, SPA should be thought of as all physical activity behavior that emanates from an unconscious drive for movement.

RECENT FINDINGS

An example of this may be restless behavior, which can include fidgeting and gesticulating, frequent sit-to-stand movement, and more time spent standing and moving. All physical activity burns calories, and as such, SPA could be manipulated as a means to burn calories, and defend against weight gain and reduce excess adiposity. In this review, we discuss human and animal literature on the use of SPA in reducing weight gain, the neuromodulators that could be targeted to this end, and future directions in this field.

Model-based optimization approaches for precision medicine: A case study in presynaptic dopamine overactivity

Precision medicine considers an individual’s unique physiological characteristics as strongly influential in disease vulnerability and in response to specific therapies. Predicting an individual’s susceptibility to developing an illness, making an accurate diagnosis, maximizing therapeutic effects, and minimizing adverse effects for treatment are essential in precision medicine. We introduced model-based precision medicine optimization approaches, including pathogenesis, biomarker detection, and drug target discovery, for treating presynaptic dopamine overactivity. Three classes of one-hit and two-hit enzyme defects were detected as the causes of disease states by the optimization approach of pathogenesis. The cluster analysis and support vector machine was used to detect optimal biomarkers in order to discriminate the accurate etiology from three classes of disease states. Finally, the fuzzy decision-making method was employed to discover common and specific drug targets for each classified disease state. We observed that more accurate diagnoses achieved higher satisfaction grades and dosed fewer enzyme targets to treat the disease. Furthermore, satisfaction grades for common drugs were lower than for specific ones, but common drugs could simultaneously treat several disease states that had different etiologies.

18F-Fluorodeoxyglucose Positron Emission Tomography Cortical Metabolic Activity Associated with Distinct Agitation Behaviors in Alzheimer Disease

OBJECTIVE

This study aimed to investigate the neurobiologic correlates of two distinct clusters of agitation symptoms to identify the unique biologic substrates underlying agitated behaviors.

METHODS

Eighty-eight outpatients with mild to moderate Alzheimer disease (AD) were recruited from the VA Greater Los Angeles Healthcare System Geropsychiatry Outpatient Program. A cross-sectional investigation was conducted of the relationship between cerebral glucose metabolism measured via ¹⁸F-fluorodeoxyglucose positron emission tomography and agitated symptoms from the Neuropsychiatric Inventory (NPI) in patients with AD. Two empirically derived clusters of agitation symptoms were investigated: an Agitation factor comprising agitation/aggression and irritability/lability items of the NPI, and a Behavioral Dyscontrol factor comprising elation/euphoria, disinhibition, aberrant motor behavior, sleep, and appetite items of the NPI. Mean cerebral metabolism for patients who scored positively on each of the two factors was compared with mean cerebral metabolism for those who did not.

RESULTS

Patients with AD who scored positively on the Agitation factor showed reduced glucose metabolism of the right temporal, right frontal, and bilateral cingulate cortex. In contrast, the Behavioral Dyscontrol factor did not show specific neurobiologic correlates.

CONCLUSION

Symptoms encompassed within the Agitation factor have distinct neurobiologic underpinnings. The precipitants, course, and outcomes related to these symptoms may be unique from other neuropsychiatric symptoms characteristic of AD. Special attention to treatment of agitated behaviors involving anger, aggressiveness, hostility, and irritability/emotional lability is warranted, because they appear to reflect a clinically relevant symptom cluster with unique underlying neurobiologic correlates.

Quercetin reduces manic-like behavior and brain oxidative stress induced by paradoxical sleep deprivation in mice

Quercetin is a known antioxidant and protein kinase C (PKC) inhibitor. Previous studies have shown that mania involves oxidative stress and an increase in PKC activity. We hypothesized that quercetin affects manic symptoms. In the present study, manic-like behavior (hyperlocomotion) and oxidative stress were induced by 24h paradoxical sleep deprivation (PSD) in male Swiss mice. Both 10 and 40mg/kg quercetin prevented PSD-induced hyperlocomotion. Quercetin reversed the PSD-induced decrease in glutathione (GSH) levels in the prefrontal cortex (PFC) and striatum. Quercetin also reversed the PSD-induced increase in lipid peroxidation (LPO) in the PFC, hippocampus, and striatum. Pearson's correlation analysis revealed a negative correlation between locomotor activity and GSH in the PFC in sleep-deprived mice and a positive correlation between locomotor activity and LPO in the PFC and striatum in sleep-deprived mice. These results suggest that quercetin exerts an antimanic-like effect at doses that do not impair spontaneous locomotor activity, and the antioxidant action of quercetin might contribute to its antimanic-like effects.

Cortisol and Wake Time in Nursing Home Residents With Behavioral Symptoms of Dementia

Alterations in sleep and behavioral symptoms are consistently reported among nursing home residents with dementia. Disregulation in the hypothalamic-pituitary-adrenal axis (HPA), indexed by basal cortisol levels, offers one explanation. The purpose of this study is to examine the relationship between wake time and cortisol slope in residents with behavioral symptoms. The study included 27 residents aged 71 to 84 years with dementia and behavioral symptoms. Using a within-subject longitudinal design, the researchers documented wake time and collected saliva samples for 4 consecutive days upon waking and at 30 min, 6 hr, and 12 hr after waking. Within-person cortisol slopes were categorized into zero-positive and negative slopes. The zero—positives (35%) exhibited an earlier wake time than the negatives (65%). These preliminary results suggest both a relationship between wake time and HPA diurnal profile and an association between the sleep-wake cycle and cortisol secretion among nursing home residents with dementia.

A population pharmacokinetic model for R- and S-citalopram and desmethylcitalopram in Alzheimer's disease patients with agitation

The citalopram for Alzheimer’s disease trial evaluated citalopram for the management for agitation in Alzheimer’s disease patients. Sparse data was available from this elderly patient population. A nonlinear mixed effects population pharmacokinetic modeling approach was used to describe the pharmacokinetics of R- and S-citalopram and their primary metabolite (desmethylcitalopram). A structural model with 4 compartments (one compartment/compound) with linear oral absorption and elimination described the data adequately. Overall, the model showed that clearance of the R-enantiomer was slower than the clearance of the S-enantiomer. Without accounting for any patient-specific covariates, the population estimate of the metabolic clearance of citalopram was 8.6 (R-citalopram) and 14 L/h (S-citalopram). The population estimate of the clearance of desmethylcitalopram was 23.8 (R-Dcit) and 38.5 L/h (S-Dcit). Several patient-specific covariates were found to have a significant effect on the pharmacokinetics of R,S-citalopram and desmethylcitalopram. A significant difference in the metabolic clearance of R-citalopram between males and females (13 vs 9.05 L/h) was identified in this analysis. Both R- and S-citalopram metabolic clearance decreased with age. Additionally, consistent with literature reports S-citalopram metabolic clearance increased with increasing body weight and was significantly influenced by CYPC19 genotype, with a difference of 5.8 L/h between extensive/rapid and intermediate/poor metabolizers. R,S-desmethylcitalopram clearance increased with increasing body weight. This model may allow for the opportunity to delineate the effect of R- and S-citalopram on pharmacodynamics outcomes related to the management of agitation in Alzheimer’s disease.

Mother/offspring co-administration of the traditional herbal remedy yokukansan during the nursing period influences grooming and cerebellar serotonin levels in a rat model of neurodevelopmental disorders

Neurodevelopmental impairment in the serotonergic system may be involved in autism spectrum disorder. Yokukansan is a traditional herbal remedy for restlessness and agitation in children, and mother-infant co-administration (MICA) to both the child and the nursing mother is one of the recommended treatment approaches. Recent studies have revealed the neuropharmacological properties of Yokukansan (YKS), including its 5-HT1A (serotonin) receptor agonistic effects. We investigated the influence of YKS treatment on behavior in a novel environment and on brain monoamine metabolism during the nursing period in an animal model of neurodevelopmental disorders, prenatally BrdU (5-bromo-2'-deoxyuridine)-treated rats (BrdU-rats). YKS treatment did not influence locomotor activity in BrdU-rats but reduced grooming in open-field tests. YKS treatment without MICA disrupted the correlation between locomotor behaviors and rearing and altered levels of serotonin and its metabolite in the cerebellum. These effects were not observed in the group receiving YKS treatment with MICA. These data indicate a direct pharmacological effect of YKS on the development of grooming behavior and profound effects on cerebellar serotonin metabolism, which is thought to be influenced by nursing conditions.

Embryonic GABA(B) receptor blockade alters cell migration, adult hypothalamic structure, and anxiety- and depression-like behaviors sex specifically in mice

Neurons of the paraventricular nucleus of the hypothalamus (PVN) regulate the hypothalamic- pituitary-adrenal (HPA) axis and the autonomic nervous system. Females lacking functional GABA_B receptors because of a genetic disruption of the R1 subunit have altered cellular characteristics in and around the PVN at birth. The genetic disruption precluded appropriate assessments of physiology or behavior in adulthood. The current study was conducted to test the long term impact of a temporally restricting pharmacological blockade of the GABA_B receptor to a 7-day critical period (E11–E17) during embryonic development. Experiments tested the role of GABA_B receptor signaling in fetal development of the PVN and later adult capacities for adult stress related behaviors and physiology. In organotypic slices containing fetal PVN, there was a female specific, 52% increase in cell movement speeds with GABA_B receptor antagonist treatment that was consistent with a sex-dependent lateral displacement of cells in vivo following 7 days of fetal exposure to GABA_B receptor antagonist. Anxiety-like and depression-like behaviors, open-field activity, and HPA mediated responses to restraint stress were measured in adult offspring of mothers treated with GABA_B receptor antagonist. Embryonic exposure to GABA_B receptor antagonist resulted in reduced HPA axis activation following restraint stress and reduced depression-like behaviors. There was also increased anxiety-like behavior selectively in females and hyperactivity in males. A sex dependent response to disruptions of GABA_B receptor signaling was identified for PVN formation and key aspects of physiology and behavior. These changes correspond to sex specific prevalence in similar human disorders, namely anxiety disorders and hyperactivity.

Differences in brain metabolism associated with agitation and depression in Alzheimer's disease

OBJECTIVE

Agitation and depression are among the commonest behavioural and psychological symptoms exhibited by Alzheimer's disease patients. However, their pathophysiology remains unclear. We therefore investigated the relationship between the brain metabolism in the posterior cingulate gyrus and the dorsolateral prefrontal cortex, and agitation and depression in patients diagnosed with Alzheimer's disease.

METHODS

We recruited 26 patients (14 women and 12 men) with a mean age of 75 years and probable Alzheimer's disease. All patients completed the Mini-Mental State Examination (MMSE), the Geriatric Depression Scale-Short Form (GDS) assessment, and the Cohen-Mansfield Agitation Inventory (CMAI) in order to evaluate cognition, depression, and agitation, respectively. All subjects underwent magnetic resonance imaging and (1)H-magnetic resonance spectroscopy of the brain. The ratios of N-acetylaspartate (NAA), choline (Cho), and myo-inositol (mI) to creatine (Cr) in the posterior cingulate gyrus and the dorsolateral prefrontal cortex were measured and compared with neuropsychological test results.

RESULTS

The MMSE scores correlated positively with the NAA/Cr ratio in the left posterior cingulate gyrus (r = 0.56; p = 0.001). The CMAI scores correlated negatively with the NAA/Cr ratio in the left posterior cingulate gyrus (r = -0.46; p = 0.02). The GDS scores correlated positively with the Cho/Cr ratio in the left dorsolateral prefrontal cortex (r = 0.59; p = 0.01), and mI/Cr in both left (r = 0.47; p = 0.03) and right (r = 0.47; p = 0.03) cingulate gyri.

CONCLUSIONS

Agitation and depression levels correlated with different neurochemical metabolites in specific brain areas. We conclude that various neuropsychiatric symptoms might have separate pathophysiologies.

Involvement of the K+-Cl- co-transporter KCC2 in the sensitization to morphine-induced hyperlocomotion under chronic treatment with zolpidem in the mesolimbic system

Benzodiazepines are commonly used as sedatives, sleeping aids, and anti-anxiety drugs. However, chronic treatment with benzodiazepines is known to induce dependence, which is considered related to neuroplastic changes in the mesolimbic system. This study investigated the involvement of K(+) -Cl(-) co-transporter 2 (KCC2) in the sensitization to morphine-induced hyperlocomotion after chronic treatment with zolpidem [a selective agonist of γ-aminobutyric acid A-type receptor (GABAA R) α1 subunit]. In this study, chronic treatment with zolpidem enhanced morphine-induced hyperlocomotion, which is accompanied by the up-regulation of KCC2 in the limbic forebrain. We also found that chronic treatment with zolpidem induced the down-regulation of protein phosphatase-1 (PP-1) as well as the up-regulation of phosphorylated protein kinase C γ (pPKCγ). Furthermore, PP-1 directly associated with KCC2 and pPKCγ, whereas pPKCγ did not associate with KCC2. On the other hand, pre-treatment with furosemide (a KCC2 inhibitor) suppressed the enhancing effects of zolpidem on morphine-induced hyperlocomotion. These results suggest that the mesolimbic dopaminergic system could be amenable to neuroplastic change through a pPKCγ-PP-1-KCC2 pathway by chronic treatment with zolpidem.

Prodrug approaches to reduce hyperexcitation in the CNS

Hyperexcitation in the central nervous system is the root cause of a number of disorders of the brain ranging from acute injury to chronic and progressive diseases. The major limitation to treatment of these ailments is the miniscule, yet formidable blood-brain barrier. To deliver therapeutic agents to the site of desired action, a number of biomedical engineering strategies have been developed including prodrug formulations that allow for either passive diffusion or active transport across this barrier. In the case of prodrugs, once in the brain compartment, the active therapeutic agent is released. In this review, we discuss in some detail a number of factors related to treatment of central nervous system hyperexcitation including molecular targets, disorders, prodrug strategies, and focused case studies of a number of therapeutics that are at a variety of stages of clinical development.

The role of dopamine receptors in ventrolateral orbital cortex-evoked antinociception in a rat formalin test model

The present study examined the roles of dopamine and D(1)- and D(2)-like dopamine receptors in ventrolateral orbital cortex (VLO)-evoked antinociception in rats with persistent inflammatory pain. Following formalin injection into the rat unilateral hindpaw pad, the effects of dopamine receptor agonist and antagonist microinjections into the VLO on nociceptive behavior were observed. Results demonstrated that VLO microinjection of the non-selective dopamine receptor agonist apomorphine (R(-)-apomorphine hydrochloride, 1.0, 2.5 and 5.0μg) depressed later-phase nociceptive behavior induced by formalin injection; this effect was attenuated by the D(2)-like dopamine receptor antagonist S(-)-raclopride(+)-tartrate salt (raclopride, 3.0μg), but not by the D(1)-like dopamine receptor antagonist R(+)-SCH-23390 hydrochloride (SCH-23390, 1.0μg). Apomorphine-induced antinociception was mimicked by microinjection of the D(2)-like dopamine receptor agonist (-)-quinpirole hydrochloride (2.0 and 5.0μg) into the same VLO site, and this effect was antagonized by raclopride (3.0μg). In addition, microinjection of the D(1)-like dopamine receptor agonist R(+)-SKF-38393 hydrochloride (5.0μg) had no effect on formalin-induced nociceptive behavior during the later phase. However, the D(1)-like dopamine receptor antagonist SCH-23390 (2.5, 5.0 and 10μg) depressed nociceptive behavior in a dose-dependent manner. These results suggested that dopamine mediated VLO-induced antinociception via different mechanisms in the persistent inflammatory pain model; D(2)-like receptors mediated dopamine-induced antinociception, while D(1)-like dopamine receptors exhibited tonic facilitatory action on nociceptive behavior, thereby blocking D(1)-like dopamine receptors could induce antinociception.

Olanzapine orally disintegrating tablet vs. risperidone oral solution in the treatment of acutely agitated psychotic patients

OBJECTIVE

Efficacy and tolerability of risperidone oral solution (RIS-OS) and olanzapine orally disintegrating tablet (OLZ-ODT) were compared for the treatment of acute psychotic agitation.

METHOD

During a 2-month period, patients scoring > or =15 on the Excited Component for Positive and Negative Syndrome Scale (PANSS-EC) were assigned to treatment with OLZ-ODT (n=34) or RIS-OS (n=53) on psychiatric emergency situations, and assessed every 15 min.

RESULTS

Two (OLZ-ODT and RIS-OS) by five (0-, 15-, 30-, 45- and 60-min time points) repeated-measures analysis of variance revealed only a significant main effect of time course on PANSS-EC (F=82.2, P<.0001). No differences in the number of patients receiving additional injection due to worsening were found (OLZ-ODT, 11.8%; RIS-OS, 9.4%). No differences in rate of extrapyramidal symptoms and patient satisfaction with assigned treatment were found. However, patients in the OLZ-ODT group recovered significantly more from tachycardia than those in the RIS-OS group (t=2.17, P=.03).

CONCLUSION

OLZ-ODT and RIS-OS treatments yielded similar improvements in acutely agitated patients who accepted oral medication. However, on one physiological parameter (i.e., tachycardia) OLZ-ODT might be superior to RIS-OS. Physiological indicators may also be useful for measuring levels of agitation.

Parameter identification and sedative sensitivity analysis of an agitation-sedation model

Sedation administration and agitation management are fundamental activities in any intensive care unit. A lack of objective measures of agitation and sedation, as well as poor understanding of the underlying dynamics, contribute to inefficient outcomes and expensive healthcare. Recent models of agitation-sedation dynamics have enhanced understanding of the underlying dynamics and enable development of advanced protocols for semi-automated sedation administration. In this research, the agitation-sedation model parameters are identified using an integral-based fitting method developed in this work. Parameter variance is then analysed over 37 intensive care unit patients. The parameter identification method is shown to be effective and computationally inexpensive, making it suited to real-time clinical control applications. Sedative sensitivity, an important model parameter, is found to be both patient-specific and time-varying. However, while the variation between patients is observed to be as large as a factor 10, the observed variation in time is smaller, and varies slowly over a period of days rather than hours. The high fitted model performance across all patients show that the agitation-sedation model presented captures the fundamental dynamics of the agitation-sedation system. Overall, these results provide additional insight into the system and clinical dynamics of sedation management.

Schnurri-2 mutant mice are hypersensitive to stress and hyperactive

The bone morphogenetic protein (BMP)/transforming growth factor-beta (TGF-beta)/activin superfamily regulates development of the nervous system during embryogenesis and is also suggested to be involved in adult brain function. However, how BMP/TGF-beta/activin signals modulate neuronal function remains unknown. Schnurri is a transcription factor that contains two metal finger regions. Mammalian Shn-2 enters the nucleus from the cytoplasm in response to BMP-2 stimulation and plays an important role in BMP-dependent adipogenesis. To investigate whether mammalian Shn plays a role in adult brain function, we examined the behaviors of mutant mice lacking Shn-2 (Shn-2(-/-)). Shn-2(-/-) mice exhibited hypersensitivity to stress accompanied by anxiety-like behavior. Consistent with this, stress-induced corticosterone levels were significantly higher in Shn-2(-/-) mice compared to wild-type controls. Interestingly, Shn-2(-/-) mice were more active than wild-type mice in a familiar environment. The basal and stress-induced expression levels of the immediate early genes, including c-Fos, were decreased in Shn-2(-/-) mice compared to wild-type mice. Thus, Shn-2 plays a critical role in locomotion and anxiety-like behavior.

Pten and the brain: sizing up social interaction

In a comprehensive set of experiments in this issue of Neuron, Kwon et al. demonstrate that conditional inactivation of Pten leads to behavioral abnormalities and neuropathological changes. Pten mutants displayed reduced social interaction and heightened responses to sensory stimuli. Additionally, neuronal hypertrophy, as well as macrocephaly was observed. Based on rare human mutations in PTEN and the PI3K pathway, the authors suggest they have produced a potential animal model of autism with macrocephaly.

The 'drive for activity' and "restlessness" in anorexia nervosa: potential pathways

This paper discusses the hypothesis that a 'drive for activity" in the presence of physiological and endocrine changes consistent with starvation is a characteristic symptom of acute anorexia nervosa (AN). This 'drive for movement', along with alertness and lack of fatigue, so unlike the motor slowing and loss of energy observed in simple starvation has been recognized in AN throughout history, but has received little attention in the past fifty years. Clinical reports and experimental evidence suggest that 'restlessness' and a 'drive for activity' vary in intensity, they appears to be starvation-dependent and to wane with food intake. Central nervous system (CNS) systems known to be involved in mediating activity and arousal levels that are altered by the negative energy expenditure in AN are reviewed. Among these, the corticotropin-releasing hormone (CRH) system, the melanocyte stimulating hormone/agouti-related protein (MSH/AGRP) system and the norepinephrine/epinephrine (NE/EPI) and dopamine (DA) system may contribute to the 'drive for activity' and alertness in AN. AN appears to represent a disorder of gene/environment interaction. Future research will reveal whether in individuals predisposed to AN, the 'drive for activity' reflects the reactivation of mechanisms important in food scarcity, controlled by one or more evolutionary conserved genes including those regulating foraging behavior. Recognition of the 'drive for activity' as a diagnostic symptom of AN and its assessment prior to re-nutrition would permit clarification of its role in the etiology of AN.

Serotonin2C receptors (5-HT2C R) control expression of cocaine-induced conditioned hyperactivity

Environmental cues can become classically conditioned to cocaine exposure and are known to contribute to drug craving and relapse in addicts. The 5-HT2C receptor (5-HT2C R) has been shown to control the behavioral effects of acute cocaine administration and, in the present study, we investigated the role of this receptor in the expression of cocaine-induced conditioned hyperactivity. Rats received repeated pairings of a distinct test environment with either saline or cocaine (15 mg/kg, i.p.) for 7 days. In a drug-free test 2 days after the last pairing, expression of conditioned hyperactivity was seen in the rats previously exposed to cocaine in the test environment. The 5-HT2C R agonist MK 212 (0.0625-0.5 mg/kg, i.p., 5 min before test) significantly decreased, while the 5-HT2C R antagonist SB 242084 (0.5-1 mg/kg, i.p. 30 min prior to test) enhanced, expression of cocaine-induced conditioned hyperactivity. The effective doses of MK 212 and SB 242084 did not alter basal activity on the test session. These results suggest that the 5-HT2C R controls expression of cocaine-induced conditioned hyperactivity and suggest that such ligands may be useful in preventing relapse and promoting abstinence in cocaine-dependent individuals.

Clinical features of argyrophilic grain disease: a retrospective survey of cases with neuropsychiatric symptoms

OBJECTIVE

Although argyrophilic grain disease (AGD) appears common in post-mortem series, its clinical features are not widely known. The aim of this study was to explore such clinical features in neuropathologically-confirmed AGD cases.

METHODS

After completing a neuropathological assessment of 386 patients, 33 cases (8.5%) were diagnosed as having AGD; 10 were diagnosed as "pure" cases. These subjects had been admitted to geriatric wards of mental hospitals because of behavioral or neuropsychiatric symptoms requiring medical management. Assessment of the clinical features of the pure cases was based on the evaluations in medical records.

RESULTS

The average age at onset was 82.2 years. Amnesia was the most common initial symptom; irritability and agitation were also common as initial symptoms. During the course of the illness, irritability was the most frequently observed, followed by delusions (mostly delusions of persecution), dysphoria, and then agitation, and apathy. In contrast to the severity of amnesia, other cognitive functions were relatively spared, and the sensorimotor symptoms were not remarkable.

CONCLUSIONS

AGD is a late-onset dementing disorder clinically characterized by amnesia, with other cognitive functions relatively spared, and prominent neuropsychiatric features. These features may correlate with the high level of AGD seen in limbic structures. Future studies are needed to elucidate whether these features are common to all AGD patients or to a clinical subtype with neuropsychiatric symptoms.

Modeling and control of the agitation-sedation cycle for critical care patients

Agitation-sedation cycling in critically ill patients, characterized by oscillations between states of agitation and over-sedation, is damaging to patient health, and increases length of stay and healthcare costs. The mathematical model presented captures the essential dynamics of the agitation-sedation system for the first time, and is statistically validated using recorded infusion data for 37 patients. Constant patient-specific patient parameters are used, illustrating the commonality of these fundamental dynamics over a broad range of patients. The validated model serves as a basis for comparison of sedation administration methods, devices, therapeutics and protocols. Heavy derivative feedback control is shown to be an effective means of managing agitation, given consistent agitation measurement. The improved agitation management reduces the modeled mean and peak agitation levels 68.4% and 52.9% on average, respectively. Some patients showed over 90% reduction in mean agitation level through increased control gains. This improved agitation management is achieved via heavy derivative feedback control of sedation administration, which provides an essentially bolus-driven management approach, aligned with recent sedation practices.

Primer on clinical acid-base problem solving

Acid-base problem solving has been an integral part of medical practice in recent generations. Diseases discovered in the last 30-plus years, for example, Bartter syndrome and Gitelman syndrome, D-lactic acidosis, and bulimia nervosa, can be diagnosed according to characteristic acid-base findings. Accuracy in acid-base problem solving is a direct result of a reproducible, systematic approach to arterial pH, partial pressure of carbon dioxide, bicarbonate concentration, and electrolytes. The 'Rules of Five' is one tool that enables clinicians to determine the cause of simple and complex disorders, even triple acid-base disturbances, with consistency. In addition, other electrolyte abnormalities that accompany acid-base disorders, such as hypokalemia, can be incorporated into algorithms that complement the Rules and contribute to efficient problem solving in a wide variety of diseases. Recently urine electrolytes have also assisted clinicians in further characterizing select disturbances. Acid-base patterns, in many ways, can serve as a 'common diagnostic pathway' shared by all subspecialties in medicine. From infectious disease (eg, lactic acidemia with highly active antiviral therapy therapy) through endocrinology (eg, Conn's syndrome, high urine chloride alkalemia) to the interface between primary care and psychiatry (eg, bulimia nervosa with multiple potential acid-base disturbances), acid-base problem solving is the key to unlocking otherwise unrelated diagnoses. Inasmuch as the Rules are clinical tools, they are applied throughout this monograph to diverse pathologic conditions typical in contemporary practice.

Dopamine overflow is increased in olfactory bulbectomized rats: an in vivo microdialysis study

Olfactory bulbectomy (OBX) in rats produces behavioral, physiological, and neurochemical changes that resemble symptoms of depression in humans. The procedure thus serves as a rodent model of affective disorder. Many of the behavioral effects of OBX resemble psychomotor agitation. The possible role of dysregulation of ventral striatal dopamine (DA) systems in this phenomenon was investigated. Basal levels of DA, norepinephrine (NE), homovanillic acid, dihydroxyphenylacetic acid, and 5-hydroxyindoleacetic acid were examined in the striatum of OBX and sham-operated controls using in vivo microdialysis. OBX rats exhibited significantly higher basal DA levels (192%) and lower NE levels (12%) than sham-operated controls. Locomotor activity in response to novelty and footshock stress was elevated in OBX rats. The finding of higher DA levels in striatum may explain this "agitation-like" behavior, a commonly observed phenomenon in the OBX model.

Effect of central administration of carnosine and its constituents on behaviors in chicks

Even though their contents in the brain are high, the function of brain carnosine and its constituents has not been clarified. Both carnosine and anserine inhibited food intake in a dose dependent fashion when injected intracerebroventricularly. The constituents of carnosine, beta-alanine (beta-Ala) and l-histidine (His), also inhibited food intake, but their effects were weaker than carnosine itself. Co-administration with beta-Ala and His inhibited food intake similar to carnosine, but also altered other behaviors. Injection of carnosine induced hyperactivity and increased plasma corticosterone level, whereas beta-Ala plus His induced hypoactivity manifested as sleep-like behavior. This later effect seemed to be derived from beta-Ala, not His. These results suggest that central carnosine may act in the brain of chicks to regulate brain function and/or behavior in a manner different from its constituents.

Serotoninergics attenuate hyperlocomotor activity in rats. Potential new therapeutic strategy for hyperactivity

Hyperactivity is thought to be associated with an alteration of dopamine (DA) neurochemistry in brain. This conventional view became solidified on the basis of observed hyperactivity in DA-lesioned animals and effectiveness of the dopaminomimetics such amphetamine (AMP) in abating hyperactivity in humans and in animal models of hyperactivity. However, because AMP releases serotonin (5-HT) as well as DA, we investigated the potential role of 5-HT in an animal model of hyperactivity. We found that a greater intensity of hyperactivity was produced in rats when both DA and 5-HT neurons were damaged at appropriate times in ontogeny. Therefore, previously we proposed this as an animal model of attention deficit hyperactivity disorder (ADHD) - induced by destruction of dopaminergic neurons with 6-hydroxydopamine (6-OHDA) (neonatally) and serotoninergic neurons with 5,7-dihydroxytryptamine (5,7-DHT) (in adulthood). In this model effects similar to that of AMP (attenuation of hyperlocomotion) were produced by m-chlorophenylpiperazine (m-CPP) but not by 1-phenylbiguanide (1-PG), respective 5-HT2 and 5-HT3 agonists. The effect of m-CPP was shown to be replicated by desipramine, and was largely attenuated by the 5-HT2 antagonist mianserin. These findings implicate 5-HT neurochemistry as potentially important therapeutic targets for treating human hyperactivity and possibly childhood ADHD.

Forebrain-specific trkB-receptor knockout mice: behaviorally more hyperactive than "depressive"

BACKGROUND

According to the neurotrophin hypothesis of depression, decreased activity of brain-derived neurotrophic factor (BDNF) contributes to behavioral and plasticity-related alterations in depressed patients. We investigated the hypothesis that mice with a forebrain-specific knockout of the trkB receptor, the main mediator of BDNF signaling, represent a genetic animal model for depression.

METHODS

Using the CRE-loxP system, we bred trkB(CaMKII-CRE) mice with a trkB-receptor disruption in the forebrain. We subjected trkB-mutant mice to a battery of behavioral tests, comprising open field, elevated zero maze, emergence test, novel object test, and forced swim. Additionally, we investigated the hypothalamic-pituitary-adrenal (HPA) axis immunohistochemically and by plasma analyses.

RESULTS

trkB(CaMKII-CRE) mice showed a stereotyped hyper-locomotion with reduced explorative activity, and impulsive reactions to novel stimuli. The trkB-mutant mice did not exhibit depressionlike behaviors such as increased "despair" in the forced swim test, increased anxiety in the elevated zero maze, or neophobia in the novel object test. Furthermore, no HPA dysregulation was observed under normal and stressful conditions.

CONCLUSIONS

trkB(CaMKII-CRE) mice cannot be regarded as a genetic mouse model of depression. Instead, the behavioral symptoms of trkB(CaMKII-CRE) mice, comprising hyper-locomotion, stereotyped behaviors, and cognitive impairments, are similar to those postulated for mouse models of attention-deficit disorder.

Herpes virus-mediated preproenkephalin gene transfer in the ventral striatum mimics behavioral changes produced by olfactory bulbectomy in rats

The syndrome of behavioral, physiological, and neurochemical changes caused by ablation of the olfactory bulbs (OBX) in rats serves as a reliable and well-validated model of depression. Previous experiments have demonstrated that OBX leads to increased expression of the preproenkephalin (ENK) gene in the olfactory tubercle (OT) portion of the ventral striatum in rats. The aim of the present experiments was to investigate the role of OBX-induced ENK overexpression in the OT in the behavioral abnormalities exhibited by bulbectomized rats. A recombinant herpes virus carrying human preproENK cDNA was used to manipulate ENK gene expression in the OT of bulbectomized and sham-operated rats. Motivational deficits were assessed by the sucrose preference test, and 'agitation-like' behaviors were measured with the novel open field and footshock-induced freezing tests. ENK gene transfer in sham-operated rats mimicked some of the effects of OBX; it decreased freezing behavior in response to mild footshock and produced behavioral activation in the open field. In another experiment, virally mediated ENK gene transfer into the OT of intact rats decreased footshock-induced freezing, and this effect was reversed by naltrexone administration. PreproENK gene transfer into the OT did not produce analgesic effects in the tail-flick test. No effects on freezing behavior were observed following preproENK gene transfer into the frontal cortex. An additional experiment revealed that naltrexone administration attenuated the OBX-induced abnormality in freezing behavior. The results indicate that overexpression of the preproENK gene in the ventral striatum may mediate the 'agitation-like' behavior exhibited by bulbectomized rats.

On the role of noradrenaline in psychostimulant-induced psychomotor activity and sensitization

RATIONALE

Psychostimulant drugs exert their behavioral effects primarily through enhancement of monoaminergic neurotransmission. Augmented dopamine activity is thought to play a critical role in the psychomotor stimulant effects of amphetamine and cocaine, as well as in the development of long-term behavioral sensitization evoked by repeated exposure to amphetamine. However, despite the fact that brain dopamine and noradrenaline systems are closely interconnected, the extent to which noradrenergic transmission contributes to these behavioral effects of psychostimulants is a relatively unexplored issue.

OBJECTIVES

By inhibiting noradrenergic neurotransmission with the alpha2-adrenoceptor agonist clonidine, the alpha1-antagonist prazosin and the beta-antagonist propranolol, we investigated the involvement of noradrenaline neurotransmission in the psychomotor stimulant and long-term sensitizing effects of d-amphetamine and cocaine in rats.

METHODS

Clonidine (0.003-0.1 mg/kg), prazosin (0.1-3.0 mg/kg) and propranolol (1.0-3.0 mg/kg) were administered prior to d-amphetamine (1.0 mg/kg), cocaine (15 mg/kg) or apomorphine (1.0 mg/kg) and psychomotor activity was measured. In separate studies, clonidine (0.03 mg/kg), prazosin (1.0 mg/kg) or propranolol (3.0 mg/kg) were co-administered with d-amphetamine (2.5 mg/kg) or cocaine (30 mg/kg) for 5 days, and locomotor sensitization was assessed 3 weeks post-treatment.

RESULTS

The psychomotor stimulant effect of d-amphetamine, but not that of cocaine or apomorphine, was dose-dependently inhibited by clonidine and prazosin, and enhanced by propranolol. Clonidine, prazosin, and propranolol did not influence the induction of sensitization by amphetamine or cocaine.

CONCLUSIONS

Enhancement of synaptic noradrenaline concentrations contributes to the psychomotor stimulant effect of d-amphetamine, but not cocaine or apomorphine. In addition, noradrenergic neurotransmission is not critically involved in the induction of psychostimulant sensitization.

Adverse effects associated with physical restraint

OBJECTIVE

Restraint use is not monitored in the US, and only institutions that choose to do so collect statistics. In 1999, investigative journalists reported lethal consequences proximal to restraint use, making it a life-and-death matter that demands attention from professionals. This paper reviews the literature concerning actual and potential causes of deaths proximal to the use of physical restraint.

METHOD

Searching the electronic databases Medline, Cinahl, and PsycINFO, we reviewed the areas of forensics and pathology, nursing, cardiology, immunology, psychology, neurosciences, psychiatry, emergency medicine, and sports medicine.

CONCLUSIONS

Research is needed to provide clinicians with data on the risk factors and adverse effects associated with restraint use, as well as data on procedures that will lead to reduced use. Research is needed to determine what individual risk factors and combinations thereof contribute to injury and death.

Mood stabilizers in Alzheimer's disease: symptomatic and neuroprotective rationales

OBJECTIVE

This paper provides a case study of 'reverse translational research', in which empirical clinical trials focused on relieving psychopathological symptoms of Alzheimer's disease (AD) ultimately led to mechanism-based trials addressing aspects of the underlying pathophysiology of Alzheimer's disease. AD is multi-dimensional in nature, characterized not only by cognitive and functional decline but by neuropsychiatric symptoms that develop commonly and are associated with considerable morbidity. There have been a large number of empirical trials of various pharmacological agents to reduce these symptoms, such as agitation. Although antipsychotics are used most frequently for agitation, the usual effect size is modest, and there is a range of tolerability and/or safety issues, leading to the hope that alternatives can be found. Furthermore, most clinical trials addressing psychopathology have not been mechanism-based and none have attempted an alternative approach, namely, to delay or prevent the emergence of psychopathology.

FINDINGS

The evidence of clinical trials is reviewed regarding the safety, tolerability, and apparent efficacy of the mood stabilizers carbamazepine and valproate for agitation associated with AD. Possible mechanisms of action of valproate are reviewed, leading to the surprising conclusion that neuroprotective properties may account for some of its clinical effects. These mechanisms (including activation of wnt-dependent signaling and upregulation of bcl-2, among others) may be particularly relevant for long-term treatment of AD.

CONCLUSIONS

These clinical and mechanistic findings were combined in the development of a novel clinical trial examining whether chronic valproate therapy can attenuate the clinical progression of AD, which will be implemented by the Alzheimer's Disease Cooperative Study. The design addresses valproate's potential to delay or prevent the onset of agitation in patients lacking agitation to begin with, as well as to slow progressive decline in cognition and daily functioning.

The effect of therapeutic touch on agitated behavior and cortisol in persons with Alzheimer's disease

Agitated behavior in persons with Alzheimer's disease (AD) presents a challenge to current interventions. Recent developments in neuroendocrinology suggest that changes in the hypothalamic-pituitary-adrenal (HPA) axis alter the responses of persons with AD to stress. Given the deleterious effects of pharmacological interventions in this vulnerable population, it is essential to explore noninvasive treatments for their potential to decrease a hyperresponsiveness to stress and indirectly decrease detrimental cortisol levels. This within-subject, interrupted time-series study was conducted to test the efficacy of therapeutic touch on decreasing the frequency of agitated behavior and salivary and urine cortisol levels in persons with AD. Ten subjects who were 71 to 84 years old and resided in a special care unit were observed every 20 minutes for 10 hours a day, were monitored 24 hours a day for physical activity, and had samples for salivary and urine cortisol taken daily. The study occurred in 4 phases: 1) baseline (4 days), 2) treatment (therapeutic touch for 5 to 7 minutes 2 times a day for 3 days), 3) posttreatment (11 days), and 4) post- "wash-out" (3 days). An analysis of variance for repeated measures indicated a significant decrease in overall agitated behavior and in 2 specific behaviors, vocalization and pacing or walking, during treatment and posttreatment. A decreasing trend over time was notedfor salivary and urine cortisol. Although this study does not provide direct clinical evidence to support dysregulation in the HPA axis, it does suggest that environmental and behavioral interventions such as therapeutic touch have the potential to decrease vocalization and pacing, 2 prevalent behaviors, and may mitigate cortisol levels in persons with AD.

Morphine microinjections into the rat nucleus submedius depress nociceptive behavior in the formalin test

Our previous studies have indicated that the thalamic nucleus submedius (Sm) is involved in modulation of nociception and plays an important role in an endogenous analgesic system (a feedback loop) consisting of spinal cord-Sm-ventrolateral orbital cortex-periaqueductal gray-spinal cord. To investigate whether opioids are involved in this antinociception pathway, the effects of microinjection of morphine and naloxone into the Sm on the nociceptive behavior (agitation) evoked in the formalin test were investigated in the awake rat using an automated movement detection system. The results indicate that a unilateral microinjection of morphine (5 micro g, 0.5 microl) into the Sm suppresses the formalin-induced agitation response, but does not influence spontaneous motor activity, and that the morphine-induced depression can be reversed by microinjection of the opioid receptor antagonist naloxone (1.0 micro g, 0.5 microl) into the same Sm site. The results suggest that opioid receptors in the Sm may be involved in the Sm-mediated depression of persistent inflammatory pain.

Evaluation of stress factors and body weight adjustments currently used to estimate energy expenditure in hospitalized patients

BACKGROUND

The purpose of this study was to critically examine current approaches for estimating energy expenditure and requirements of hospitalized patients requiring nutrition support.

METHODS

All indirect calorimetry tests performed by our adult nutrition support service from 1991 to 2000 were reviewed. Stress factors were calculated as the measured energy expenditure divided by the predicted energy expenditure using the Harris-Benedict equation. Various methods for adjusting the body weights of obese subjects for use in the Harris-Benedict equation were evaluated.

RESULTS

The average stress factor for these hospitalized patients was 1.25, and there were no differences in the stress factors between men and women. For obese subjects, using an adjusted body weight equal to ideal body weight plus 50% of the difference between ideal and actual body weight in the Harris-Benedict equation gave stress factors comparable with normal weight subjects. For underweight subjects, using the actual rather than ideal body weight gave stress factors that were most similar to normal weight patients. Disease-specific stress factors were calculated and compared with literature values. Mechanical ventilation, recent feeding, fever, and restlessness during the indirect calorimetry measurement increased the measured energy expenditure.

CONCLUSIONS

Our findings provide nutrition support services with updated information on disease-specific stress factors that can be used for estimating energy expenditure in hospitalized patients. An adjusted body weight equal to ideal body weight plus 50% of the excess body weight should be used for estimating the energy requirements of obese patients requiring nutrition support.

Characterization of butyrylcholinesterase antagonism of cocaine-induced hyperactivity

Although there are several published demonstrations that exogenous butyrylcholinesterase (EC 3.1.1.8) works to antagonize cocaine in vivo, a systematic characterization of the enzyme-drug interaction is lacking as is confirmation of the mechanism of effect. This has been addressed using cocaine-induced locomotor activity in mice as a behavioral endpoint. The enzyme was effective, but the enzyme dose-antagonist effect relationship revealed an asymptotic partial maximum effect. This effect was not due to dose-dependent enzyme pharmacokinetics or to a stimulant effect of the cocaine metabolites but rather to partial metabolism of cocaine. Since neither metabolite of cocaine inhibited enzyme activity as potently as cocaine, partial metabolism is not likely due to end-product inhibition. The enzyme reduced the maximum effect of cocaine on locomotor activity. The mechanistic data are generally consistent: the enzyme was inactive against the nonester dopamine/norepinephrine uptake inhibitor, nomifensine, and a paraoxon-inactivated sample of enzyme was ineffective. However, the enzyme was effective against bupropion, a nonester dopamine uptake inhibitor.

Hyperactivity and dopamine D1 receptor activation in mice lacking girk2 channels

RATIONALE

G-protein-coupled inwardly rectifying potassium channels (GIRKs) regulate synaptic transmission and neuronal firing rates. Co-localization of GIRK2 channels and dopamine receptors in the mesolimbic system suggests a role in regulation of motor activity.

OBJECTIVES

To explore the role of GIRK channels in the regulation of motor behavior.

METHODS

GIRK2 null mutant mice (knockout) were used. Locomotor activity in a mildly stressful situation was conducted either in a circular open field with video tracking or in standard mouse cages equipped with infrared sensors. Drugs were injected intraperitoneally or subcutaneously.

RESULTS

GIRK2 knockout mice demonstrated a transient "hyperactive" behavioral phenotype with initially higher motor activity and slower habituation in a novel situation, increased levels of spontaneous locomotor activity during dark phase in their home cages, and impaired habituation in the open-field test. After habituation, GIRK2 knockout mice showed higher motor activity, which was inhibited by the D(1) receptor antagonist SCH 23390 and was more sensitive to the activating effects of the D(1) receptor partial agonist SKF 38393. In a novel environment (open-field) only the highest dose of SKF 38393 used (20 mg/kg) produced significant activation, perhaps due to a ceiling effect in GIRK2 knockout mice. SCH 23390 inhibited the basal activity levels of mice of both genotypes.

CONCLUSIONS

Activation of the dopamine D(1)receptor in a stressful environment may be stronger in GIRK2 deficient mice, and this modified function of D(1) receptors may cause the transient hyperactive behavioral phenotype of these mice.

Continuous phencyclidine treatment induces schizophrenia-like hyperreactivity of striatal dopamine release

Functional dopaminergic hyperactivity is a key feature of schizophrenia. Recent in vivo imaging studies have demonstrated greater striatal dopamine release in response to amphetamine challenge in schizophrenia subjects than in normal controls. N-methyl-D-aspartate (NMDA) receptors are known to play a prominent role in regulation of striatal dopamine release. In humans, NMDA antagonists induce a psychotic state that closely resembles schizophrenia. The present study investigates the degree to which chronic continuous administration of the NMDA antagonist phencyclidine (PCP) induces schizophrenia-like hyperreactivity of striatal dopamine release to amphetamine in rodents. Rats were treated with 10 or 15 mg/kg/d PCP for two weeks by osmotic minipump, and striatal dopamine release to amphetamine challenge (1 mg/kg) was monitored by microdialysis. PCP-treated rats showed significant enhancement in amphetamine-induced dopamine release, along with significantly enhanced locomotor activity. These findings support the concept that NMDA receptor dysfunction may contribute to dopaminergic dysfunction in schizophrenia.

Increased alpha 2-adrenergic receptor binding in locus coeruleus projection areas in dementia with Lewy bodies

Clinical studies suggest involvement of brain noradrenergic systems in the pathophysiology of disruptive agitation in Alzheimer's disease (AD). This behavioral problem is even more prevalent in dementia with Lewy bodies (DLB). Here we used receptor autoradiography with [(125)I]para-iodoclonidine to estimate alpha-2 adrenergic receptor (A2R) density in locus coeruleus (LC) projection areas in postmortem brain tissue from age and gender comparable groups of DLB (n = 6), AD (n = 5) and normal (n = 7) subjects. LC neuronal loss was substantial and equivalent in DLB and AD. A2R density was greater in DLB than in normals in the deep layers of the frontal cortex. A2R density was greater in DLB than in AD in hippocampus (CA-1, CA-3 and dentate hilus) and in the granule layer of the cerebellum. Increased A2R binding in DLB is consistent with expression of presynaptic A2R on fibers from surviving LC neurons involved in reinnervation of LC projection areas. These areas develop compensatory noradrenergic hyperinnervation in a rat model of partial LC ablation. It is also consistent with upregulation of post-synaptic A2R in response to loss of LC noradrenergic innervation. Either mechanism could lower the threshold for increased agitation in response to noradrenergic outflow in these dementing disorders.

Hyperactivity and impaired response habituation in hyperdopaminergic mice

Abnormal dopaminergic transmission is implicated in schizophrenia, attention deficit hyperactivity disorder, and drug addiction. In an attempt to model aspects of these disorders, we have generated hyperdopaminergic mutant mice by reducing expression of the dopamine transporter (DAT) to 10% of wild-type levels (DAT knockdown). Fast-scan cyclic voltammetry and in vivo microdialysis revealed that released dopamine was cleared at a slow rate in knockdown mice, which resulted in a higher extracellular dopamine concentration. Unlike the DAT knockout mice, the DAT knockdown mice do not display a growth retardation phenotype. They have normal home cage activity but display hyperactivity and impaired response habituation in novel environments. In addition, we show that both the indirect dopamine receptor agonist amphetamine and the direct agonists apomorphine and quinpirole inhibit locomotor activity in the DAT knockdown mice, leading to the hypothesis that a shift in the balance between dopamine auto and heteroreceptor function may contribute to the therapeutic effect of psychostimulants in attention deficit hyperactivity disorder.

Pharmacokinetics and pharmacodynamics of sedatives and analgesics in the treatment of agitated critically ill patients

The pharmacokinetics and pharmacodynamics of sedatives and analgesics are significantly altered in the critically ill. These changes may account for the large differences in drug dosage requirements compared with other patient populations. Drugs that in other settings may be considered short-acting often have significantly altered onset and duration of action in critically ill patients, necessitating a change in dosage. Of the benzodiazepines, lorazepam is the drug whose parameters are the least likely to be altered in critical illness. The presence of active metabolites with other benzodiazepines complicates their use during periods of prolonged use. Similarly, the presence of active metabolites of morphine and pethidine (meperidine) warrants caution in patients with renal insufficiency. The fewer cardiovascular effects seen with high-potency opioids, such as fentanyl and sufentanil, increase their usefulness in haemodynamically compromised patients. The pharmacodynamics of propofol are not significantly altered in the critically ill. Ketamine should be used with a benzodiazepine to prevent the emergence of psychomimetic reactions. Lower sedative doses of benzodiazepines and anaesthetics may not provide reliable amnesia. Barbiturates and propofol probably do not induce hyperalgesia and lack intrinsic analgesic activity. The antipsychotic agent haloperidol has a calming effect on patients and administration to the point of sedation is generally not necessary. Combinations of sedatives and analgesics are synergistic in producing sedation. The costs of sedation and analgesia are very variable and closely linked to the pharmacokinetics and pharmacodynamics of the drug. Monitoring of sedation and analgesia is difficult in uncooperative patients in the intensive care unit. In the future, specific monitoring tools may assist clinicians in the regulation of infusions of sedative and analgesic agents.

Paradoxical increases of circulating nonesterified fatty acids in somatotropin treated cattle undergoing mild disturbances

Effects of various doses of bovine somatotropin (bST) on plasma concentrations of nonesterified fatty acids (NEFA) were studied in a 14-d Latin square with six Holstein heifers. Animals were given daily injections of excipient or bST at 12:00 p.m. and fed twice daily at 7:00 a.m. and 7:00 p.m. On Day 14, plasma NEFA remained low through the day except around the 7:00 p.m. feeding when they were substantially elevated. The elevation was significantly greater in bST-treated animals and corresponded to the excitement of the animals in anticipation of the evening feeding. To further investigate this phenomenon, a second experiment was conducted in which nine growing Holstein steers were fed hourly and received either daily intramuscular (i.m.) injection of excipient or bST (120 mg/kg BW) for 15 d in a crossover design. Daily profiles of NEFA were obtained under undisturbed conditions or concurrently with intensive handling. Although no elevations could be detected in any case in control animals, bST caused a substantial rise in NEFA concentration only when animals were subjected to intensive handling. This suggested that NEFA peaks noted in bST-treated heifers in the first experiment resulted from increased ability of adipose tissue to respond to adrenergic stimulation associated with the anticipation of feeding. Consistent with this hypothesis, plasma NEFA concentrations in bST-treated steers were increased to a greater extent during a challenge involving i.v. injection of epinephrine. This amplification of adipose tissue response by bST must be considered when conducting intensive studies. Even the minimal excitement associated with blood sampling can confound the results regarding lipid mobilization, and this may have contributed to the notion that ST is a lipolytic hormone.

Biologic markers and neurochemical correlates of agitation and psychosis in dementia

Behavioral and psychiatric symptoms frequently accompany the cognitive deterioration of dementia occurring in up to 80% of both community-based and nursing home patients. In Alzheimer's disease (AD), behavioral complications may develop at any stage of the disease process and tend to follow a more unpredictable course than the core cognitive symptoms. Over the past 15 years, our knowledge of the biologic and neurochemical basis of dementia, and of AD in particular, has increased significantly. Great emphasis has been placed on the cholinergic system abnormalities in the context of the cognitive impairment in AD and on the psychopharmalogic enhancement of cholinergic transmission in AD. However deficits in other neurotransmitter systems, such as the noradrenergic, serotonergic, and dopaminergic systems, also occur and may contribute to the core cognitive symptoms of AD. More recently, there has been increased interest in the biologic and neurochemical basis of behavioral and psychiatric disturbances in dementia. This article reviews the evidence for biologic and neurochemical correlates of psychosis and agitation in dementia, and discusses the treatment implications for these findings.

Factors associated with severe intracranial hypertension in candidates for emergency liver transplantation

Cerebral edema is the leading cause of death in patients with fulminant hepatic failure (FHF). Emergency OLT is often a life-saving therapy for FHF but severe cerebral edema is a contraindication to transplantation. We attempted to identify clinical and biochemical factors associated with the development of severe intracranial hypertension in FHF. Fever, psychomotor agitation, and arterial hypertension were more frequently observed preceding episodes of severe intracranial hypertension, and more than 50% of FHF patients with uncontrolled intracranial hypertension sustained severe brain injury in our series. These observations suggest that vigorous treatment of fever, arterial hypertension, and agitation are important aspects of the intensive care management of FHF patients to maintain their OLT candidacy.

[Hyperexcitability syndrome in the neonatal period: study of etiological factors]

Forty-five newborn infants with hyperexcitability lasting more than 72 hours were studied in the neonatal period. The association with metabolic disturbances, mainly hypocalcemia, was observed in 53% of cases. Neonatal asphyxia was observed in 21 cases (46%), although all infants had 5 minutes Apgar scores above 6. Only 6 cases had association between neonatal asphyxia and metabolic disturbances. The hyperexcitability syndrome faded away in 1/3 of the infants with metabolic abnormalities after their correction.

Selective D1- and D2-dopamine receptor blockade both induces akathisia in humans--a PET study with [11C]SCH 23390 and [11C]raclopride

Pharmacological effects were recorded and time course for receptor binding in brain was followed by positron emission tomography after IV injection of the selective D1-dopamine receptor antagonist SCH 23390 in four healthy subjects in doses of 310-810 micrograms. Akathisia, the syndrome of motor restlessness, appeared after the three highest doses. The akathisia was transient and occurred only when [11C]SCH 23390 binding in the basal ganglia was at a high level with a central D1-dopamine receptor occupancy of 45-59%. The D2-dopamine receptor antagonist [11C]raclopride was injected IV into 20 healthy subjects and 13 schizophrenic patients. Akathisia appeared in 14 healthy subjects and 7 patients and coincided with maximal [11C]raclopride binding in the basal ganglia. The findings for [11C]raclopride and [11C]SCH 23390 are the first demonstration of a relationship between time courses for radioligand binding in the human brain and simultaneously induced pharmacological effects.

Evaluating oxygen delivery and oxygen utilization with mixed venous oxygen saturation monitoring: a case study approach

Three cases studies are presented to demonstrate clinical application of mixed venous oxygen saturation (SvO2) monitoring in critical care nursing practice. Examples of critically ill patients are used to demonstrate how SvO2 monitoring can be used in clinical practice to reflect an imbalance between oxygen delivery and oxygen utilization. In the first case, the patient had a problem with oxygen delivery. Continuous SvO2 data aided nurses in guiding, adjusting, and assessing therapy. The second case demonstrates how SvO2 monitoring can provide an early sign of a life-threatening complication. The final case is one in which the patient had a problem with oxygen utilization. In all the cases, continuous SvO2 data provided important information about the balance between oxygen delivery and oxygen utilization.