French National Protocol for genetic of amyotrophic lateral sclerosis

Relationships between genes and amyotrophic lateral sclerosis (ALS) have been widely accepted since the first studies highlighting pathogenic mutations in the SOD1 gene 30years ago. Over the last three decades, scientific literature has clearly highlighted the central role played by genetic factors in the disease, in both clinics and pathophysiology, as well as in therapeutics. This implies that health professionals who care for patients with ALS are increasingly faced with patients and relatives eager to have answers to questions related to the role of genetic factors in the occurrence of the disease and the risk for their relatives to develop ALS. In order to address these public health issues, the French ALS network FILSLAN proposed to the Haute Autorité de santé (HAS) the drafting of a French National Protocol (PNDS) on ALS genetics. This PNDS was developed according to the "method for developing a national diagnosis and care protocol for rare diseases" published by the HAS in 2012 (methodological guide for PNDS available on the HAS website: http://www.has-sante.fr/). This document aims to provide the most recent data on the role of genes in ALS and to detail the implications for diagnosis and care.

Functions of the Hsp90-Binding FKBP Immunophilins

The Hsp90 chaperone is known to interact with a diverse array of client proteins. However, in every case examined, Hsp90 is also accompanied by a single or several co-chaperone proteins. One class of co-chaperone contains a tetratricopeptide repeat (TPR) domain that targets the co-chaperone to the C-terminal region of Hsp90. Within this class are Hsp90-binding peptidylprolyl isomerases, most of which belong to the FK506-binding protein (FKBP) family. Despite the common association of FKBP co-chaperones with Hsp90, it is abundantly clear that the client protein influences, and is often influenced by, the particular FKBP bound to Hsp90. Examples include Xap2 in aryl hydrocarbon receptor complexes and FKBP52 in steroid receptor complexes. In this chapter, we discuss the known functional roles played by FKBP co-chaperones and, where possible, relate distinctive functions to structural differences between FKBP members.

Neuraxial analgesia is not associated with an increased risk of post-partum relapses in MS

Background:

Obstetrical analgesia remains a matter of controversy because of the fear of neurotoxicity of local anesthetics on demyelinated fibers or their potential relationship with subsequent relapses.

Objective:

To assess the impact of neuraxial analgesia on the risk of relapse during the first 3 months post-partum, with a focus on women who experienced relapses during pregnancy.

Methods:

We analyzed data of women followed-up prospectively during their pregnancies and at least 3 months post-partum, collected in the Pregnancy in Multiple Sclerosis (PRIMS) and Prevention of Post-Partum Relapses with Progestin and Estradiol in Multiple Sclerosis (POPARTMUS) studies between 1992–1995 and 2005–2012, respectively. The association of neuraxial analgesia with the occurrence of a post-partum relapse was estimated by logistic regression analysis.

Results:

A total of 389 women were included, 215 from PRIMS and 174 from POPARTMUS. In total, 156 women (40%) had neuraxial analgesia. Overall, 24% experienced a relapse during pregnancy and 25% in the 3 months post-partum. Women with a pregnancy relapse were more likely to have a post-partum relapse (odds ratio (OR) = 1.83, p = 0.02), independently of the use of neuraxial analgesia. There was no association between neuraxial analgesia and post-partum relapse (OR = 1.08, p = 0.78).

Conclusion:

Neuraxial analgesia was not associated with an increased risk of post-partum relapses, whatever multiple sclerosis (MS) activity during pregnancy.

Tetratricopeptide repeat domain 9A negatively regulates estrogen receptor alpha activity

Tetratricopeptide repeat domain 9A (TTC9A) is a target gene of estrogen and progesterone. It is over-expressed in breast cancer. However, little is known about the physiological function of TTC9A. The objectives of this study were to establish a Ttc9a knockout mouse model and to study the consequence of Ttc9a gene inactivation. The Ttc9a targeting vector was generated by replacing the Ttc9a exon 1 with a neomycin cassette. The mice homozygous for Ttc9a exon 1 deletion appear to grow normally and are fertile. However, further characterization of the female mice revealed that Ttc9a deficiency is associated with greater body weight, bigger thymus and better mammary development in post-pubertal mice. Furthermore, Ttc9a deficient mammary gland was more responsive to estrogen treatment with greater mammary ductal lengthening, ductal branching and estrogen target gene induction. Since Ttc9a is induced by estrogen in estrogen target tissues, these results suggest that Ttc9a is a negative regulator of estrogen function through a negative feedback mechanism. This is supported by in vitro evidence that TTC9A over-expression attenuated ERα activity in MCF-7 cells. Although TTC9A does not bind to ERα or its chaperone protein Hsp90 directly, TTC9A strongly interacts with FKBP38 and FKBP51, both of which interact with ERα and Hsp90 and modulate ERα activity. It is plausible therefore that TTC9A negatively regulates ERα activity through interacting with co-chaperone proteins such as FKBP38 and FKBP51.

[Unilateral Creutzfeld-Jakob disease: report of a probable case on electroclinical, MRI and biological criteria]

We report the case of a 70-year-old man who developed probable unilateral Creutzfeldt-Jakob disease. Clinically, he presented with right hemiparesis, progressive aphasia, temporospatial disorientation and cerebellar ataxia and later on, myoclonia. The MRI showed a hypersignal from the left caudate in DWI with decreased ADC. Repeated electroencephalograms showed a slow background rhythm in the left hemisphere with superimposed periodic, biphasic and triphasic sharp-wave complexes in the left temporal region. Death occurred after 5weeks. Although exceptional, unilateral Creutzfeldt-Jakob disease was retained as possible.

[Research in amyotrophic lateral sclerosis: what is new in 2009?]

This paper, written by French amyotrophic lateral sclerosis (ALS) center experts, presents an update of recent advances in fundamental, epidemiological and clinical research in ALS based on a review of the literature between September 2008 and November 2009. Among other pathophysiological mechanisms, the role of stress of the endoplasmic reticulum and the importance of energetic metabolic disturbances have been underscored. In the field of genetics, research has been advanced through the identification of mutations of the gene FUsed in Sarcoma/Translated in LipoSarcoma (FUS/TLS) in individuals with familial and sporadic ALS. This gene is involved in the regulation of transcription, splicing and RNA transport, and has functional homology to another ALS gene, TARDBP, which suggests that a common mechanism may underlie motor neuron degeneration. A report showed that mice expressing a mutant form of human TDP-43 develop a progressive and fatal neurodegenerative disease reminiscent of both ALS and frontotemporal lobar degeneration with ubiquitin aggregates (FTLD-U), providing a new animal model that may help to better understand the pathophysiology and test new therapeutics. Beside genetic studies, several epidemiologic studies have investigated the role of environmental factors. A recent study suggests that smoking is a risk factor for developing ALS and it is hypothesized that this could occur through lipid peroxidation via formaldehyde exposure. From a neuroprotective perspective, trials with IGF-1, sodium valproate, coenzyme Q or glatiramer acetate have failed to demonstrate any beneficial effect. A study published in 2008 argued that lithium may have a neuroprotective effect in ALS mice and also in patients. However, two preclinical studies failed to replicate the neuroprotective effect of lithium in ALS mice. Therapeutic trials have been performed or are currently ongoing in Europe and North America. Their results have not yet been published.

Are there differences between cephalic and extracephalic cutaneous allodynia in migraine patients?

Cutaneous allodynia (CA), pain in response to innocuous cutaneous stimuli, is recognized as a sign of central sensitization during migraine episodes. It is either restricted within the pain area on the ipsilateral head, or extends within and outside the head. Moreover, CA can be elicited in response to thermal (heat or cold) and/or mechanical stimuli. This raises the question as to whether cephalic and extracephalic CAs share the same properties. We assessed cephalic and extracephalic CAs in migraine episodic patients using a questionnaire completed at home during migraine attacks. A total of 67 episodic migraine patients (58 women, nine men; 40 ± 13 years old) addressed all questions in the questionnaire. Forty-nine patients (73%) cited one or more allodynic symptoms during or immediately after the migraine attack. Almost all 49 patients reported cephalic CA, whereas 24 (49%) also reported extracephalic CA. Occurrence and extension of CA correlated ( P = 0.005) with headache intensity. Modalities of cephalic and extracephalic CA were different (χ2 = 12.03; P = 0.002), extracephalic CA being mostly thermal (75%) whereas cephalic CA was mostly mechanical (92%). This suggests that cephalic and extracephalic CAs involve different mechanisms.

Causes of death amongst French patients with amyotrophic lateral sclerosis: a prospective study

BACKGROUND AND PURPOSE

To prospectively investigate causes of death and the circumstances surrounding death in 302 patients with amyotrophic lateral sclerosis (ALS). The functional status of patients immediately before death was also determined.

METHODS

Information was obtained from neurologists at ALS centres, patients' files, and, when deaths occurred outside a medical facility, attending physicians.

RESULTS

Most patients (63%) died in a medical facility. The most frequently reported cause of death was respiratory failure (77%), including terminal respiratory insufficiency (58%), pneumonia (14%), asphyxia due to a foreign body (3%) and pulmonary embolism (2%). Ten per cent of patients died from other causes: post-surgical or traumatic conditions (5%), cardiac causes (3.4%), suicide (1.3%) and sudden death of unknown origin (0.7%). The cause of death could not be determined in 13% of cases (6% inside a medical facility and 25% outside). At the time of death, only 55% of patients were receiving riluzole, 33% were undergoing non-invasive ventilation, 3% had a tracheotomy and 37% a gastrostomy.

CONCLUSION

The information provided by this study helps to improve our understanding of the natural history of the disease and may help optimize the quality of care we can offer patients at the end of life.

The development of a testosterone stimulation test in the Virginia opossum (Didelphis virginiana) and its use in evaluating deslorelin contraception

The aims of the present study were to examine the variability of testosterone secretion in the Virginia Opossum over a 24 h period and to develop a testosterone stimulation test that would provide an index of the prevailing testosterone biosynthetic capacity of the testes; the latter was used to clinically evaluate the efficacy of a gonadotrophin-releasing hormone agonist contraceptive. Sexually-mature captive opossums (n = 12) located in Africam Safari (Mexico) sampled every 12 h over 24 h consistently showed basal (<0.21 ng mL(-1)) blood testosterone concentrations. Intra-muscular injection of buserelin (2 microg mL(-1)) and human chorionic gonadotrophin (hCG; 1000 IU) resulted in an increase (P < 0.05) of plasma testosterone concentrations with maximal concentrations (3.9 ng mL(-1) and 5.8 ng mL(-1) respectively) occurring 120 min after injection. Plasma testosterone declined relatively rapidly to basal concentrations after 240 min with hCG but remained elevated after the same period of time with buserelin. Male opossums treated with (n = 6) and without (n = 6) a controlled-release deslorelin implant (Suprelorin; 4.7 mg deslorelin) were evaluated over a 10-week period for changes in testosterone secretion (hCG stimulation test) and sperm production (spermatorrhea). At the end of this period, the animals were hemi-castrated and their relative testicular quantitative histology compared. Testosterone concentration decreased over the course of the study in both treated and control animals (P < 0.0001) but there was no apparent effect of deslorelin on testosterone secretion, testicular histology (relative proportions of testicular cell types and seminiferous tubule diameter), or sperm production (presence of sperm in the cauda epididymis or urine).

Reduced inhibition of cortical glutamate and GABA release by halothane in mice lacking the K+ channel, TREK-1

BACKGROUND AND PURPOSE

Deletion of TREK-1, a two-pore domain K(+) channel (K(2P)) activated by volatile anaesthetics, reduces volatile anaesthetic potency in mice, consistent with a role for TREK-1 as an anaesthetic target. We used TREK-1 knockout mice to examine the presynaptic function of TREK-1 in transmitter release and its role in the selective inhibition of glutamate vs GABA release by volatile anaesthetics.

EXPERIMENTAL APPROACH

The effects of halothane on 4-aminopyridine-evoked and basal [(3)H]glutamate and [(14)C]GABA release from cerebrocortical nerve terminals isolated from TREK-1 knockout (KO) and littermate wild-type (WT) mice were compared. TREK-1 was quantified by immunoblotting of nerve terminal preparations.

KEY RESULTS

Deletion of TREK-1 significantly reduced the potency of halothane inhibition of 4-aminopyridine-evoked release of both glutamate and GABA without affecting control evoked release or the selective inhibition of glutamate vs GABA release. TREK-1 deletion also reduced halothane inhibition of basal glutamate release, but did not affect basal GABA release.

CONCLUSIONS AND IMPLICATIONS

The reduced sensitivity of glutamate and GABA release to inhibition by halothane in TREK-1 KO nerve terminals correlates with the reduced anaesthetic potency of halothane in TREK-1 KO mice observed in vivo. A presynaptic role for TREK-1 was supported by the enrichment of TREK-1 in isolated nerve terminals determined by immunoblotting. This study represents the first evidence for a link between an anaesthetic-sensitive 2-pore domain K(+) channel and presynaptic function, and provides further support for presynaptic mechanisms in determining volatile anaesthetic action.

Bile acids in combination with low pH induce oxidative stress and oxidative DNA damage: relevance to the pathogenesis of Barrett's oesophagus

BACKGROUND

Barrett's oesophagus is a premalignant condition associated with an increased risk for the development of oesophageal adenocarcinoma (ADCA). Previous studies indicated that oxidative damage contributes to the development of ADCA.

OBJECTIVE

To test the hypothesis that bile acids and gastric acid, two components of refluxate, can induce oxidative stress and oxidative DNA damage.

METHODS

Oxidative stress was evaluated by staining Barrett's oesophagus tissues with different degrees of dysplasia with 8-hydroxy-deoxyguanosine (8-OH-dG) antibody. The levels of 8-OH-dG were also evaluated ex vivo in Barrett's oesophagus tissues incubated for 10 min with control medium and medium acidified to pH 4 and supplemented with 0.5 mM bile acid cocktail. Furthermore, three oesophageal cell lines (Seg-1 cells, Barrett's oesophagus cells and HET-1A cells) were exposed to control media, media containing 0.1 mM bile acid cocktail, media acidified to pH 4, and media at pH 4 supplemented with 0.1 mM bile acid cocktail, and evaluated for induction of reactive oxygen species (ROS).

RESULTS

Immunohistochemical analysis showed that 8-OH-dG is formed mainly in the epithelial cells in dysplastic Barrett's oesophagus. Importantly, incubation of Barrett's oesophagus tissues with the combination of bile acid cocktail and acid leads to increased formation of 8-OH-dG. An increase in ROS in oesophageal cells was detected after exposure to pH 4 and bile acid cocktail.

CONCLUSIONS

Oxidative stress and oxidative DNA damage can be induced in oesophageal tissues and cells by short exposures to bile acids and low pH. These alterations may underlie the development of Barrett's oesophagus and tumour progression.

[Lyme disease: basis for treatment strategy, primary preventive care and secondary preventive care]

Lyme disease is the most common tick borne disease and is caused by Borrelia burgdorferi sensu lato. Ticks of the genus Ixodes are the vectors that transmit the infection to host mammals in endemic foci. Ixodes is infected by Borrelia at larval stage when it feeds on infected mammals. Man is an occasional host. The infection risk is linked to interaction between human and the natural environment. Strategies for prevention are closely related to the enzootic cycle of the Ixodes tick. Environmental measures to reduced tick density or host mammals are expensive, need to be repeated annually and cannot be applied to large areas. The primary prevention could be reduced to personal preventive measures such as reducing the amount of exposed skin and frequent checking for ticks. The risk of Lyme disease transmission after a tick bite is relatively low, and remains under 4%. The transmission rate depends on the duration of feeding. A rapide tick removal with fine tweezers or preferably special forceps and disinfection of the bite site appear to be the best technique. The absence of scientific evidence, and the risk of adverse events does not lead to recommending antimicrobial prophylaxis. Follow-up and educating the patients on the disease, clinical manifestation, and later primary prevention should be undertaken.

[Symptomatic treatments in amyotrophic lateral sclerosis]

ALS is a progressive, fatal, degenerative motor neuron disease of unknown cause. Although advances in understanding pathophysiology of ALS have stimulated the development of new therapies, most of them remain few efficient or ineffective and the main management of ALS patient, to improve quality of life by alleviating symptoms, is symptomatic treatment. This article discusses the approaches now in use to manage some of the most common symptoms of ALS including the following: spasticity, cramps, pain, laryngospasm, pseudobulbar syndrome, salivation and drooling, sleep disorders and fatigue, constipation and trophic troubles.

Nociceptive stimulation activates locus coeruleus neurones projecting to the somatosensory thalamus in the rat

In the thalamus, noradrenergic output from the pontine nucleus locus coeruleus (LC) may actively shape the response properties of various sensory networks en route to the cortex. Little is known, however, about the involvement of ascending noradrenergic innervation of the somatosensory thalamus in the processing of nociceptive information. To address this question, we combined the study of Fos expression upon nociceptive tooth pulp stimulation in the anaesthetized rat, with the detection of retrogradely traced neurones from the somatosensory thalamus. Cell bodies labelled retrogradely from the left thalamus were observed on both sides of the LC, with an ipsilateral predominance (n = 8). Electrical stimulation of the right incisor pulp (n = 4) provoked a significantly stronger Fos expression (around twice) than sham surgery (n = 4), in both the ipsi- and contralateral LC. Significantly larger numbers of double labelled neurones were counted in the LC of tooth-pulp-stimulated animals (representing around 30% of retrogradely labelled cells in LC) than in the LC of sham animals. They were found bilaterally, but with a clear, significant, ipsilateral (i.e. left) predominance. The present data offer an anatomical framework to understand how the LC is involved in the sensory processing of nociceptive information in the thalamus. For the first time, it is shown that nociceptive stimulation activates LC neurones projecting to the somatosensory thalamus. This suggests a new role for LC in modulating nociception within the thalamus.

TREK-1, a K+ channel involved in neuroprotection and general anesthesia

TREK-1 is a two-pore-domain background potassium channel expressed throughout the central nervous system. It is opened by polyunsaturated fatty acids and lysophospholipids. It is inhibited by neurotransmitters that produce an increase in intracellular cAMP and by those that activate the Gq protein pathway. TREK-1 is also activated by volatile anesthetics and has been suggested to be an important target in the action of these drugs. Using mice with a disrupted TREK-1 gene, we now show that TREK-1 has an important role in neuroprotection against epilepsy and brain and spinal chord ischemia. Trek1-/- mice display an increased sensitivity to ischemia and epilepsy. Neuroprotection by polyunsaturated fatty acids, which is impressive in Trek1+/+ mice, disappears in Trek1-/- mice indicating a central role of TREK-1 in this process. Trek1-/- mice are also resistant to anesthesia by volatile anesthetics. TREK-1 emerges as a potential innovative target for developing new therapeutic agents for neurology and anesthesiology.

Risk factors for the development of extended-spectrum beta-lactamase-producing bacteria in nonhospitalized patients

Although the risk factors for acquiring infection by extended-spectrum beta-lactamase (ESBL)-producing bacteria have been investigated in hospitalized patients, such risk factors have not been defined in the community setting. In this study, clinical data from a total of 311 nonhospitalized patients with community-acquired urinary tract infection (128 with ESBL-positive strains and 183 with ESBL-negative strains) were obtained. According to a multivariate analysis, the following were identified as independent risk factors: previous hospitalization in the past 3 months (OR=8.95, 95%CI, 3.77-21.25), antibiotic treatment in the past 3 months (OR=3.23, 95%CI, 1.76-5.91), age over 60 years (OR=2.65, 95%CI, 1.45-4.83), diabetes (OR=2.57, 95%CI, 1.20-5.51), male gender (OR=2.47, 95%CI, 1.22-5.01), Klebsiella pneumoniae infection (OR=2.31, 95%CI, 1.17-4.54), previous use of third-generation cephalosporins (P=0.014, OR=15.8, 95%CI, 1.7-143), previous use of second-generation cephalosporins (P<0.0001, OR=10.1, 95%CI, 4.2-24), previous use of quinolones (P=0.001, OR=4.1, 95%CI, 1.8-9.0), and previous use of penicillin (P=0.003, OR=4.0, 95%CI, 1.6-9.0).

Spontaneous internal carotid artery dissection with lower cranial nerve palsy

BACKGROUND

Typical presentation of spontaneous internal carotid artery (ICA) dissection is an ipsilateral pain in neck and face with Horner's syndrome and contralateral deficits. Although rare, lower cranial nerve palsy have been reported in association with an ipsilateral spontaneous ICA dissection.

CASE STUDIES

We report three new cases of ICA dissection with lower cranial nerve palsies.

RESULTS

The first symtom to appear was headache in all three patients. Examination disclosed a Horner's syndrome in two cases (1 and 2), an isolated XIIth nerve palsy in two patients (case 1 and 3) and IX, X, and XIIth nerve palsies (case 2) revealing an ipsilateral carotid dissection, confirmed by MRI and angiography. In all cases, prognosis was good after a few weeks.

CONCLUSIONS

These cases, analysed with those in the literature, led us to discuss two possible mechanisms: direct compression of cranial nerves by a subadventitial haematoma in the parapharyngeal space or ischemic palsy by compression of the ascending pharyngeal artery.

The effect of long-term antipsychotic treatment on the body weight of patients suffering from chronic schizophrenia: clozapine versus classical antipsychotic agents

The aim of this study was to evaluate the effect of long-term clozapine treatment on body weight changes in neuroleptic-resistant chronic schizophrenic patients and to compare it with that of classical antipsychotic agents. The body mass index (BMI) of 96 neuroleptic-resistant chronic schizophrenic patients was calculated before the beginning and after long-term (mean +/- SD 1.7 +/- 1.3 years) clozapine treatment. These data were compared to the BMI of 98 chronic schizophrenic patients maintained on classical antipsychotic agents for a similar duration (mean +/- SD 1.9 +/- 1.6 years). A significant elevation in BMI was detected in both groups during these periods (P < 0.0001 versus baseline, for both groups). The change in BMI (delta BMI) was similar in both groups (P < 0.9). We conclude that the increase in body weight caused by long-term (> 6 months) clozapine treatment is comparable to that obtained following long-term classical antipsychotic agents treatment.

Clomipramine-induced urinary retention in a cat

A 10-year-old, female, spayed shorthair with presumed psychogenic alopecia was treated with clomipramine (1 mg/kg body weight/day). The cat developed urinary retention within 2 days. Clomipramine was discontinued. Clinical signs resolved over the next 7 days. The urinary retention was attributed to the anticholinergic effects of clomipramine.

The impact of clozapine treatment on serum lipids in chronic schizophrenic patients

The aim of this retrospective study is to determine whether lipid levels rise in neuroleptic-resistant chronic schizophrenic patients during clozapine treatment and if this rise is correlated with a decrease in aggressive and suicidal behavior. Seventy neuroleptic-resistant schizophrenic patients treated with clozapine for at least 6 months were compared with 30 chronic schizophrenic patients treated with classic antipsychotic agents for the same length of time. Data on serum levels of cholesterol and triglycerides and on aggressive and suicidal behavior, as measured by the Overt Aggression Scale (OAS), were collected in both groups before treatment and 6 months later. A significant reduction in aggressive and suicidal behavior was noted in the clozapine-treated group but not in the classical antipsychotic-treated group. Clozapine treatment was associated with an elevation in serum triglyceride level, whereas classic antipsychotic treatment was associated with an increase in serum cholesterol level. We conclude that serum cholesterol level does not play a role in the clozapine-induced attenuation in aggressive and suicidal behavior in neuroleptic-resistant schizophrenic patients, though the accompanying elevation in triglycerides may be relevant to a behavioral effect.

Diminished suicidal and aggressive behavior, high plasma norepinephrine levels, and serum triglyceride levels in chronic neuroleptic-resistant schizophrenic patients maintained on clozapine

Impulsiveness and aggressiveness may be the most common behavioral correlates of central serotonergic dysfunction. The aim of this study was to determine whether clozapine, an atypical antipsychotic agent with a potent serotonergic antagonistic activity, affects impulsiveness and aggression. Its effects on serum lipids, platelet-poor plasma serotonin (5-HT), and norepinephrine (NE) levels were also studied. Thirty neuroleptic-resistant chronic schizophrenic patients, maintained on clozapine for 1 year, were evaluated for aggressiveness, impulsiveness, and suicidality in comparison with 30 chronic schizophrenic patients maintained on classical antipsychotic agents for the same period of time. Clozapine treatment was associated with less impulsiveness (p < 0.05), aggressiveness (p < 0.01) and fewer suicidal attempts (p < 0.05). Serum triglycerides and plasma NE levels were significantly higher (p < 0.01 and p < 0.0001, respectively) in the patients treated with clozapine, as compared with patients treated with classical neuroleptic drugs. The authors conclude that long-term clozapine treatment may be effective in controlling aggressive, impulsive, and suicidal behavior in neuroleptic-resistant chronic schizophrenic patients. The elevated plasma NE levels in patients treated with clozapine as compared to those treated with classical neuroleptic drugs may be relevant for the anti-aggressive/antisuicidal activity of clozapine.

[Clozapine for resistant schizophrenia and characteristics of those responding]

Clozapine (Leponex) is an atypical antipsychotic drug which is effective in the treatment of resistant schizophrenia. The most severe side-effect is agranulocytosis, which occurs in 12%. 50 patients with resistant schizophrenia were screened retrospectively in order to characterize features which might help predict good response to the drug. The drug was more effective in young patients with recent onset of illness and short total duration of hospitalization.

Brain chimeras for the study of an avian model of genetic epilepsy: structures involved in sound and light-induced seizures

The epileptic homozygotes of the Fayoumi strain of chickens (Fepi) are affected by photogenic reflex epilepsy with complete penetrance. Here we demonstrate that they are equally affected by audiogenic reflex epilepsy induced by intense sound stimulation. All the Fepi display sound-induced seizures from hatching to adulthood consisting of initial 'ictal arousal' and running fits usually followed by generalized clonico-tonic convulsions. A running fit is the preconvulsive motor symptom specifically induced by auditory stimulation while neck myoclonus is the preconvulsive motor symptom specifically induced by photic stimulation. The EEG interictal spikes and spike and waves are suppressed and replaced by a desynchronized trace during the seizures of both kinds. Viable neural chimeras were obtained by graft of embryonic brain vesicles from Fepi donors into normal chick embryos. Transfer of the complete audiogenic and photogenic phenotypes was obtained in chimeras resulting from embryonic substitution of both the prosencephalon and mesencephalon. The substitution of the prosencephalon alone resulted in transfer of interictal paroxysmal EEG activity accompanied by the sound and light-induced desynchronization and 'ictal arousal' with no motor seizures. Chimeras with embryonic substitution of the mesencephalon alone displayed running fits and convulsions induced by sound stimulation but only neck myoclonus following light stimulation. The conclusions are reached that: (i) the Fepi is a model of audiogenic and photogenic reflex epilepsy; (ii) in both types, the seizure initiator and the convulsion generator are localized in the brainstem, although reinforcement from telencephalic visual structures is needed to trigger photogenic generalized convulsions.

Reflex epilepsy of the fowl and its transfer to normal chickens by brain embryonic grafts

The genetic photosensitive epilepsy of the Fayoumi chicken was transferred to normal chickens by in situ grafts at 2 days of incubation, of both the prosencephalic and mesencephalic brain vesicles taken from epileptic embryos. However, mesencephalic graft is sufficient to allow convulsions under sound stimulation. Typical EEG patterns are recorded in chimeras having the prosencephalon plus or not the mesencephalon. We conclude that, in this mutant, the whole neural tissue is affected, but the seizure generator is localized inside the mesencephalon, and specific sensory pathways are necessary for seizures to occur.

[A case of self-circumcision]

A 29-year-old bachelor had immigrated from Uzbekistan to Israel 2 years before to improve his economic situation. He began drinking at the age of 20, and increased to 1-1.5 bottles of vodka a day. He was unable to keep a job more than a few months. When called up for limited military service, he thought that the army might be a solution for his employment problem. However, he felt that he would not be able to integrate into the army, and later into Israeli society, unless he was circumcised. The Ministry of Religion deferred his request for a religious circumcision because they did not consider him Jewish. Since he could not afford to pay for the operation, he read up on the procedure, drank a bottle of vodka as premedication, and tried to circumcise himself with a razor blade. Since he was unable to control bleeding, he applied to the hospital emergency room half an hour later, where the circumcision was completed and sutured. The psychiatric diagnosis was an unspecified personality disorder with psychopathic but not psychotic features.

[Mediagenic psychoses]

Disturbances of psychotic intensity resulting from external trauma at times of crisis and tension have been described in the literature, particularly in combat reactions, including the Saddam syndrome. Acute psychoses as reactions to mystical-religious fervor have also been described. We describe 2 clusters of patients admitted with an acute, delusional, psychotic picture against the background of the Vanunu treason trial and later the strong messianic expectations aroused among the followers of the Rebbe of Lubavitch. Both of these events received extensive coverage in the Israeli press and electronic telecommunication media. The emergence of the mental disturbances and the content of the psychoses were linked to the particularly strident and dramatic media coverage of these 2 events. The impact of the reports of wide-spread messianic fantasies in the contemporary news bulletins on those with preexisting premorbid sensitivity was sufficient to trigger the psychoses. The delusional content was topical, and not that of the traditional psychotic delusions such as that of being Napoleon. This emphasizes that not only an authentic major external trauma such as a war is capable of triggering psychosis, but also emotionladen, stressful news items, frequently repeated in the media (such as reports of espionage or messianic fervor), may have similar effects.

[Retrograde ejaculation as a side-effect of clozapine]

3 chronic paranoid schizophrenic men, aged 29, 30 and 37 years, respectively, developed retrograde ejaculation, a rare side-effect of clozapine. It disappeared after the dose was lowered in 1 of the patients and after stopping the drug in the other 2. On rechallenging with the drug, retrograde ejaculation recurred.

Ejaculatory Dysfunction Produced by Clozapine. Three Case Reports and Review of Pathophysiological Mechanisms

Three chronic paranoid schizophrenic patients were treated with clozapine, a new anti-psychotic agent. Retrograde ejaculation developed as a side-effect. Stopping the drug therapy or reducing the dosage caused the side-effect to disappear. Re-challenge caused the return of the side-effect. We discuss this rare side-effect to clozapine, and the pathophysiological mechanisms of ejaculation disturbances, with emphasis on those that are drug-induced.

[Combined tricyclic antidepressants and ritalin in elderly depressives]

Psychostimulants, including ritalin (methylphenidate), were used as antidepressives in the '50s but were then replaced by tricyclics and MAO inhibitors. Treatment of depression with psychostimulants is still controversial. Several anecdotal reports in the past decade approved the use of tricyclic antidepressants (TCA) together with methylphenidate in apathetic and withdrawal states in medically ill and in elderly patients. Ritalin elevates mood by releasing catecholamines and blocking their re-uptake, and also increases serum TCA levels. 5 men and 5 women between the ages of 65 and 79 were diagnosed as suffering from major depressive disorders, either single or recurrent, based on the Revised Diagnostic and Statistical Manual for Mental Disorders (DSM-III-R). They had been treated with TCA for up to several months with no response. Following addition of methylphenidate, 5-15 mg/d for 2 weeks, 4 men and 3 women improved rapidly, 2 of them within 24 hours.

Superoxide production during refeeding in patients with anorexia nervosa

The effect of undernutrition and refeeding on superoxide production by polymorphonuclear cells (PMN) was studied in 11 girls suffering from anorexia nervosa (AN) and 17 age-matched, normal, healthy, control subjects. Superoxide anion production by PMNs from undernourished AN patients was comparable to normal, while a significant decrease in this function was observed during the initial period of refeeding. After a more extended period of refeeding, superoxide production by PMNs from AN patients increased and gradually returned toward normal values. Superoxide production correlated with length of the refeeding period (RF), weight as a percentage of ideal weight for height (W/H%), and rate of weight gain (WG). These results imply that a variety of physiological parameters, including susceptibility to infection, may be altered by refeeding undernourished patients.

["Saddam syndrome:" acute psychotic reactions during the Gulf War--renewal of concept of brief reactive psychosis]

6 patients came to our psychiatric emergency room during the first 2 weeks of the Gulf War presenting the clinical picture of acute delusional paranoid psychosis (4 women and 2 men between the ages of 30-77). 4 were without previously known psychopathology, while the other 2 were known to have had some nonpsychotic cognitive impairment. The first 4 recovered completely within a short time while the other 2 continued to have psychopathological symptoms. We discuss psychogenic or reactive psychosis, and the concept of reactivation when cumulative trauma exceed the individual's personal threshold, as may occur during a war. Different phenomenological syndromes may follow.

Pattern of electroencephalographic activity during light induced seizures in genetic epileptic chicken and brain chimeras

Genetic epilepsy was studied in Fayoumi epileptic (F.Epi) chickens and in neural chimeras obtained by selective substitution of embryonic brain vesicles of F.Epi donors in normal recipient chickens. Typical motor seizures accompanied by convulsions were evoked by intermittent light stimulation in F.Epi and in chimeras having embryonic substitution of the prosencephalon and the mesencephalon. The motor seizure was less severe in chimeras receiving only the prosencephalon. In the F.Epi, as well as in all the chimeras, the EEG during seizures was characterized by a desynchronized (or a flattening) pattern of activity. F.Epi and chimeras had a lower threshold to Metrazol induced seizures than control chickens. The experimental animals show that, in this model, large prosencephalic and mesencephalic areas are involved in the epileptic disease. The epileptic character of this genetic dysfunction is discussed.

Serotonin facilitates GABAergic transmission in the CA1 region of rat hippocampus in vitro

1. The effect of serotonin on inhibitory synaptic transmission was examined in forty-one CA1 pyramidal neurones using intracellular voltage recordings in vitro. 2. Serotonin (20-50 microM) increased the synaptic noise of most (85%) neurones loaded with chloride (n = 33). The duration of this effect was enhanced with increasing concentrations of serotonin and was fully reversible within 5 min. When serotonin was applied at short intervals (less than 10 min), fading of the response was observed. 3. The effect of serotonin on synaptic noise persisted in the presence of the glutamate NMDA and non-NMDA antagonists, APV (100 microM) and CNQX (10 microM), but it was blocked (n = 5) by a GABAA antagonist, bicuculline (10 microM). 4. The increase in inhibitory synaptic events resulted from an enhanced frequency of unitary IPSPs from 4.6 +/- 3.8 Hz in control to 17.2 +/- 12.5 Hz (n = 5) in serotonin, especially of large events. Serotonin caused no change in the amplitude and frequency of miniature synaptic events recorded in the presence of TTX (n = 5). The mean amplitude of unitary inhibitory postsynaptic potentials (IPSPs) increased from 1.37 +/- 0.35 mV in control to 3.67 +/- 1.38 mV in serotonin. The coefficient of variation of unitary IPSPs increased from 0.40 +/- 0.11 in control to 0.74 +/- 0.23 in serotonin when quantal size appeared unchanged. 5. The 5-HT3 agonist 2-methyl-serotonin (52 microM, n = 4) partially mimicked the effect of serotonin, increasing the inhibitory noise without affecting the pyramidal neurone conductance. The serotonin-induced facilitation of unitary IPSPs was blocked by the 5-HT3 antagonists ICS 205-930 (1-90 nM, n = 3) and metoclopramide (30 microM, n = 1). 6. These results suggest that serotonin directly excites GABAergic interneurones acting on a 5-HT3 receptor and consequently increasing the frequency of inhibitory synaptic events recorded in CA1 pyramidal cells.

Voluntary dislocation of shoulder

Voluntary dislocation of the shoulder is rarely seen by primary care physicians, but they must be able to recognize it and treat it correctly. Patients often use this ability to attract attention to themselves. Since the dislocations are painless and are performed at will, surgical intervention is not required. Proper treatment involves preventing repetition of the dislocations and providing emotional support for the patient.