新型抗抑郁药氯胺酮的研究进展

近年来,氯胺酮在精神疾病治疗中越来越受到重视。不同于5-羟色胺(5-HT)再摄取抑制剂,氯胺酮作为N-甲基-D-天冬氨酸(NMDA)受体拮抗剂的新型抗抑郁药,应用于难治性抑郁症患者,具有快速改善患者抑郁症状及显著降低自杀风险的优势。本文对氯胺酮用于抗抑郁治疗的研究进展进行综述。     

大鼠CVLM中NMDA和非NMDA受体在介导动脉压力感受器反射中的作用

在氨基甲酸乙酯麻醉、制动的大鼠,研究尾端延髓腹外侧区(CVLM)中NMDA和非NMDA受体在介导动脉压力感受器反射(ABR)中的作用.双侧CVLM微量注射选择性NMDA受体拮抗剂氯胺酮(50mmol/L,100 n1)或非NMDA受体拮抗剂kynurenic acid(KYA,50 mmol/I.,100 nl)后平均动脉压(MAP)和心率(HR)均明显升高(P＜0.05),同时观察到CVLM微量注射氯胺酮或KYA后电刺激主动脉神经(AN)导致的血压下降比对照有明显的减少,双侧CVLM微量注射氯胺酮和KYA的混合物(均为50mmol/L,50 nl)后能完全阻断电刺激AN后导致的降压反应.本研究结果提示CVLM中NMDA和非NM-DA受体在紧张性维持交感神经的兴奋活动和介导ABR中起十分重要的作用.     

抗N-甲基-D-天冬氨酸受体脑炎一例

目的 探讨抗N-甲基-M-天冬氨酸(NMDA)受体脑炎的临床特点、诊断及治疗.方法报道1例伴卵巢畸胎瘤的抗NMDA受体脑炎患者的临床表现及诊治过程,并总结其临床特征.结果患者为青年女性,表现为精神行为异常及抽搐,意识障碍及通气不足.早期发现畸胎瘤,脑脊液中抗NMDA受体抗体阳性.行畸胎瘤手术切除,联合静脉用免疫球蛋白和激素冲击治疗,患者临床痊愈.结论 抗NMDA受体脑炎是一种自身免疫性的、能用血清学方法诊断的疾病.早期明确诊断和给予及时治疗,预后良好.     

大鼠CVLM中NMDA和非NMDA受体在介导动脉压力感受器反射中的作用

在氨基甲酸乙酯麻醉、制动的大鼠 ,研究尾端延髓腹外侧区 (CVLM)中 NMDA和非 NMDA受体在介导动脉压力感受器反射 (ABR)中的作用。双侧 CVLM微量注射选择性 NMDA受体拮抗剂氯胺酮 (50mmol/L ,1 0 0 nl)或非 NMDA受体拮抗剂 kynurenic acid(KYA,50 mmol/L ,1 0 0 nl)后平均动脉压 (MAP)和心率 (HR)均明显升高 (P<0 .0 5) ,同时观察到 CVLM微量注射氯胺酮或 KYA后电刺激主动脉神经(AN)导致的血压下降比对照有明显的减少 ,双侧 CVLM微量注射氯胺酮和 KYA的混合物 (均为 50mmol/L,50 nl)后能完全阻断电刺激 AN后导致的降压反应。本研究结果提示 CVLM中 NMDA和非 NM-DA受体在紧张性维持交感神经的兴奋活动和介导 ABR中起十分重要的作用     

Kainate受体与癫痫的研究进展

Kainate(KA)受体属于离子型谷氨酸受体(iGluRs)的一类亚型受体,与其它两种iGluRs,NMDA受体(N-甲基-D-门冬氨酸)和AMPA受体(氨基-3-羟基-5甲基-4-异恶丙酸)相比,具有其自身的生物学特性.近几年随着对KA受体研究的深入,发现KA受体与癫痫病的发病机制有一定的内在联系,因此对KA受体与癫痫关系的研究,可能为癫痫的临床治疗及新药研发开辟一条新的途径.本文介绍KA受体近年来的药理学特性、生理学功能及其在癫痫发病过程中的作用机制的研究进展.     

静注氯胺酮快速改善抑郁症状一例

临床上常用的抗抑郁药物主要通过作用于单胺受体而发挥抗抑郁作用,但该类药物常需2～4周才能发挥治疗作用,这对于急需缓解抑郁症状(如伴自杀倾向)的患者是非常不利的.先前研究表明一种应用较广的麻醉药氯胺酮在单次静脉注射后能够在2h内快速显著改善抑郁症状[1].为了验证其快速改善抑郁症状的疗效.我们选择一例反复发作的抑郁症患者.单次静脉推注亚麻醉剂量氯胺酮以观察其治疗效果.现将治疗结果报道如下.     

氯胺酮对NMDA诱导大鼠脊髓背角星形胶质细胞损伤的保护作用

目的观察氯胺酮对N-甲基-D-天冬氨酸(NMDA)受体过度激活诱导大鼠脊髓背角星形胶质细胞凋亡影响,并探讨其可能的作用机制.方法取新生2～3 d wistar大鼠T11-L6脊髓背角星形胶质细胞原代纯化培养,GFAP鉴定星形胶质细胞纯度达98%后用于实验.将细胞随机分6组:对照组(C组),NMDA组(N组),氯胺酮组(K组)和三种不同浓度氯胺酮加NMDA组(0.1,0.5,1 mmol/L,标记为NK1～NK3组),再培养24 h后检测SOD活性和MDA含量,免疫组化HE复染观察Bcl-2蛋白和形态学变化,流式细胞仪检测星形胶质细胞凋亡率.结果N组细胞发生了大量凋亡,SOD活性显著降低,MDA含量明显增加,Bcl-2蛋白表达不明显;NK3组细胞凋亡被显著抑制,Bcl-2蛋白强阳性表达,SOD活性明显增加和MDA含量低.结论NMDA受体过度激活可诱导大鼠脊髓背角星形胶质细胞大量凋亡,适量氯胺酮显著抑制了细胞凋亡,其机制可能是增强了星形胶质细胞Bcl-2蛋白表达,同时抑制了自由基的产生和增强了SOD活性.     

抗NMDA受体脑炎患者1例报道及文献学习

目的探讨抗N-甲基-D-天冬氨酸(NMDA)受体脑炎的临床特点、诊断及治疗,提高对该疾病的认识。方法报道1例抗NMDA受体脑炎患者的临床表现及诊治过程,并总结其临床特征。结果患者为青年女性,表现为精神行为异常及抽搐,意识障碍及通气不足。脑脊液中抗NMDA受体抗体阳性。联合静脉用免疫球蛋白、激素冲击及血浆置换等治疗,患者临床痊愈。结论抗NMDA受体脑炎是一种自身免疫性的、能用血清学方法诊断的疾病。早期明确诊断和给予及时治疗,预后良好。     

代谢型谷氨酸受体1阻滞剂LY367385对NMDA所致神经元损伤的保护作用

目的探讨代谢型谷氨酸受体1在神经系统兴奋性损伤中的作用。方法用代谢型谷氨酸受体1特异性阻滞剂LY367385预处理神经元细胞1 h,加入N-甲基-D-门冬氨酸(NMDA)造成兴奋性损伤;采用甲基噻唑基四唑(MTT)比色实验检测细胞活性; LDH试剂盒检测培养基中乳酸脱氢酶(LDH)活性;转移酶介导的三磷酸脱氧鸟苷-生物素刻痕末端标记(TUNEL)法检测细胞凋亡指数;免疫共沉淀和免疫印迹实验检测NMDA受体2B亚基(NR2B)和突触后致密物质95(PSD95)相互作用。结果 MTT、LDH和TUNEL实验显示,LY367385能减轻NMDA造成的神经元损伤(P 0. 05);免疫共沉淀和免疫印迹实验显示,NMDA受体与PSD95存在相互关系,LY367385可以减轻兴奋性损伤造成的NMDAR-PSD95表达增高(P 0. 05)。结论 LY367385能够明显减轻NMDA造成的神经元损伤,其机制可能与阻断代谢型谷氨酸受体1可以减少NMDA受体与PSD95连接相关。     

血管性痴呆小鼠海马NMDA受体mRNA表达特征及喜得镇的影响

目的观察喜得镇对血管性痴呆(vascular dementia,VD)小鼠海马神经元N-甲基D-天门冬氨酸(N-methyl-D-aspartate,NMDA)受体原位杂交变化的影响,并探讨NMDA受体原位杂交变化特征及喜得镇对其变化的影响.方法双侧颈总动脉结扎,反复缺血-再灌注法制备模型,药物组用喜得镇溶液灌胃,跳台试验和水迷宫试验观察其行为学改变,采用原位杂交技术观察小鼠海马神经元NMDA受体的表达变化.结果药物组小鼠学习、记忆成绩优于模型组(P＜0.01),其海马N-甲基-D-天门冬氨酸受体表达也明显增高(P＜0.01).结论喜得镇能改善血管性痴呆小鼠模型的学习、记忆功能,这可能与N-甲基D-天门冬氨酸受体mRNA水平正常化有关.     

Diagnostic Difficulties and Treatment Implications

Summary: Differentiation between types of epileptic seizures has been aided in recent years by the introduction of intensive neurodiagnostic techniques and the development of increasingly detailed classification systems. Paradoxically, these developments have not simplified the task of matching the appropriate antiepileptic drug to a particular seizure type. It is reasonable to assume that anticonvulsant drugs will have different effects on different types of seizures, but faulty, circular reasoning can enter the picture if one also assumes that responses of seizures to different drugs signify different seizure types. There are several examples of differential diagnoses that can fall prey to this problem, including the diagnosis between partial seizures with secondary generalization and generalized tonic-clonic seizures, and the diagnosis between complex partial seizures and absence seizures with automatisms, among others. Considerations of etiology in future classification systems can further complicate the problem: should one then choose an anticonvulsant drug on the basis of individual seizure type or on the basis of the type of epilepsy? Ramifications of this issue extend even to the drug approval process. Official sanction is not given for use of a drug for a seizure type not included in the original efficacy studies, even if later scientific evidence shows that seizure type to be related to a type that is included. New trials must be undertaken. These problems arise from how we choose to classify seizures.     

Cognitive Dysfunction Associated with Antiepileptic Drug Therapy

Summary: Epilepsy is frequently associated with cognitive dysfunction. However, the reasons for this correlation are unclear. Possible influential factors include patient age; duration, frequency, etiology, and type of seizures; hereditary factors; psychosocial issues; and antiepileptic drug (AED) therapy. Whereas many of these factors are beyond the physician's control, AED therapy is one element that can be addressed in treatment decisions by recognizing the potential cognitive effects of particular AEDs. For example, phenobarbital impairs memory and concentration; phenytoin affects attention, problem solving ability, and performance of visuomotor tasks. In contrast, carbamazepine may affect concentration, while valproate would appear to have minimal effects on cognition. Moreover, cognitive effects of AEDs are amplified with coadministration of multiple anticonvulsants (polytherapy). A review of studies on the cognitive effects of monotherapy with AEDs, as opposed to those of polytherapy, provides evidence that drug-related cognitive dysfunction can be reversed if patients are switched to a simpler therapeutic regimen. Future research should be directed toward developing reliable measures for assessing and monitoring cognition, and understanding the particular cognitive side effects of each AED. Physicians also need to revise their opinions about which side effects are "tolerable" for epileptic patients.     

Carbamazepine Efficacy in Adults With Partial and Generalized Tonic-Clonic Seizures

Summary: Carbamazepine and phenytoin are drugs of choice in initial monotherapy for adult partial and secondarily generalized tonic-clonic seizures. These designations reflect the results of the Veterans Administration Epilepsy Cooperative Study Group of 1985. An earlier comparative study of carbamazepine and phenytoin by Ramsay and associates found both drugs equally effective in controlling new-onset seizures. Among the advantages of carbamazepine is that it causes relatively few cognitive and dysmorphic side effects. Its disadvantages are its unavailability in parenteral formulation and its metabolic autoinduction. The latter must be compensated for by planned dosage increases to maintain therapeutic plasma steady-state levels during the first 2 or 3 months of treatment. Carbamazepine is judged a drug of choice in the treatment of these secondarily generalized tonic-clonic seizures, and the drug of choice in children, adolescents, and women susceptible to the dysmorphic side effects associated with other anticonvulsant agents.     

Etiologic and Preventive Aspects of Epilepsy in the Child–Bridging the Gap Between Laboratory and Clinic

Summary: Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.     

Predisposing and Causative Factors in Childhood Epilepsy

Summary: We review information from large studies of defined populations, examining the role of known factors and especially of prenatal and perinatal factors in contributing to nonfebrile seizure disorders of early childhood. We depend especially, but not exclusively, on the recently completed analyses from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, the NCPP. About 4% of children in the NCPP who had at least one non-febrile nonsymptomatic seizure by the age of 7 years had a previous seizure during acute neurologic illness, such as meningitis or during the acute illness after trauma. Many such seizures should potentially be preventable. Of children with seizures, 10% had had a neonatal seizure and 13% had had a febrile seizure. Among the hundreds of prenatal and perinatal factors explored as predictors of childhood seizure disorders, the principal predictors identified were congenital malformations of the fetus, cerebral and noncerebral; family history of certain neurologic disorders; and neonatal seizures. In agreement with the British National Child Development Study, labor and delivery factors in the NCPP appeared to contribute very little to childhood seizure disorders. Maldevelopment, rather than damage at birth to an initially intact nervous system, appeared to be the more common mechanism. Most seizure disorders of early childhood remained unexplained by the large set of prenatal and perinatal characteristics examined.     

Anticonvulsant Drugs and Cognitive Function: A Review of the Literature

Summary: Alterations of cognitive function are separate from disturbances of behavior seen in association with epilepsy. The nature of the cognitive disability may to a certain extent depend on the seizure type. Partial seizures, mainly derived from a temporal lobe focus, impair memory tasks, while generalized seizures seem to have more effect on attentional abilities. A number of studies, reviewed in this paper, suggest that anticonvulsant drugs further impair cognitive function. Maximal impairments are seen in patients receiving polytherapy: rationalization of polytherapy improves cognitive abilities. Studies in children and adults have allowed differentiation of the effects of various commonly used antiepileptic agents. Maximal cognitive deficits are seen with. phenytoin, while phenobarbital and sodium valproate induce moderate disturbances, and carbamazepine seems relatively free from such toxicity. Further research is needed on the interrelationship between types of seizure disorders, types of anticonvulsant medications, and cognitive function.     

Effects of NMD A- and AMPA-Receptor Antagonists on Different Forms of Epileptiform Activity in Rat Temporal Cortex Slices

Summary: Lowering extracellular magnesium induces different patterns of epileptiform activity in rat hippocampus and entorhinal cortex. Short recurrent epileptiform discharges in the hippocampus are stable over time, whereas seizurelike events (SLEs) in the entorhinal cortex, the subiculum, and the neighboring neocortex develop into late recurrent discharges which are not blocked by clinically employed antiepileptic drugs. We tested the sensitivity of the different epileptiform discharge patterns to. /V-methyl-D-aspartate (NMDA)- and non-NMDA-receptor antagonists. As NMDA-receptor antagonist we used dextrorphan, ket-amine, and 2-aminophosphonovalerate (2APV); as α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA)-receptor antagonist we employed the quinoxaline derivative glutamate 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX). The findings show that the different patterns of epileptiform activity, including the late recurrent discharges, are sensitive to all NMDA-receptor antagonists. However, when dextrorphan was employed to suppress seizure-like events, later recurrent discharges did not develop during the remaining time course of the experiment. CNQX reversibly suppressed recurrent discharges in the hippocampus and SLEs in the entorhinal cortex. However, late recurrent discharges become insensitive to CNQX, even at a high concentration of 60 μM m. This finding suggests a prominent role for NMDA receptors in the generation of late recurrent discharges.     

The influence of comorbid depression on seizure severity

PURPOSE: To determine the relation between depressive symptoms and seizure severity among people with epilepsy. METHODS: A postal questionnaire was used to survey a nationwide community sample about seizures and depression. The Seizure Severity Questionnaire (SSQ) assessed the severity and bothersomeness of seizure components. The Centers for Epidemiological Studies-Depression scale categorized levels of depression. RESULTS: Respondents categorized as having current severe (SEV, n = 166), mild-moderate (MOD, n = 74), or no depression (NO, n = 443) differed significantly in SSQ scores (all p < 0.0001). People with SEV or MOD reported significantly worse problems than did those with NO depression for overall seizure recovery (mean, 5.3, 4.9, 4.5, respectively); overall severity (5.0, 4.5, 4.2); and overall seizure bother (5.3, 4.8, 4.4) (all p < 0.005). Cognitive, emotional, and physical aspects of seizure recovery also were rated worse among people with SEV than with NO depression (all p < 0.05). Symptoms of depression were significantly correlated with higher levels of all components of generalized tonic-clonic seizure severity (r = 0.33-0.48; all p < 0.0001), and partial seizures (r = 0.31-0.38; all p < 0.01). CONCLUSIONS: Clinically depressed people with epilepsy reported higher levels of perceived severity and bother from seizures, as well as greater problems with overall seizure recovery than did nondepressed people experiencing similar types of seizures. The pervasive influence of depressive symptoms on reports of seizure activity suggests that people with epilepsy should be screened for depression. These data highlight the importance of detecting and treating depression among people with epilepsy.     

Une phénoménologie de la dépendance à l'alcool. Une expérience primordiale de la « nostrité »

The phenomenological approach to alcoholism interestingly focuses on specific dynamics of interpersonal relationships displaying the founding of the Self from a primary “us” and its original basis in the human feast. Priorities for treatment intervention recommend to involve social setting and relationships of the patients, reaching their active participation to a motivational and long term group treatment, underlying the specific therapeutic effect of world exchanges. Biopsychosocial determination of alcoholism could be primarily based on components of interpersonal relationships. Regarding social background, drinking is one of the most famous supports for the achievement of the feast, a founding marker of present time. Taking an existential point of view, the feast appears as the heart of mankind because it presents a primary “us”, a plural state which indicates the beginning and founding of the Self from the others. During the feast, we regularly have to reach our Self from the “us” while avoiding two main dangers, drunkenness, an increase in the dizziness of upright verticality, and addiction, an opposite vertical surrender to alcohol and falling into in the alcoholic relapse, both situations imply a spatial domination and the disappearance of others. Treatment programs of alcohol addicts need to integrate the necessity of reaching the existential basic trust from the support of a group to the appropriation of the community which can be defined as an original “usness”.