缺血性额叶白质病变的认知功能损害研究

目的探讨皮质下缺血性血管病患者额叶白质病变对认知功能的影响。方法回顾性收集2013年1月至2015年1月期间我科住院诊断为皮质下缺血性脑血管病患者121例,根据额叶白质病变程度,将皮质下缺血性脑血管病患者分为轻度(67例)和重度(54例)脑白质病变组。同时选择同年龄段60例健康、无认知障碍者为对照组;所有受试者均为右利手,且母语均为中文。对三组受试者进行神经心理量表测定,评估其认知功能、记忆功能及执行功能,并对额叶白质病变的程度与认知功能进行非参数等级相关分析。结果与轻度脑白质病变组和对照组相比,重度脑白质病变组的MMSE评分、AVLT评分、ROCF评分及Stroop评分明显降低,P值均0.05。患者MMSE评分与脑白质病变损害严重程度呈正相关(R=0.933,P=0.013),即脑白质病变的严重程度与认知障碍程度呈正相关。结论皮质下缺血性脑血管病患者,额叶的脑白质主要累及认知功能、记忆功能及执行功能,且脑白质病变的严重程度与认知障碍程度呈正相关。     

脑小血管病患者认知状态与神经影像学特征的相关性分析

目的:本研究旨在探讨脑小血管病患者认知状态与皮质下腔隙性梗死部位及病灶数、白质病变和内侧颞叶萎缩之间的关系。方法:本研究纳入59例在上海交通大学医学院附属仁济医院神经内科脑血管病二级预防门诊登记的最近一次症状性缺血性卒中病史3个月的脑小血管病患者。根据详细的神经心理学评估结果,将59例患者分入无认知障碍组(24例)、轻度认知障碍组(22例)和血管性痴呆组(13例),采用头颅磁共振成像多重序列检查及斜冠状面重建,依据所得图像进行皮质下腔隙性梗死病灶计数、白质病变评分和内侧颞叶萎缩评分。结果:脑小血管病患者认知障碍的发生与皮质下腔隙性梗死病灶总数有关(P=0.004),其中皮质下白质部位腔隙性梗死病灶数在3组之间的差异有统计学意义(P=0.001);轻度认知障碍组和血管性痴呆组患者丘脑部位腔隙性梗死病灶数多于无认知障碍组的患者,但差异无统计学意义(P=0.058)。大部分的白质病变病灶位于额叶和顶枕叶,颞叶和基底节的白质病变较少。3组之间双侧额叶(P=0.033)和双侧基底节(P=0.009)的白质病变评分差异有统计学意义。59例患者中,43例完成磁共振成像斜冠状面重建。左右内侧颞叶萎缩一般呈同步发展;3组之间左或右内侧颞叶萎缩评分的差异均有统计学意义(P值均0.001)。在13例左内侧颞叶萎缩评分≥2分的患者中,11例为无认知障碍组和轻度认知障碍组患者;血管性痴呆组患者均有内侧颞叶萎缩,其中6例患者的左右侧平均内侧颞叶萎缩评分≥2分。多因素分析结果显示,皮质下白质腔隙性梗死病灶数[比值比:2.39(95%可信区间:1.19~5.80),P=0.005]和左内侧颞叶萎缩评分[比值比:10.21(95%可信区间:2.02~51.75),P=0.003]是脑小血管病认知功能的独立危险因素。结论:脑小血管病患者的认知损害程度与皮质下白质腔隙性梗死病灶数和左内侧颞叶萎缩评分相关。     

皮质下缺血性血管病患者血清sCD40L水平变化及其与认知功能的相关性研究

目的探讨皮质下缺血性血管病(SIVD)患者血清可溶性CD40配体(sCD40L)的表达水平及其对认知功能的影响。方法选取SIVD患者82例为SIVD组,筛选同时期健康体检者44例为对照组,依据头颅MRI表现评估入选者白质病变(WML)程度(Fazekas评分)和腔隙性脑梗死(LI)数量,ELISA法测定血清sCD40L水平,采用MoCA量表评估总体的认知功能,比较SIVD组与对照组之间一般资料、血清sCD40L水平、脑损伤程度、认知功能评分,并分析sCD40L水平与脑损伤程度、认知功能评分的相关性。结果 SIVD组血清sCD40L水平、Fazekas评分、LI数量显著高于对照组,MoCA评分显著低于对照组,差异均有统计学意义(P0.05);相关分析显示,sCD40L水平与Fazekas评分、LI数量呈正相关(r=0.346、0.344,P0.01),sCD40L水平与MoCA评分具有负相关性(r=-0.716,P0.001);多元回归分析显示,总胆固醇(OR=2.427,95%CI 1.037～5.682)、sCD40L水平(OR=1.248,95%CI 1.147～1.359)均是SIVD的独立影响因素(P0.05)。结论血清sCD40L水平升高可能是SIVD的独立危险因素,且血清sCD40L水平与SIVD严重程度、认知功能密切相关。     

皮质下缺血性血管性痴呆患者认知功能与脑白质弥散张量成像的关系

目的探讨皮质下缺血性血管性痴呆(SIVD)患者认知功能与脑白质弥散张量成像(DTI)的关系。方法采用MMSE、蒙特利尔认知测评量表(Mo CA)及临床痴呆量表(CDR)评价60例SIVD患者(SIVD组)和45名正常对照者(正常对照组)。应用DTI技术测量患者脑白质不同感兴趣区(ROI)各向异性分数(FA)和表观弥散系数(ADC)。SIVD组用常规头颅MRI采用年龄相关白质改变(ARWMC)评分方法对侧脑室周围脑白质高信号严重程度进行评分。结果与SIVD组比较,正常对照组MMSE及Mo CA评分显著增高,CDR评分显著降低(均P0.01)。与正常对照组比较,SIVD组双侧额叶前部、双侧侧脑室前角区及后角区的FA值显著下降,ADC值显著升高(P0.05~0.01)。其余各区FA及ADC值差异无统计学意义。SIVD组ARWMC评分为1分11例(18.3%),2分31例(51.7%),3分18例(30.0%)。正常对照组中5人(11.1%)为1分。Spearman相关性分析显示,SIVD组ARWMC评分与双侧侧脑室前角区及后角区FA值呈负相关(r=-0.912,P0.01),与ADC值呈正相关(r=0.891,P0.01)。双侧额叶前部皮质下白质及海马区FA值与MMSE及Mo CA评分呈正相关(P0.05~0.01)。结论 SIVD患者多个ROI的FA值降低及ADC值的增高程度,可以反映认知功能障碍的程度。     

不同程度脑白质病变对腔隙性梗死患者认知功能的影响

目的分析腔隙性梗死(LI)脑白质病变(WML)程度与认知功能的相关性。方法以30例LI无WML者为对照组,30例LI合并轻度WML者为轻度组,30例LI合并中度WML者为中度组,30例LI合并WML者为重度组,分析4组认知功能及WML程度与认知功能的相关性。结果 4组间各项MMSE评分、MMSE总评分、各项MoCA评分及MoCA总评分比较,差异有统计学意义(P0.05),均以重度组最低,对照组最高。同时,WML程度与MMSE总评分及MoCA总评分存在负向直线相关性(P0.05)。结论 LI患者WML程度与认知功能存在显著的相关性,可用于评估患者认知功能。     

脑白质病变与轻度认知功能障碍的关系

目的 探讨脑白质病变(WML)与轻度认知功能障碍(MCI)的关系.方法 71例WML患者根据头颅MRI检查分为轻度组(27例)、中度组(21例)、重度组(23例),39例无WML的对照者为对照组.对入组者进行神经心理学量表检查;比较各组MCI的患病率,分析WML与MCI的相关性.结果 WML轻、中、重度组的MCI患病率明显高于对照组(均P＜0.01);WML中、重度组简易精神状态检查(MMSE)及蒙特利尔认知评估量表(MoCA)评分显著低于WML轻度组和对照组(均P＜0.01);随着WML程度的加重,除了抽象能力评分,MoCA其他各认知领域的评分均显著降低(均P＜0.05).多元线性相关分析显示,WML程度与MMSE、MoCA总分及除抽象思维能力的各认知域评分呈负相关(r=-0.252 ～-0.782,均P＜0.01).结论 WML可导致MCI,其对认知功能障碍的影响与WML的程度有关.     

皮质下缺血性血管性认知损害扩散张量成像研究

目的通过扩散张量成像(DTI)探讨皮质下缺血性血管性认知损害患者白质微结构变化及其与认知功能之间的相关性。方法采集49例皮质下缺血性脑血管病患者[轻度血管性痴呆(VaD)10例、非痴呆型血管性认知损害(VCIND)20例、认知功能正常19例]DTI数据并观察皮质下白质微结构改变,分析VaD组患者DTI参数与认知功能间的相关性。结果与对照组相比,VaD组内侧前额叶、前扣带回、胼胝体干、双侧顶叶、右侧颞叶、双侧眶额叶,以及VCIND组右侧额下回、右侧海马、双侧楔前叶FA值减低(均P=0.000);与VCIND组比较,VaD组内侧前额叶、前扣带回、胼胝体、双侧顶叶、右侧颞叶FA值减低(P=0.000)。与对照组相比,VaD组内侧前额叶、胼胝体、双侧顶叶、双侧颞叶、前扣带回,以及VCIND组双侧楔前叶、右侧海马MD值升高(均P=0.000);与VCIND组相比,VaD组右侧内侧前额叶、前扣带回、胼胝体干、双侧顶叶、双侧颞叶MD值升高(均P=0.000)。VaD组内侧前额叶FA值与数字连线测验A时呈显著负相关(r=-0.782,P=0.007),双侧额下回MD值与数字连线试验A时程呈显著正相关(r=0.877,P=0.001)。结论 DTI对皮质下缺血性认知损害患者白质微结构改变更敏感,能够反映患者认知功能早期异常改变;内侧前额叶白质微结构的改变是影响患者执行能力的重要因素。     

脑小血管病患者伴发非痴呆血管性认知功能损害情况及尼莫地平疗效的研究

目的探讨脑小血管病(cerebral small vessel disease,SVD)不同亚型伴发非痴呆血管性认知功能损害的情况,评价尼莫地平对SVD的疗效。方法选择SVD患者118例,包括52例腔隙灶脑梗死(LI)和66例白质疏松(WML)患者。分别将LI组和WML组患者随机分组为治疗组(基础治疗加尼莫地平治疗)和对照组(基础治疗),进行6个月治疗。治疗前后对所有患者采用蒙特利尔认知评估量表(MoCA)、简易智能状态检查表(MMSE)、语义分类流畅测验(动物)、Stroop测验(计算错误数)、画钟试验、积木测验、数字广度顺背测验、数字符号测验、逻辑记忆亚测验和再生亚测验进行认知功能评价,并比较各组患者治疗前后认知功能评分。结果治疗前,LI组患者语义分类流畅测验(动物)、数字符号测验、逻辑记忆亚测验、视觉再生亚测验、MoCA、MMSE评分显著高于WML组患者,Stroop测验得分显著低于WML组患者。经过6个月治疗后,LI组和WML组患者中的对照组治疗前后各项认知功能评分均没有统计学差异(P>0.05)。LI组患者中治疗组MoCA、画钟试验和数字广度顺背测验得分升高,Stroop测验得分下降(均P<0.05);WML组患者中治疗组MoCA、MMSE、画钟试验、数字广度顺背测验和视觉再生亚测验得分升高,Stroop测验得分下降(均P<0.05)。结论 SVD两个亚型伴发非痴呆血管性认知功能损害情况不同,LI患者损害程度比WML患者轻。尼莫地平治疗可较好的改善患者的执行功能、视空间结构能力和注意力。     

老年脑梗死患者早期记忆障碍特点研究

目的探讨老年脑梗死患者早期记忆障碍的特点。方法前瞻性收集老年脑梗死患者76例,根据头颅MRI病灶部位分为额叶、颞叶、顶枕叶、小脑、基底节、脑干等亚组,根据病灶大小及数量分为大梗死、中梗死、小梗死、腔隙性梗死和多发性梗死等亚组;以同期健康体检者76名为健康对照。分别对脑梗死组及对照组应用蒙特利尔认知评价表(MoCA)评定认知功能,临床记忆量表(CMS)、Fuld物体记忆测验(FOM)、言语流畅性测验(RVR)评定记忆功能。结果 76例脑梗死患者中44例(57.9%)MoCA评分26分。与对照组相比,脑梗死组及其亚组额叶、颞叶、顶枕叶、基底节组MoCA评分及各项记忆功能评分下降(P0.01);脑梗死各亚组中,额叶、颞叶、顶枕叶及基底节组之间两两比较,额叶、颞叶、顶枕叶组记忆商(MQ)、FOM、RVR评分较基底节组下降(P0.05);额叶、颞叶、顶枕叶组各项记忆功能评分无明显差别(P0.05);各亚组不同病灶类型相比,额叶及颞叶梗死亚组中,中梗死组各项记忆功能评分均低于小梗死和腔隙性梗死组(P0.01),小梗死组各项记忆功能评分均低于腔隙性梗死组(P0.01);顶枕叶及基底节梗死亚组中,中梗死组各项记忆功能评分均低于小梗死组和腔隙性梗死组(P0.01),小梗死组与腔隙性梗死组比较,各项记忆功能差异无统计学意义(P0.05)。结论老年脑梗死患者早期认知功能下降发生率较高,其记忆障碍表现及记忆功能损害程度与梗死灶部位及大小有关。     

急性腔隙性脑梗死伴脑白质病变对认知功能的变化影响

目的探讨急性腔隙性脑梗死（LI）伴脑白质病变（WML）患者的认知功能障碍特点。方法收集137例患者和正常对照组30例,根据头颅MRIT2加权像及FLAIR像,将病例组分为LI组、WML组和u合并WML组,应用蒙特利尔认知评估量表（MoCA）进行认知评估。结果与对照组相比,WML组的延迟回忆与语言评分明显下降（P〈0．01）;LI组患者注意计算、语言、执行功能评分显著降低（P〈0．01）;LI合并WML组患者延迟记忆、视空间与执行功能评分显著降低（P〈0．01）。与LI组和WML组相比,执行功能障碍在LI合并WML组更明显（P〈0．01）。结论LI合并WML可导致患者认知功能障碍,主要表现为延迟记忆、视空间与执行等认知功能的受损;MoCA在皮层下缺血性脑血管病引起的血管性认知障碍的评定中具有很大的优势。     

Early stages in the formation of the cerebellum in the frog

The formation of the cerebellum was studied during the first 6 months of the tadpole stage of the bullfrog by using standard histological methods and reconstructions from serial horizontal sections. Three major developmental phases were noted in the formation of the cerebellum. (1) During the first 5 weeks of development, the neuroepithelium proliferated and the dorsal mesencephalic plates increased in size. (2) Starting in the sixth week, a patch of neuroepithelium began to differentiate and gave rise to a small population of Purkinje cells. In subsequent weeks, the area of differentiation continued to spread and a Purkinje cell layer became established along the dorsal margin of the cerebellar plate. (3) In the 12th week, the ventrolateral part of the cerebellar plate began to increase in size and generate two populations of small cells. The lateralmost part of the neuroepithelium in this area generated a group of cells that formed an external granular layer that was one cell deep. Cells of this external granular layer migrated inward into the primitive molecular layer, and by the 26th week only a remnant of an external granular layer remained in the cerebellum. The more medially situated part of the neuroepithelium gave rise to another population of small cells that formed a column, which appeared to be continuous with the Purkinje cells, but differed from them in size. It should be noted that full maturation of the cerebellum occurs during metamorphosis, which in this species remains some 2 years away.     

Inhomogeneities in the propagation of the slow wave in the stomach

The propagation of the slow wave in the stomach and its role in inducing sweeping peristaltic contractions toward the pylorus, essential for a proper digestion and emptying, have been studied for many years. Irregularities in the timing or in the pattern of propagation of the slow wave have been known to induce various gastric malfunctions and, recently, several types of gastric dysrhythmias have been described which could lead to gastric contraction abnormalities. In this study, Du et al. have analyzed the disturbances caused by a simple transmural incision in a human stomach, performed to obtain a biopsy of the muscle, on the propagation pattern of the slow wave. In addition, they show that such an incision may by itself also induce new types of gastric dysrhythmias. These results are important in demonstrating that the function of the stomach can easily be disturbed by such procedures. This mini‐review describes several ways in which inhomogeneities in propagation may affect the conduction pattern of the slow wave, including the genesis of several dysrhythmias, and what is currently known about their impact on gastric contraction and digestion.     

Cells in the pretectal olivary nucleus are in the pathway for the direct light reflex of the pupil in the rat

Extracellular microelectrode recordings from 148 single cells in the pretectum of the hooded rat were classified according to their temporal response properties to light stimulation of their retinal receptive fields. Fifty-six cells were classified as tonic-on cells, 22 cells were classified as tonic-off cells, and 53 cells were classified as phasic cells. Seventeen cells could not be assigned to one of these 3 groups. The diameters of the receptive field centers of the tonic-on pretectal cell were clustered about a mean of 31° and the temporal response of these cells was sustained. Constriction of the contralateral pupil was produced by electrical stimulation through the recording electrode at sites containing tonic-on pretectal cells, but not at sites containing tonic-off pretectal cells or phasic pretectal cells. For this reason, we argue that tonic-on cells are likely to mediate constriction in the light reflex of the rat's pupil. Receptive field maps together with electrolytic marking lesions at recording and stimulation sites showed that tonic-on pretectal cells are retinotopically organized and are aggregated in a strip running from the dorso-medial tip of the pretectum to the ventro-lateral boundary. The anatomical distribution of these cells is coextensive with the region known as the pretectal olivary nucleus (PO) in the rat^26,27.Using fine microelectrodes, recordings were obtained from 27 axons presumed origin (fibers). Of these, 14 were tonic-on, 10 were phasic, 2 were tonic-off, and 2 were unclassified. Recordings from tonic-on fibers were obtained near tonic-on pretectal cells, typically in the most dorsal light-responsiveness region of the pretectum. These fibers were activated by single pulse electrical stimulation of the optic chiasm. The mean receptive field center diameter of 6 tonic-on fibers was 10.1°, or about a factor of 3 less than that of pretectal tonic-on cells. The mean conduction velocity of 14 tonic-on fibers was 3.1 m/s.We argue that the tonic-on cells of the PO serve to integrate signals from tonic-on center retinal ganglion cells with adjacent receptive fields to provide signals for constriction of the pupil to neurons in the oculomotor nucleus.     

Organization in the descending tracts of the dorsolateral funiculus in the cat

Organization of the fibers in the descending tracts of the dorsolateral funiculus of the cervical spinal cord was investigated in cats. The spinal cord was penetrated with microelectrodes at 400 mum intervals in the medio-lateral direction at the c5/c6 and c6/c7 segmental borders. Silicon substrate microelectrodes with a linear arrangement of activated iridium contacts were used. The stimulus consisted of a 20 ms train of charge balanced biphasic current pulses at 330 Hz. The evoked activities from selected forelimb muscles were acquired into computer. Only the data points with an activation threshold of less than 35 muA were considered in the analysis. Muscle contractions were mostly in the form of short twitches. In both spinal segments, an area of high threshold was found in the middle of the dorsolateral funiculus. Majority of the muscles studied had a dorsal or ventral concentration of activation points. The distal muscles were mostly activated in the ventro-lateral aspect of the funiculus, while the elbow muscle maps spread to both dorsal and ventral sides. These results show a functional organization in both cervical segments studied, with overlapping regions between the areas dedicated for each forelimb muscle.     

Dysthymic disorder in the aged in the community

Summary The prevalence of dysthymic disorder and and its relationship to social and health variables were investigated in a Finnish population aged 60 years or over. The prevalence was lower in men (17.2 per 100) than in women (22.9 per 100). In the total population the occurrence was higher in the widowed (24.9 per 100) than in the married (18.3 per 100). In men, dysthymic disorder was more common in those with a lower educational level (22.6 per 100) than with a higher educational level (15.1 per 100), and more common in persons receiving long-term institutional care or home nursing or home help (28.7 per 100) than in persons living independently at home (14.6 per 100). The rate was not related to age, marital status or occupation. In women, the occurrence was not related to age, marital status, education, occupation or form of social and health care. The female rate was higher than the male in the older group (70 yrs. +), in married persons, in those with a higher educational level and in those living independently at home. Underdiagnosing was evident. The occurrence of dysthymic disorder was related to poor health and poor functional status and to the occurrence of social and health stressors. No differences were found in the occurrence of the related factors between persons with dysthymic disorder and persons with major depression. Our results support the conclusion that the majority of cases of dysthymic disorders in the elderly are affective illnesses and not personality disorders.     

Issues in the assessment of outcome in depressive illness in the elderly

Different approaches to assessment of outcome of psychiatric illness generally are critically appraised. The article examines research design, outcome criteria and statistical analysis, including newer statistical approaches. Measurement of outcome is complex and a more detailed and sophisticated approach needs to be adopted than in the past. Some of the special problems associated with outcome studies of depressive illness in the elderly are discussed. Specific recommendations are suggested for future outcome studies of depression in the elderly. Such studies should be prospective, recruit a wide range of patient severity and make greater use of newer statistical analyses, eg survival analysis and proportional hazards model. Outcome criteria should be precisely defined, measured using standardized instruments and be comprehensive (clinical, physical health, psychosocial, etc.). Attention should be given to inter-episode symptomatology.     

Changes in the mitochondria in the initial part of the axon during regeneration

Summary The initial part of the axon including the axon hillock, the initial unmyelinated segment and the beginning of myelinated axon was studied electron microscopically during regeneration, 1–30 days following a crush lesion of the rat hypoglossal nerve. Large mitochondria reaching 1.1 m in diameter, with abundant cristae and dense granules in the matrix were observed between days 3–21. They formed clusters in the initial myelinated segment of the axon. End-to-end contacts and ribosomes around them were very often visible.The large mitochondria exhibited strong succinate dehydrogenase and NAD · H₂ diaphorase activities.The relationship between the appearance of large and active mitochondria in the initial part of the axon and the elevated axonal transport during regeneration of the peripheral nerve is also discussed.     

Experiences in the United States--a difference in the status in the United States and that in Japan]

Child and adolescent psychiatry has been established as a subspecialty in the United States. The systematic education, training and research opportunities are currently available and child and adolescent psychiatry is a major part of psychiatric practice in the US. However, there are many burdens to overcome to provide adequate child mental health care. Several important focus on child mental health care in US are to 1) improve the assessment of and recognition of mental health needs in children, 2) promote scientifically-proven and evidence based interventions and 3) increase access to and coordination of quality mental health care services. To understand the current status and problems in child and adolescent psychiatry in US may help the Japanese psychiatrists to develop and establish child and adolescent psychiatry in Japan.     

Apoplexy in the everyday practice in the eighteenth century

We report the original recipes applied to treat apoplexy in the eighteenth century, as written in the personal notes of doctor of that century.