成功老龄化机制的系列研究:随访部分

目的探索成功老龄（SA）化的可能机制。，方法（1）样本来源于社区≥65岁老年人。共完成随访156例，其中成功老龄（SA）组73例，常态老龄（uA）组57例，轻度认知功能损害（MCI）组26例。（2）研究工具采用中国老年成套神经心理测验和上海市社区老年人群健康问卷SA2004等。结果（1）SA组老年人在即刻记忆、延迟记忆、长时记忆提取相关测验成绩随访前后差异无统计学意义（P〉0．05），执行功能、序列学习和逻辑推理相关测验成绩随访前后差异有统计学意义（P〈0．05）；UA组老年人在工作记忆、执行功能方面的下降有统计学意义（P〈0．05）；MCI组老年人成绩的下降项目仅4项。（2）按年龄分组后，神经心理项目测验成绩随访前后比较，差异有统计学意义（P〈0．05）的分量表有10项，其中有9项在71—75岁组下降数值相对最大。（3）躯体活动能力、心理状况及认知功能等基线指标与随访结局指标（健康状况调查问卷各分量表评分）的差异有统计学意义（P〈0．05）。结论（1）SA老年人的高认知水平与大脑的整合功能及有效代偿相关，认知老化过程中执行功能可能属于易感领域，而71—75岁则可能是老年人认知老化的敏感时期。（2）UA、MCI老年人的认知功能仍具一定的可塑性，SA化干预具有现实意义。     

老年轻度认知功能损害的脑磁共振显像三维测量研究

目的 研究老年轻度认知功能损害者的脑形态结构变化特点。方法 于1999年1月至2000年6月用脑磁共振显像（MRI）三维测量法组织分割和体积测量分析技术,检查有轻度认知功能损害的老年人21例（MCI组）和认知功能正常的老年人29名（NC组）。结果 （1）MRI测量：与NC组相比,MCI组的颅内总体积少5．2％,灰质体积少8．8％,灰质百分比少3．9％,总脑脊液多12．3％,两组差异有显著或非显著性（P＜0．05或P＜0．01）。（2）多元逐步判别分析：脑灰质和侧脑室体积具有非常显著性判别意义（P＜0．01）,两组判别总正确率为74．5％。结论 MRI三维测量有助于了解老年轻度认知功能损害者的脑部形态结构的改变。     

老年轻度认知功能损害的4种脑诱发电位实验研究

目的 探讨老年轻度认知功能损害（MCI）的脑诱发电位（BEPs)变化。方法 应用美国Nicolet Spirit脑电生理仪记录23例MCI老年人（MCI组）的脑干听觉效应（ABR）,关联性负变（CNV）,P300和视觉诱发电位,并与29名认知功能正常的老年人（NC组）进行比较。结果 （1）与NC组相比,MCI组的听觉脑干反应波V绝对波幅和P300的P3靶波幅显著降低（P＜0．01）。（2）多元逐步判别分析;ABR波V绝对波幅和P300的P3靶波幅具有极显著性判别意义（P＜0．01）,两组判别总正确率为75％。结论 多项BEPs检测有助于MCI的诊断。     

阿尔茨海默病和血管性痴呆听觉事件相关电位P300比较研究

目的 探讨阿尔茨海默病（AD）和血管性痴呆（VD）在听觉事件相关电位P300检测中的不同特点。方法 收集符合ICD-10诊断标准的30例AD和36例VD患者，并以35例健康老人作对照组（NC）。使用丹麦仪器以及“听觉靶-非靶刺激序列”为诱发事件，完成P300检测。结果 （1）3组在靶潜伏期Cz脑区N2以及在靶波幅Cz脑区P2、P3和非靶波幅Cz脑区P2上均有显著差异（P〈0．01）。（2）AD主成分N2表现为延迟，与NC组和VD组有极显著性差异（P〈0．01）。（3）AD组和VD组靶波幅P3和非靶波幅P2均见降低，与NC组比较也有显著性差异（P〈0．05-〈0．01）。结论 提示作为反映AD和VD认知功能障碍的客观生理指标，P300有可能作为AD和VD辅助诊断的一个脑电生理学标志。P300检查可作为老年神经精神科的必查项目。     

轻度认知障碍患者的经颅多普勒屏气试验临床研究

目的应用经颅多普勒（TCD）进行屏气试验检测,观察轻度认知障碍（MCI）患者的脑血管反应性（CVR）特点。方法180例受试者编入正常对照组、MCI组及阿尔茨海默病（Alzheimerdis—ease,AD）,分析屏气指数（BHI）与认知功能及脑血流动力学指标的关系。结果MCI组与正常组及AD组比较,BHI结果有统计学意义（P〈0．01）;BHI与视觉ERP的P300潜伏期的相关性最强（r=0．411,P〈0．001）;MCI组不同CVR状态下,各组受试者脑动脉硬化及血管狭窄检出率有差异,事件相关电位（ERP）和TCD常规检测指标比较有统计学意义（P〈0．05）。结论BHI的改变与MCI患者的认知功能损害密切相关,CVR检测有助于MCI的病因诊断。     

轻度认知功能障碍老年人的睡眠实验研究

目的探讨轻度认知功能障碍（MCI）老年人多导睡眠图（PSG）变化特点。方法应用多导睡眠生理仪,采用眼电图和下颌肌电图及脑电图技术,对19例MCI老年人（MCI组）的PSG进行全夜监测,并与20名正常老年人（NC组）对照。结果与NC组比较,MCI组睡眠总时间减少[NC组（381±37）min,MCI组（313±67）min,P〈0.01],觉醒时间增加[NC组（30±10）min,MCI组（53±17）min,P〈0.01],睡眠维持率下降[NC组（94±10）%,MCI组（85±13）%,P〈0.05],第1阶段睡眠增加[NC组（14±2）%,MCI组（28±10）%,P〈0.01],第2阶段睡眠降低[NC组（60±4）%,MCI组（51±18）%,P〈0.05]和第3阶段睡眠降低[NC组（9±5）%,MCI组（4±3）%,P〈0.01],REM强度增强[NC组（21±4）%,MCI组（40±22）%,P〈0.01]。结论PSG中的浅睡眠增多,慢波睡眠S3减少可能是MCI病人所具有的电生理学指标之一。     

糖尿病对老年人总体认知功能水平及各认知领域的影响

目的研究糖尿病(DM)对社区老年人总体认知功能水平及各认知功能领域的影响。方法根据街道人口登记册确定符合条件的调查对象名单,根据入组和排除标准纳入3 745例社区居民(包括有糖尿病史的居民),分为3组:DM病程6年组,DM病程≤6年组和非DM组。应用全套认知功能量表(华山版)评估研究对象的认知功能,并用Z评分标准化不同认知领域评分。依据美国精神病协会精神障碍与统计手册Ⅳ(DSM-Ⅳ)和Peterson标准确立痴呆和轻度认知功能障碍(MCI)诊断。比较3组不同认知领域评分差异,以广义线性模型分析不同病程DM患者各认知领域受损的特点。结果 3组研究对象的痴呆患病率分别为4. 1%、4. 2%和5. 9%; MCI患病率分别为17. 7%、18. 6%和27. 2%,且3组认知状况(痴呆、MCI和正常)差异有统计学意义(均P 0. 05)。3组简易智力状态检查量表(MMSE)、搭火柴测验、物品分类测验、听觉词语学习测验以及连线测验A和B量表评分比较,差异有统计学意义(P 0. 05)。校正血糖、年龄、性别、受教育年限、吸烟、饮酒、心脏病、高血压病、DM、脑卒中、APOE-ε4水平、肥胖、抑郁、焦虑等因素后,广义线性模型结果表明DM病程6年组与非DM组比较,连线测验A、连线测验B、连线耗时、搭火柴和物品分类(类别)等分项测验,差异有统计学意义(均P 0. 05)。DM病程≤6年组各分项测验得分与非DM组比较,差异无显著性。结论长病程DM患者的痴呆和MCI患病率显著高于短病程DM患者和非DM者;长病程DM患者的执行功能、语言和视觉空间能力损害显著,短病程DM患者各认知领域未见受损;尽早发现和治疗DM对老年人认知功能保护具有重要意义。     

无症状脑梗死与认知功能的关系

目的探讨无症状脑梗死（SCI）与认知功能障碍的关系。方法采用简易精神状态检查法（MMSE）及临床痴呆评定量表（CDR）对61例无症状脑梗死患者和79例健康体检者的认知功能进行评分，比较两组轻度认知功能障碍（MCI）的发生率。结果无症状脑梗死组发生轻度认知功能障碍者13例（21．3％），显著高于健康体检组（P〈0．05）。结论SCI与认知功能障碍关系密切。     

阿尔茨海默病、血管性痴呆血脂浓度分析

目的：研究阿尔茨海默病（AD）、血管性痴呆（VD）及轻微认知功能损害（MCI）患者血脂水平的特点。方法：所有研究对象均来自广州市城乡社区及养老院。痴呆诊断采用美国精神障碍诊断与统计手册第4版的标准，MCI诊断参照Petersen的标准。采用酶法进行血脂测定。结果：AD、VD、MCI及正常老人血浆总胆固醇（TC）、三酰甘油（TG）浓度差异无显著性（P〉0．05）。按痴呆程度分组，中度、重度AD患者血浆TG浓度、重度AD患者血浆TC浓度均显著低于正常老人及轻度AD患者（P〈0．05）；轻度AD患者与正常老人血浆TC、TG浓度的差异无显著性（P〉0．05）。不同程度VD患者及正常老人血浆TC和TG浓度的差异无显著性（P均〉0．05）。结论：VD、MCI及轻度AD患者的血浆TC、TG浓度与正常老人相似。AD患者痴呆程度越重，血浆TC、TG浓度越低。     

情感性精神障碍患者认知功能障碍的对照研究

目的　探讨情感性精神障碍患者是否存在认知功能损害，比较各亚型患者认知功能损害的特征。方法　对120例（抑郁症组、双相抑郁组、躁狂组及双相躁狂组各30例）情感性精神障碍患者（以下简称患者组）使用汉密尔顿抑郁量表（17项）、YOUNG躁狂量表、临床疗效总评量表、威斯康星卡片分类测验（WCST）、韦氏智力量表、韦氏记忆量表及Halstead—Retain神经心理成套检查（HRB—RC）分别于治疗前和治疗第12周末评定及比较。对照组为30名正常人。结果　（1）各亚型患者组治疗前WCST操作的总测验次数、持续错误数、随机错误数、分类数、智商（IQ）值、记忆商（MQ）值，以及抑郁症组、双相抑郁组的正确数与对照组比较，差异均有统计学意义（P〈0．05或P〈0．01）。各亚型患者组治疗第12周末与对照组比较，WCST操作的总测验次数、持续错误数、随机错误数、分类数及MQ值的差异有统计学意义（P〈0．05或P〈0．01）。在各患者组中，WCST操作的总测验次数、随机错误数、分类数、IQ值和MQ值治疗前与治疗第12周末的差异均有统计学意义（P〈0．05或P〈0．01），而组间的差异无统计学意义（P〉0．05）。（2）治疗前与治疗第12周末比较，各患者组中的HRB—RC测验的连线乙、触摸总时间、范畴，抑郁症组中的连线甲，抑郁症组、双相抑郁组治疗前的敲击次数等，与对照组的差异均有统计学意义（P〈0．05或P〈0．01）。结论　部分情感性精神障碍患者存在认知功能损害，各亚型患者间的差异不明显。     

Treatment Considerations in Anticonvulsant Monotherapy

Summary: The long-standing practice of polypharmacy in treating epilepsy is giving way to use of monotherapy. Monotherapy can improve seizure control as well as reduce the risk of serious idiosyncratic reactions, dose-related side effects, and complex drug interactions. Monotherapy also offers improved compliance and cost-effectiveness. The basis of monotherapy is accurate diagnosis and assessment of the patient's seizure type(s), followed by selection of a single appropriate anticonvulsant drug. Many patients currently treated with multiple anticonvulsants can be successfully converted to monotherapy with a carefully monitored program in which troublesome and redundant drugs are gradually withdrawn from the therapeutic regimen.     

Dextromethorphan: Cellular Effects Reducing Neuronal Hyperactivity

Summary: Dextromethorphan is a dextrorotary morphinan without affinity for opioid receptors, commonly used as an antitussive medication. During the past 5 years, interest in the compound and its demethylated derivative, dextrorphan, has been revived because additional neuroprotective and an-tiepileptic properties were found in in vitro studies, animal experiments, and a few clinical cases. Both morphinans are able to inhibit N -methyl-D-aspartate (NMDA) receptor channels and voltage-operated calcium and sodium channels with different potencies. The inhibition of the NMDA receptor is believed to be the predominant mechanism of action responsible for the anticonvulsant and neuroprotective properties of the compounds.     

Pediatric Epilepsy Surgery

Summary: The use of implantable arrays of epidural electrodes has made it possible to carry out extraoperative electrocorticography (ECoG) and functional localization in the awake child. This has permitted cortical excisions that are determined by criteria similar to those obtained during surgical procedures performed under local anesthesia in adults. In addition, the method also permits simultaneous ECoG and video monitoring during the child's symptomatic seizures, providing additional important localizing information that is impractical to obtain in operations under local anesthesia. We report our experience with 75 children, ages 5 months to 15 years, whom we have managed with epidural electrode arrays. The method of extraoperative ECoG is described and illustrative cases are presented to demonstrate its feasibility and utility in children. In addition, we call attention to gliomas as a common cause of chronic focal seizures in children. Of 49 children undergoing resection and followed for from 1 to 14 years (mean of 5.8 years), 32 (65%) are either seizure free or have had a significant reduction in seizure frequency that has unambiguously improved their quality of life. The results are analyzed further by relating the surgical outcome to each of the pathologic entities that caused the seizures. This analysis reveals the variety of neurological conditions that commonly cause intractable focal seizure disorder in children and distinguishes those pathologic entities in which the seizure disorder is apt to respond to surgical intervention from those that will not.     

Un nouveau cadre conceptuel de travail pour une psychiatrie revisitée ? Introduction à deux articles de E. Kandel

In two articles which appeared in the American Journal of Psychiatry and that were subsequently translated for Évolution Psychiatrique, E. Kandel examines the bases for a reinterpreted psychiatry that is prepared to confront the major challenge of the 3rd millenium: that of insight into the mind and brain. This requires a major reorganization of the discipline, which involves a reinvestment of the scientific approach and a critical  assessment of the data provided by psychoanalytical psychiatry and cognitive neurosciences. Seven concepts have therefore been proposed for interactive re-examination: consciousness, the unconscious, memory, emotion, development, desire, impulse. The dynamic relations existing between genetics and the environment allow one to see how evolutions are possible from actions at different levels, both psychotherapeutic and pharmacological. Imaging and other techniques provide additional objective information to the process of human interaction which remains the basis of psychiatry. A common framework for psychiatry and the neurosciences, a reconsideration and renewal of the psychoanalytical approach are both possible and necessary.     

Opioids and the developing organism: A comprehensive bibliography, 1984–1988

A comprehensive bibliography of the literature concerned with opioids and the developing organism for 1984-1988 is presented. Utilized with companion papers (Neurosci. Biobehav. Rev. 6:439-479; 1982; 8:387-403; 1984), these articles cover the clinical and laboratory references beginning in 1875. For the years 1984, 1985, 1986, 1987, and 1988, a total of 877 citations were recorded. A series of indexes accompanies the citations in order to make the literature more accessible. These indexes are divided into clinical and laboratory topics, and subdivided into such topics as the type of opioid explored and the general area of biological interest (e.g., physiology).     

La biologie et le futur de la psychanalyse : un nouveau cadre conceptuel de travail pour une psychiatrie revisitée

The American Journal of Psychiatry has received a number of letters in response to my earlier “Framework” article (1). Some of these are reprinted elsewhere in this issue, and I have answered them briefly there. However, one issue raised by some letters deserves a more detailed answer, and that relates to whether biology is at all relevant to psychoanalysis. To my mind, this issue is so central to the future of psychoanalysis that it cannot be addressed with a brief comment. I therefore have written this article in an attempt to outline the importance of biology for the future of psychoanalysis.     

Facteurs de risque environnementaux à la schizophrénie

Schizophrenia is currently a major concern, its prevalence being estimated at around 1% and its social consequences being severe. The elucidation of the pathophysiology of the disease is difficult due to the great variability of clinical expressions, the instability of the clinical symptoms during the evolution and the absence of reliable biological markers. The existence of a familial aggregation in schizophrenia is well known, the risk of presenting the disease for first-degree relatives of patients being 5 to 10 times higher than the risk observed in the general population. The genetic component was further confirmed by twin and adoption studies. Although the concordance for the disease is higher (40 to 70%) among monozygotic twins as compared with dizygotic twins (15%) it does not reach 100%, which implies that environmental factors modulate the effects of the genotype. However, the role of these factors and especially their interaction with genetic factors remain unclear but the implications of some specific environmental factors are well documented by recent research data. The current literature on sex differences in schizophrenia is consistent. Several studies have suggested that male and female patients may differ in age at the onset and expression of clinical symptoms. Complications during pregnancy or birth-giving may increase the risk of developing schizophrenia later in life. The major complications are oxygen deprivation during pregnancy, bleeding, maternal malnutrition or infection (exposure to influenza, for example). A low birth weight is associated with an increased risk of schizophrenia. Psychoses are more common among people living in an urban environment and among those born during winter months. Schizophrenia is probably more prevalent in people who are living promiscuously, are subject to toxic abuse, poor nutrition and stress but here more precise data are needed. Moreover, immigrants have a higher risk of developing psychotic disorders. In addition, head traumas are associated with an increased risk of schizophrenia. Though they are contentious, some studies suggest that substance abuse (cannabis use in European countries) is related to the development of schizophrenia, especially in people with genetic vulnerability. Moreover, substance misuse may worsen the symptoms. If the environment is sufficiently stressful, people with a high genetic vulnerability will develop some degree of mental illness, including schizophrenia. Conversely, a less stressful or a protective environment may decrease the risk of its onset in persons with a predisposition to schizophrenia.     

Introduction: Goals

Summary: Epilepsy is characterized by recurrent seizures. Many epilepsies with focal seizures as well as convulsive generalized seizures respond satisfactorily to antiepileptic drugs (AEDs) that reduce repetitive firing (e.g., phenytoin, carbamazepine, and valproate) or that augment GABA_A-mediated inhibition (e.g., phenobarbital and benzodiazepines). A number of drugs presently under development, such as NMDA receptor antagonists, loreclezole, losigamone, meth-ysticine, and dextromethorphan, are promising in acute animal models of otherwise drug-resistant convulsant activity. As a result of recent studies in both experimental models and surgically resected human epileptic brain, the prospects for development of AEDs have significantly improved. Several new AEDs recently have reached the commercial market or are in experimental or clinical trials. A comparative presentation of the standing of the new AEDs with respect to their efficacy and side effects is necessary, but still very difficult. Because initial experience with new AEDs is restricted to populations with severe drug-resistant epilepsy, the crucial question whether potential new AEDs can alter prognosis is not yet definitively answered. There is a clear need to compare the effects of standard AEDs and new AEDs in naive patients and over longer follow-up periods. Moreover, because of the strong desire to develop antiepileptic therapy that directly treats the primary etiology of a given epileptic syndrome , or modifies the neurobiological processes that cause recurrent seizures, better experimental epilepsy models for chronic epilepsy and further clinical studies are necessary to increase the knowledge on the pathophysiology of distinct epileptic syndromes. In this respect, studies on the differences between responders and nonresponders to a given AED treatment are extremely valuable.