立体定向手术治疗难治性精神分裂症(附256例报告)

目的:探讨立体定向技术和多靶点组合对难治性精神病的治疗意义,综合评估临床疗效。方法:在立体定向基础上,应用CT、电阻值和微电极电生理进行核团定位,对256例难治性精神病患者,采用杏仁核、内侧隔区、扣带回等多靶点组合射频热凝治疗。应用临床疗效总评量表(clinical grobal impressions scale,CGI)、简明精神病评定量表(brief psychiatric rating scale,BPRS)、阴性和阳性综合量表(the postitve and negative syndrome,PNSS)精神病评定量表在术后6个月对治疗效果进行评定。结果:依据减分率标准,256例患者中,显著进步140例,进步108,无变化8例。手术前后量表评分有显著差异(P<0.05=无严重并发症和后遗症发生。结论:多靶点组合的立体定向技术是难治性精神病的有效治疗方法之一,靶点组合设计和亚核团的准确定位,对提高疗效,降低并发症有较大意义。     

Changes in retrograde memory following temporal lobectomy

Extensive retrograde memory deficits have been detected in patients with temporal lobe epilepsy (TLE) and in patients who have undergone temporal lobectomy (TL). To date, no group study has used a prospective longitudinal design. We assessed memory for public and autobiographical facts and events in patients (n = 15) with focal left- or right-sided TLE before and after TL using a battery of tests that covered the life span. Patients who underwent TL demonstrated material-specific memory decline in retrograde memory. Left TL was associated with a significant drop in recall of famous people’s names. Patients who underwent right TL exhibited a significant decline in the recall of autobiographical events from across the life span. Our study indicates for the first time that TL is associated with a risk of mild, material-specific retrograde memory decline. Verifications with a larger sample size and other measures of remote memory are needed.     

White-matter vascular lesions correlate with alpha EEG sources in mild cognitive impairment

It is an open issue if vascular and Alzheimer's disease (AD) lesions represent additive factors in the development of mild cognitive impairment (MCI), as a preclinical stage of Alzheimer's disease (AD) at group level. In the present study, we tested the hypothesis that electroencephalographic (EEG) alpha rhythms, which are affected (i.e. decreased in amplitude) by AD processes, are relatively preserved in MCI subjects in whom the cognitive decline is mainly explained by white-matter vascular load. Resting EEG was recorded in 40 healthy elderly (Nold), 80 MCI, and 40 AD subjects. In the MCI subjects, white-matter vascular load was quantified based on MRI (0-30 Wahlund visual rating scale). EEG rhythms of interest were delta (2-4Hz), theta (4-8Hz), alpha 1 (8-10.5Hz), alpha 2 (10.5-13Hz), beta 1 (13-20Hz), and beta 2 (20-30Hz). Low resolution electromagnetic source tomography (LORETA) was used for EEG source analysis. As expected, we observed that alpha 1 sources in parietal, occipital, and temporal areas were lower in amplitude in the AD and MCI subjects than in the Nold subjects, whereas the amplitude of wide delta sources was higher in the AD than in the Nold and MCI subjects. As novel results, the amplitude of parietal, occipital, and temporal alpha 1 sources was higher in the MCI V+ (high vascular load; N=42; MMSE=26) than MCI V- group (low vascular load; N=37; MMSE=26.7). Furthermore, a weak but significant (p<0.05) positive statistical correlation was found between the parietal alpha 1 sources and the score of Wahlund scale across all MCI subjects (i.e. the more severe white-matter lesions, the higher parietal alpha source power). The present results are in line with the additive model of cognitive impairment postulating that this arises as the sum of neurodegenerative and cerebrovascular lesions.     

Serum S100B but not NSE Levels are Increased in Morbidly Obese Individuals Affected by Obstructive Sleep Apnea–Hypopnea Syndrome

BACKGROUND: Obstructive sleep apnea-hypopnea syndrome (OSAHS) is considered a comorbidity associated with morbid obesity, mainly because of the large neck circumference. Depending on its severity, OSAHS can interfere in many homeostasis systems, for example, the central nervous system (CNS). Neuron-specific enolase (NSE) and S100B protein derived from astrocytes are considered sensitive biochemical markers of cerebral injury. We evaluated serum S100B and NSE levels in this study with the aim of detecting possible cerebral injury as a consequence of OSAHS. METHODS: This was a transverse study with data from 25 morbidly obese patients with OSAHS. Blood samples were collected before and after polysomnography (PSG) to determine S100B and NSE protein levels. We also analyzed data evaluating depression and excessive daytime sleepiness. RESULTS: S100B levels were higher after [0.029 (0.010-0.199) mg/l] compared to before [0.010 (0.010-0.025) mg/l] on PSG (P = 0.002). S100B levels were expressed as means and IQ25-IQ75. NSE levels did not show significant differences before and after PSG. CONCLUSION: Our study shows a significant increase in S100B level after PSG compared to before. This suggests that there is a CNS astrocyte reaction because of possible cerebral hypoxemia in morbidly obese patients with OSAHS.     

Microfracture of chondral lesions of the glenohumeral joint

Objective:

To determine if microfracture is successful in treating chondral lesions of the shoulder.

Design:

Case series.

Setting:

Tertiary referral practice.

Patients:

From June 2005 to November 2006, eight patients underwent shoulder arthroscopy with arthroscopic microfracture to treat full-thickness chondral lesions of less than 4 cm² size. The study group consisted of six men and two women. The mean age at surgery was 37 years (range: 27–55 years).One patient (12.5%) had an isolated chondral defect and seven patients (87.5%) had associated conditions treated simultaneously: two patients had arthroscopic subacromial decompressions, two had capsular plications for multidirectional instability, and three had anterior stabilization done (one with an associated superior labrum anterior to posterior repair and one with repair of a small rotator cuff tear). Five patients had humeral head defects and three had glenoid defects.

Intervention:

Microfracture.

Main outcome measures:

Constant score and Oxford score.

Results:

The mean follow-up period was 15.4 months, with a range of 12–27 months. The mean preoperative Constant score was 43.88 (range: 28–70) and at final follow-up the mean Constant score was 90.25 (range: 85–100); this difference was significant (P<0.005). The mean preoperative Oxford score was 25.75 (range: 12–37) and the mean postoperative Oxford score at final follow-up was 17 (range: 11–27); the difference was significant (P<0.005).There were no complications. Two patients underwent reoperation which allowed assessment of the lesion; in both cases the lesions showed good filling with fibrocartilage.

Conclusion:

Microfracture has been shown to be a reliable method of treatment for chondral lesions within the knee. We believe that this technique may also be applied to the shoulder; however, further study is required to assess its efficacy in this joint.

Level of evidence:

IV     

The CT-arthrography in the antero-inferior glenoid labral lesion: Pictorial presentation and diagnostic value

Objective:

To present the Computed Tomography (CT)-Arthrography appearance of the most common types of anterior labral lesion and to assess the diagnostic value of this technique in the detection and classification of the antero-inferior labral tears in glenohumeral joint instability.

Materials and Methods:

The pre-operative CT-Arthrography records of 43 patients, who underwent surgery for anterior shoulder instability, were retrospectively evaluated independently by two radiologists. The data were compared with arthroscopic results and the diagnostic accuracy of CT-Arthrography was calculated to detect the labral lesion and the agreement between the CT-Arthrography lesions classification and the arthroscopy classification.

Results:

The CT-Arthrography sensitivity, specificity and accuracy were: 92% / 89% (reader 1/reader 2), 86% / 86% and 91% / 88% respectively. The CT-Arthrography classification was correct in 86% of cases.

Conclusions:

CT-Arthrography appears to be an accurate means for identification and classification of the anterior labral tears and, identifying the labral degeneration, this technique can be very helpful in the selection of patient for arthroscopic stabilization of the shoulder.     

Specific role of the posterior dorsal hippocampus-prefrontal cortex in short-term working memory

Working memory in rats involves neural projections from the hippocampus (HP) to the prefrontal cortex (PFC), based on delayed task experiments in a radial-arm maze, in which the time span of working memory is longer than seconds. To determine whether the HP–PFC pathway is involved in short-term (on the order of seconds) working memory function, we lesioned the PFC and/or HP, and measured performance in an operant delayed alternation task. The posterior dorsal (pdHP) and ventral HP (vHP) were assessed separately. The bilateral PFC and bilateral pdHP ibotenate lesions produced significant working memory deficits, but the vHP lesion did not. Unilateral pdHP lesions combined with a PFC lesion in the opposite hemisphere reproduced the effects of bilaterally symmetrical lesions. By contrast, unilateral lesions of the pdHP combined with a PFC lesion in the same hemisphere had no effect on delayed alternation. These results indicate that the pdHP–PFC pathway is essential for working memory on the order of seconds in rats, and suggest that the pdHP and vHP pathways to the PFC play different behavioral roles.     

Analysis of Failed Spinal Cord Stimulation Trials in the Treatment of Intractable Chronic Pain

Objective

The purpose of this study is to identify the factors affecting the failure of trials (<50% pain reduction in pain for trial period) to improve success rate of spinal cord stimulation (SCS) trial.

Methods

A retrospective review of the failed trials (44 patients, 36.1%) among the patients (n=122) who underwent SCS trial between January 1990 and December 1998 was conducted. We reviewed the causes of failed trial stimulation, age, sex, etiology of pain, type of electrode, and third party support.

Results

Of the 44 patients, 65.9% showed unacceptable pain relief in spite of sufficient paresthesia on the pain area with trial stimulation. Four of six patients felt insufficient paresthesia with stimulation had the lesions of the spinal cord. Seventy five percent of the patients experienced unpleasant or painful sensation during stimulation had allodynia dominant pain. Third-party involvement, sex, age and electrode type had no influence on the outcome.

Conclusion

We conclude that SCS trial is less effective for patients with neuropathic pain of cord lesions, postherpetic neuropathy or post-amputation state. Further, patients with allodynia dominant pain can feel unpleasant or painful during trial stimulation.     

Nora's lesion. Clinical and therapeutic considerations

In this article we report a case of bizarre paraosteal osteochondromatous proliferation (BPOP), also known as Nora's lesion, arising on the distal phalanx of the fifth finger of the hand in a young-adult subject. In this paper, we discuss the possible therapeutic programme related to the grade of severity of the clinical features and underline the rarity of this lesion and the difficulty of diagnosis, which is exclusively histological.     

Tamoxifen effect on L-DOPA induced response complications in parkinsonian rats and primates

The contribution of striatal protein kinase C (PKC) isoform changes in levodopa (L-DOPA) induced motor response complications in parkinsonian rats was investigated and the ability of tamoxifen, an antiestrogen with a partial PKC antagonist property, to prevent these response alterations in 6-hydroxydopamine (6-OHDA) lesioned rats as well as in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) treated cynomologous monkeys was studied. Following treatment of adult male rats with L-DOPA twice daily for 3 weeks, protein levels of left (lesioned) and right (intact) striatal PKC isoforms were measured. Western blot analysis showed increased protein expression of both the novel PKC epsilon isoform and the atypical PKC lambda isoform ipsilateral to the lesion (174+/-17% for epsilon, 140+/-9% for lambda, of intact striatum in 6-OHDA lesioned plus chronic L-DOPA treated animals) in acute L-DOPA treated rats. No enhancement was observed in PKC immunoreactivity for other isoforms. Tamoxifen (5.0 mg/kg p.o.) significantly attenuated the L-DOPA induced augmentation of protein expression of PKC epsilon and PKC lambda, but had no effect on immunoreactivity for other PKC isoforms. In chronic L-DOPA treated parkinsonian rats, tamoxifen prevented (5.0 mg/kg p.o.) as well as ameliorated (5.0 mg/kg p.o.) the characteristic shortening in duration of motor response to L-DOPA challenge. In MPTP lesioned primates, similar to the ameliorative effect seen in rats, tamoxifen (1 and 3 mg/kg p.o) reduced the appearance of L-DOPA induced dyskinesia by 61% and 55% respectively (p<0.05). These results suggest that changes in specific striatal PKC isoforms contribute to the pathogenesis of L-DOPA induced motor complications and further that drugs able to selectively inhibit these signaling kinases might provide adjunctive benefit in the treatment of Parkinson's disease.