Electrophysiological evidence of persisting unilateral auditory cortex dysfunction in the late outcome of Landau and Kleffner syndrome

OBJECTIVES

In the late outcome of Landau and Kleffner syndrome (LKS), a childhood-acquired epileptic aphasia, most patients show after complete recovery of epilepsy a permanent one-ear extinction on dichotic listening tests contralateral to the temporal cortex previously affected by the epileptic focus. The pathophysiological significance of this dichotic extinction is not yet understood. It may be a consequence of a permanent dysfunction in the auditory system due to epileptic activity during the maturing period of the auditory system. Evoked potentials were used to check this hypothesis and to localize the level of the dysfunction along the auditory pathways.

METHODS

Early, middle latency and late auditory evoked potentials were recorded in 5 right-handed children having recovered from LKS. They were compared with those of 5 control children paired for age and gender.

RESULTS

In all 5 LKS patients, early and middle latency auditory evoked potentials were normal. But the amplitude of N1c (arising from associative auditory areas) was strongly reduced at temporal electrodes contralateral to the extinguished ear, whereas latency and amplitude of N1b (related to primary auditory areas) were in the normal range.

CONCLUSIONS

Unilateral voltage reduction of late auditory evoked potentials over the temporal areas previously involved by epileptic discharges suggests a permanent dysfunction in the associative auditory cortex, the behavioral expression of which is the unilateral dichotic extinction.

[The use of evidence-based medicine in psychotherapeutic medicine]

This review article gives an overview of the state of the art of evidence-based medicine (EBM) which is contrasted with some central aspects of current psychotherapy research. In the first part, three meanings of EBM are discussed: EBM as a regulative idea, EBM as a codified method and EBM as a sociopolitical movement; it follows an evaluation of the advantages and disadvantages of randomized controlled trials (RCT). In the second part, the discussions surrounding the meta-analysis of Grawe, the "Consumer Reports" study and the so-called "Empirically Supported Treatments" are touched upon briefly; it follows a discussion of the specific problems of using RCTs in psychotherapy research and of the suggestions for more naturalistic studies in this field.

Dominant partial epilepsies. A clinical, electrophysiological and genetic study of 19 European families

Nineteen families with autosomal dominant partial epilepsy were analysed clinically and electrophysiologically in detail. Seventy-one patients were studied as well as 33 non-epileptic at-risk family members. We subdivided the families into those with autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE) (n = 8), familial temporal lobe epilepsy (n = 7) and autosomal dominant partial epilepsy with variable foci (n = 4). However, the application of this nosology to certain families was difficult in cases of non-specific or conflicting clinical and electrophysiological evidence. This was underscored by the observation by depth electrode recordings in one patient that a so-called ADNFLE may originate in an extrafrontal area. The evolution of familial partial epilepsies, which exhibit great intrafamilial variability, is not always benign. The level of pharmacoresistance may reach 30%, close to that seen in classical cryptogenic partial epilepsies. The familial character of a partial epilepsy may be unrecognized in small families as some affected members may have only EEG abnormalities and are clinically asymptomatic, which reflects incomplete clinical penetrance. In view of the recent discoveries of mutations in the alpha4 nicotinic acetylcholine receptor subunit in a few families with ADNFLE, this genetic study focused on genes encoding nicotinic receptor subunits and a candidate region on chromosome 10q. No mutation was detected in the alpha4 and 012 nicotinic acetylcholine receptor subunits. Positive but not significant lod scores were obtained in four families with markers from the candidate region on chromosome 10q.

[Development of psychogenic disorders: an integrative model]

On the basis of clinical experience and empirically based data an integrative model of how psychogenic disorders develop is described in this article. The development-psychological steps of maturation from the uterine period to adolescence are examined with regard to the respective basic conflict to be derived from the step, and the disorder forms neurotization, structural disorder, and traumatisation are differentiated. Especially the process character of the respective development from the basic conflicts over the different coping strategies up to the symptom outbreak is emphasized.

[Brief report of working group OPD-CA (children and adolescents) Axis IV: structural standard]

Apart from the structural differentiation of the body and its functions, the enlargement of the child's repertoire of possibilities to make experiences and to act is a manifestation of the development of the child's psychic structure which, advancing in years, may be considered as a treasure of all the experiences one has made with oneself, with the world and with the others. Structure will develop along with the interactional experiences with the world around us and becomes manifest in one's behaviour which may be witnessed and observed. The description of the psychic structure comprises three dimensions (perception of the self and of the objects, control, communication and bonding) which will be described by certain capabilities and will be assessed with the help of an anchoring example typical for each age which serves the purpose of clinical illustration. The adaptational achievement may then be assessed on the basis of a structural standard independent of age and may be ranged on a structural level. It appears that the exemplary description of different scopes of tasks typically to be performed at certain ages which serves as a basis for the assessment of the adaptational competence during childhood and adolescence seems to be a good policy. The purpose of our studies is the development of a valid instrument which is easy to handle in practice and which has a high interrater-reliability.

Cerebral correlates of hemispheric lateralization during a pitch discrimination task: an ERP study in dichotic situation

OBJECTIVE

Electrophysiological correlates of perceptual asymmetry for dichotic pitch discrimination were investigated in 12 right-handed volunteers, whose dichotic listening performances attested the classical 'right ear advantage' in a verbal discrimination task.

METHODS

Event related potentials (ERPs), elicited by dichotic and binaural pairs of tones applied in a classical oddball paradigm including right ear targets, left ear targets and binaural targets (5% occurrence each) were recorded from medial and lateral scalp locations. Latencies and baseline to peak amplitudes were measured for P1, N1, P2, N2 and P3 components.

RESULTS

ERPs recorded in response to dichotic (compared with binaural) target pairs, exhibited delayed latencies for N2 and P3, correlated with prolonged RTs, probably linked to greater difficulty in identification of the target. They also displayed enhanced N1 and P2 voltages, which may reflect the simultaneous activation of two different populations of neurons in the auditory cortical areas. We observed specific lateralization effects for pitch discrimination with a left ear advantage on latency of early components.

CONCLUSIONS

Together with amplitude asymmetries in the N2 component, the findings bring strong electrophysiological support to Kimura's structural model for dichotic perceptions with a right hemisphere prevalence in a pitch discrimination task.

[Psychodynamic personality markers of psychotherapists in relation to therapy outcome]

In the Berlin psychotherapy study data were collected not only from the patients but also from the therapists. Thus, the influence of personality variables of the therapists on the multidimensionally registered therapy success could be studied. To this end a nonlinear k-sets canonical analysis was applied resulting in a sample-specific optimal scaling. The relationship pattern of the two sets of variables found was satisfactory as regards the internal criteria of the programme as well as its clinical meaningfulness. The results can be used in similar studies for specifying therapist-related hypotheses.

Chorea-acanthocytosis: genetic linkage to chromosome 9q21

Chorea-acanthocytosis (CHAC) is a rare autosomal recessive disorder characterized by progressive neurodegeneration and unusual red-cell morphology (acanthocytosis), with onset in the third to fifth decade of life. Neurological impairment with acanthocytosis (neuroacanthocytosis) also is seen in abetalipoproteinemia and X-linked McLeod syndrome. Whereas the molecular etiology of McLeod syndrome has been defined (Ho et al. 1994), that of CHAC is still unknown. In the absence of cytogenetic rearrangements, we initiated a genomewide scan for linkage in 11 families, segregating for CHAC, who are of diverse geographical origin. We report here that the disease is linked, in all families, to a 6-cM region of chromosome 9q21 that is flanked by the recombinant markers GATA89a11 and D9S1843. A maximum two-point LOD score of 7.1 (theta = .00) for D9S1867 was achieved, and the linked region has been confirmed by homozygosity-by-descent, in offspring from inbred families. These findings provide strong evidence for the involvement of a single locus for CHAC and are the first step in positional cloning of the disease gene.

Therapeutic alliance and transference: an exploratory study of their empirical relationship

Transference and the formation of a therapeutic alliance were studied in 126 patients from the Berlin psychotherapy project. The working hypothesis was that the internalized mother and father image would have an influence on the therapeutic alliance. The therapist rated the development of the therapeutic alliance at two points in time. When the parents' images and the therapist image were compared by using difference and similarity measures, four mother and four father types could be constructed of which some showed significant differences in the formation of therapeutic alliance. The introduction and the discussion are focused on the question as to what extent the psychoanalytic assumptions of transference can be useful in empirical therapy research for the construction of new variables and the explanation of social interactions between the two partners.

Induction of interferon regulatory factors 2'-5' oligoadenylate synthetase, P68 kinase and RNase L in chronic myelogenous leukaemia cells and its relationship to clinical responsiveness

The genes crucially determining the therapeutic response of chronic myelogenous leukaemia (CML) to interferon-alpha (IFN-alpha) are unknown. Recently, two independent IFN-alpha signalling pathways were identified: the classic pathway mediates induction of 2'-5' oligoadenylate synthetase (2-5 OAS), p68 kinase and IFN regulatory factor-2 (IRF-2), whereas the alternate pathway leads to activation of IFN regulatory factor-1 (IRF-1). We investigated whether deficient or imbalanced expression of components of these two pathways is associated with resistance of CML cells to antiproliferative action of IFN alpha/beta. Constitutive and IFN-induced transcript levels of IFN-dependent genes in mononuclear cells, granulocytes, monocytes, lymphocytes and CD34+ cells of chronic-phase CML and blast crisis patients were assessed by Northern blot techniques and were correlated with subsequent clinical responses to IFN therapy. Our results demonstrated that IFN-alpha or -beta treatment in vitro and in vivo leads to an enhanced expression of IRF-1, IRF-2. RNase L, p68 and 2-5 OAS which was independent of the degree of cellular differentiation and clonal evolution of CML. Neither the magnitude of induction of these genes nor the IRF-1/IRF-2 mRNA balance differed between chronic-phase CML patients responding or failing IFN-alpha therapy. These results indicate that failure of IFN-alpha treatment is not due to defects in mRNA induction of the above-mentioned candidate genes for the direct antiproliferative response to IFN type I.

DNA fragmentation and immediate early gene expression in rat striatum following quinolinic acid administration

Excitotoxic cell death is hypothesized to contribute to numerous neuropathologic conditions, including hypoxic/ischemic encephalopathy, hypoglycemia, Parkinson's disease, and Huntington's disease. Neuronal death from excitotoxic lesions has been shown to be an active process, with activation of immediate early gene transcription, resulting in secondary changes in gene expression. Another feature of neurotoxic cell death that has been examined is the presence of DNA fragmentation, which presumably indicates impending nuclear disintegration. A technique has been described for labeling fragmented DNA in situ, allowing precise determination of the anatomic and temporal distribution of neurons after an excitotoxic lesion. To investigate this phenomenon, we performed in situ nick translation on brain tissue from rats that have undergone stereotaxically placed intrastriatal quinolinic acid injections. Furthermore, in these same animals we analyzed the expression of c-fos mRNA to compare the time course and regional distribution of DNA fragmentation with immediate early gene activation after an excitotoxic lesion. Our analysis indicates that c-fos expression increases soon after quinolinic acid injection, is widespread in rat brain, but is effectively absent by 24 h postinjection. DNA fragmentation, however, is limited to striatum and is maximal at 24 h after injection. These results demonstrate the sensitivity of in situ nick translation for the detection of regional neuropathology and illustrate the temporal and spatial relationship of c-fos expression to excitotoxic neuronal death.

[Development of a model of operational psychodynamic diagnosis]

Since 1992 a working group called "Operationalized Psychodynamic diagnoses" conceptualized a model of operationalized psychodynamic diagnosis in Germany. This model includes the most important diagnostic dimensions from psychodynamic view which are: Axis I: Experience with illness and treatment preconditions. Axis II: Habituated relationships of the patient, Axis III: Intrapsychic conflicts of the patient, Axis IV: the structure of personality development of the patient, Axis V: The level of symptoms or syndromes. This axis is adapted to ICD-10. The development of these axis is done in special subgroups during 1992 and 1994 and in first empirical studies the reliability and other test-related dimensions of the model were proved. In this paper the essentials of the diagnostic model are shown and further developments are discussed.

[Methodological and statistical aspects of therapy evaluation exemplified by the Berlin psychotherapy study]

The answer to the question concerning the efficacy of psychotherapy is increasingly sought metaanalytically. For this purpose almost exclusively investigations are taken into consideration which have at least one control group. Using realistic data, the present paper refers to some basic considerations for the investigation and evaluation of therapeutic changes, which are however not always satisfyingly solved in metaanalytical studies. Investigations, therefore, especially of naturalistic samples, such as may be found in the context of outpatient or inpatient routine care, have a high clinical relevance for the evaluation of therapeutic changes even if they do not satisfy experimental requirements/standards. However, they do supplement experimental studies where the important aspect of external validity is concerned.

Divergent in vivo and in vitro antileukemic activity of recombinant interferon beta in patients with chronic-phase chronic myelogenous leukemia

It was the aim of this study to investigate the antileukemic activities of recombinant interferon beta (rIFN beta) in chronic-phase CML in vitro and in vivo. Nine patients in the early chronic-phase of CML were treated in a phase-II trial with escalating doses of rIFN beta. In parallel, antiproliferative and immunomodulatory activities of rIFN beta and rIFN alpha 2b were studied in vitro. rIFN beta exhibited a significantly higher antiproliferative activity on hematopoietic progenitor cells of CML patients in vitro than rIFN alpha 2b. In contrast, only very limited clinical antileukemic efficacy of rIFN beta was observed. None of the patients achieved a complete or partial hematologic response (0% response rate, 0-36% 95 C.I.). Primary resistance of CML patients to rIFN beta treatment was caused neither by antibody formation against the recombinant material nor by deficient IFN receptor targeting and/or signaling; Induction of serum levels of beta-2-microglobulin (beta-2-m) and neopterin after administration of rIFN beta was comparable to that seen after administration of rIFN alpha. However, rIFN beta treatment less effectively induced biosynthesis of interleukin-1 receptor antagonist protein (IL-1-Ra) than rIFN alpha 2b. Thus, we conclude that rIFN beta at doses up to 12 MU/day s.c. is ineffective for treatment of chronic-phase CML. Further investigations into divergent biologic responses to various type-I interferons might help to elucidate mechanisms crucial for IFN action in patients with CML.

Type-I interferons are potent inhibitors of interleukin-8 production in hematopoietic and bone marrow stromal cells

Interleukin-8 (IL-8) is produced by many cell types upon stimulation with bacterial products or inflammation-associated cytokines such as tumor necrosis factor-alpha and IL-1. Interferons (IFNs) represent another group of cytokines that are induced by similar stimuli in inflammatory reactions. We show now that type-I IFNs are potent inhibitors of IL-8 expression in vitro and in vivo. A significant reduction of both secretion of IL-8 protein and accumulation of IL-8 mRNA in vitro was observed in several cell types comprising peripheral blood mononuclear cells (PBMNC) from healthy donors and from patients with chronic myelogenous leukemia (CML), the myelomonocytic cell line THP-1, and bone marrow (BM) stromal cells as a representative model for BM microenvironment. By contrast, in lipopolysaccharide-stimulated polymorphonuclear phagocytes IFN failed to suppress IL-8 expression. In untreated patients with CML, a constitutive expression of IL-8 mRNA was detected in freshly isolated PBMNC that was markedly reduced 5 hours after therapeutic application of IFN-alpha. The mechanism of IL-8 downregulation was studied more in detail in the THP-1 cell line. The experiments showed that de novo protein synthesis was not required for the inhibitory effect. RNA decay analysis and nuclear run-on assays suggest that in THP-1 cell line the inhibition of IL-8 expression is predominantly regulated at the posttranscriptional level.

[The prognostic significance of the therapeutic working alliance from the perspective of the patient and therapist]

In general, the prognostic relevance of a working alliance for both the course and the outcome of psychotherapy is no longer a matter of dispute. Since a working alliance is conceived as an interactional variable, the results must be interpreted on the basis of several important dimensions: the perspective of the investigator and the time structure during the course of therapy. Using the data available from the Berlin Psychotherapy Study (Rudolf 1991), we investigated for the 238 patients (inpatients and outpatients who received psychoanalytically oriented therapy in the study) the prognostic relevance of diagnostic and therapy-related working alliance variables for the various outcomes investigated. A complex correlation-statistical method (latent-trait-model) was used to consider the investigator perspective with regard to the working alliance and the outcome as well as the time structure and the diagnostic variables. Our results emphasize the relevance of the therapist's perspective beginning with the diagnostic indication, the working alliance and finally the outcome. The patient's perspective, however, seems to be less relevant. The results are presented and discussed in relation to the relevant literature. One result we have found as a further important dimension is that the kind of therapy carried out must be taken into consideration. This implies that as in our study for all phases of the investigation therapy specific instruments must be applied. In this regard our results also contribute to the validation of the instrument used to measure the working alliance TAB.

Acute blockade of dopamine receptors with haloperidol: a retinal model to study impairments of dopaminergic transmission

A pulse of dopamine produces a transient dose-correlated increase in the transepithelial potential (TEP) of the chicken eye, mimicking the light-induced response, the light peak (LP). Acute blockade of retinal dopaminergic transmission with haloperidol, a mixed antagonist, produced a dose-correlated TEP voltage decrease which was rapidly reversed by intravitreal injection of dopamine. The LP recorded thereafter was strongly reduced. These data confirm the hypothesis that dopamine released by light from amacrine cells triggers light-induced changes in the TEP of the intact chicken eye, and that these potentials could well provide an electrophysiological tool to evaluate retinal dopaminergic deficiency.

Dopamine and melatonin interactions in the intact chicken eye. Electrooculographic and biochemical study

Electrophysiological and biochemical techniques were used to investigate the interactions between dopamine (DA) and melatonin (MEL) in the intact chicken eye. Endogenous DA depletion induced by intraocular administration of alpha-methyl-para-tyrosine (alpha-MPT), a selective tyrosine hydroxylase inhibitor, decreases the transepithelial potential (TEP) of the retinal pigment epithelium and reduces the light peak (LP) recorded by an indirect electro-oculographic (EOG) method. An intraocular injection of MEL also reduces the TEP but does not reduce the LP. Retinal MEL is increased after endogenous DA depletion and a tight inverse correlation between DA and MEL contents was found. The present data, together with other findings support the hypothesis (1) that in the intact chicken eye, DA and MEL play respectively a role of light and dark signals on the TEP, and (2) that a balance between these two neurohormones may be responsible for the regulation of RPE events which are dependent on light-dark conditions.