Intracarotid amobarbital procedure: II. Lateralizing value in evaluation for temporal lobectomy

The intracarotid amobarbital procedure (IAP) was assessed for lateralizing value in 37 patients who later had temporal lobectomy for intractable epilepsy. Among patients who failed IAP memory testing on one side (defined as a retention score for test items at least 20% lower on one side than the other), significantly more patients failed the injection contralateral (16 of 20, 80%) than ipsilateral (4 of 20, 20%) to the side of later resection (p = 0.008). In addition, preoperative EEG evidence of bilateral temporal epileptogenicity was significantly more frequent among patients who failed the ipsilateral IAP injection (2 of 4, 50%) than among patients who passed the ipsilateral IAP injection (2 of 33, 6%) (p = 0.050). Finally, failure of the contralateral IAP injection involved significantly more severe amnesia for test items (median retention score 25%) than did failure of the ipsilateral injection (median retention score 59%) (p = 0.047). Profoundly low retention scores less than 33% occurred only with contralateral injection. These findings suggest that the IAP has some adjunctive lateralizing value for the epileptogenic hemisphere in patients with temporal lobe epilepsy, especially when the retention score with one injection is profoundly low.

Biochemical and behavioral characterization of a novel cholinergic agonist, SR 95639

Selective M1 cholinergic agonists may be useful in treating dementias due to cholinergic hypofunction. SR 95639 has recently been described as such a compound. We found the compound to have affinity for M1 sites (Ki = 2.1 microM) which was approximately 3-fold higher than its affinity for M2 sites. Functional partial agonism was suggested by an inconsistent increase in phosphoinositide (PI) turnover in rat hippocampal slices, combined with blockade of carbachol-stimulated PI turnover. In vivo M2-mediated effects were absent. Scopolamine-induced hyperactivity was attenuated by SR 95639 and scopolamine-impaired inhibitory avoidance and radial maze performance were improved. The compound appears to be a weakly selective M1 partial agonist with potential advantages over existing compounds.

Factitious anisocoria and orthostatic hypotension

A 30-year-old woman employed by a veterinarian had many episodes of syncope. At presentation, she had anisocoria and premature ventricular beats. Hemodynamic workup revealed only moderate peripheral venous pooling. The circumstances of the fainting spells and eye examination led to the identification of medications which, if taken surreptitiously, will induce the perplexing clinical picture which the patient presented.

Outcome of psychogenic seizures in children and adolescents compared with adults

We compared outcome of psychogenic seizures documented by video-EEG in 18 nonepileptic children and adolescents (ages 8 to 18; median, 14.5 years old) and 20 adults (ages 25 to 56; median, 34.0 years old). Outcome was significantly better for the younger patients at 1 year, 2 years, and 3 years after diagnosis. At these follow-up times, the percentages of children and adolescents free of psychogenic attacks were 73%, 75%, and 81%; at the same follow-up times, the percentages of adults free of psychogenic attacks were only 25%, 25%, and 40%. Factors leading to better outcome for younger patients may have been different psychological mechanisms at different ages of onset and greater effectiveness with earlier intervention.

Psychogenic seizures in children and adolescents: outcome after diagnosis by ictal video and electroencephalographic recording

Psychogenic seizures in 21 nonepileptic children and adolescents, aged 8 to 18 (mean 14.5) years, were recorded by means of video recording and electroencephalography. The episodes included thrashing movements, limb jerking, or staring, with unresponsiveness. Ictal and interictal electroencephalograms showed no abnormalities after antiepileptic medication was discontinued. Fifteen patients had psychogenic seizures spontaneously during recording, and six had seizures in response to suggestion and intravenous saline injection. After the video-electroencephalographic evaluation, patients and families were told that the episodes were emotional in origin. All patients but 1 agreed to remain without antiepileptic medication, and 16 patients (76%) agreed to begin psychiatric treatment. At 6 to 66 (mean 30) months' follow-up, 14 of 18 (78%) were free of episodes. These data indicate that the majority of young patients with psychogenic seizures have a good outcome. A firm diagnosis is critical so that the episodes can be classified and emphasized as medically not worrisome, permitting a shift away from antiepileptic medication and toward psychiatric treatment.

Intracarotid amobarbital (Wada) test for language dominance: correlation with results of cortical stimulation

Eighty-eight patients had bilateral intracarotid amobarbital (Wada) testing to determine hemispheric dominance for language in preparation for epilepsy surgery, as well as unilateral extraoperative cortical electrical stimulation using subdural electrode arrays. In none of the patients with left dominance by Wada testing were language areas found with right-sided stimulation, but two patients with right dominance by Wada testing had language areas mapped on the left side. These findings suggest that left dominance by Wada testing is strong evidence for exclusive lateralization of language function in the left hemisphere, but there is concern about the ability of the Wada test to exclude the possibility of some left-sided language function despite apparent right-sided dominance. Patients with left dominance on Wada testing do not need cortical stimulation before extensive right temporal lobectomy, but we believe that patients with right or bilateral dominance on Wada testing should have cortical stimulation for localization of language areas if extensive left or right temporal or frontal resection is planned.

Speech manifestations in lateralization of temporal lobe seizures

To evaluate the role of speech manifestations in lateralization of temporal lobe seizures, we reviewed videotapes of 100 complex partial seizures in 35 patients who underwent temporal lobectomy for intractable epilepsy. All patients had prolonged electroencephalographic video monitoring with scalp and subdural electrodes, and their speech dominance was determined with an intracarotid amobarbital test. Speech manifestations were observed in 79 seizures and were classified as vocalization, normal speech, or abnormal speech. Vocalization of sounds without speech quality occurred ictally in 48.5% of patients. Normal speech (identifiable speech) occurred ictally in 34.2% of patients. Abnormal speech (speech arrest, dysphasia, dysarthria, and nonidentifiable speech) occurred in 51.4% of patients, either ictally or postictally. Of all the above speech manifestations, only postictal dysphasia and ictal identifiable speech had significant lateralizing value: 92% of patients with postictal dysphasia had their seizures originating from the dominant temporal lobe (p less than 0.001), and 83% of those with ictal identifiable speech had their seizures from the nondominant side (p = 0.013). This study shows that speech manifestations are common in complex partial seizures of temporal lobe origin and can provide an excellent clinical tool for lateralization of seizure onset.

The patient-analyst match and the outcome of psychoanalysis: a pilot study

This paper presents a pilot study in which we explore the possibility that the match between analyst and analysand is a factor of central importance in the analytic situation. It is an attempt to look at the issue of match across a large number of patients. The data we used were not collected for studying this topic; thus, the study has serious limitations. Nevertheless, certain patterns emerged which support our thesis that patient-analyst match plays a significant role in the outcome of psychoanalysis. We present this work as a first step in developing concepts and methods which will be pursued in a more systematic and rigorous fashion in a later study.

The dexamethasone suppression test in relation to symptomatology: preliminary findings controlling for serum dexamethasone concentrations

A diagnostically heterogeneous sample of psychiatric inpatients (n = 52) was administered the 1 mg dexamethasone suppression test (DST) shortly after hospital admission. Each was also assessed using the Hamilton Rating Scale for Depression (HRSD) and selected items of the Present State Examination (PSE) representing psychomotor retardation and anxiety. A potent determinant of postdexamethasone serum cortisol concentrations was found to be the level of serum dexamethasone concentration achieved following the oral dose. No relationship was found between postdexamethasone cortisol concentration and the scores on either the HRSD or an anxiety scale derived from selected PSE items. However, symptoms of psychomotor retardation were significantly related to postdexamethasone serum cortisol concentration, particularly when the serum dexamethasone concentrations were taken into account. It may be that DST nonsuppression in psychiatric patients is in part a reflection of the presence of psychomotor retardation, a phenomenon that cuts across diagnostic categories.

Reflections on Lacan: his origins in Descartes and Freud

Appreciation of Descartes' importance to Lacan's reading of Freud is a point of entry into Lacan's seemingly hermetic theoretical system. Lacan's analysis of Descartes' search for ontological certainty draws him, in Freud, to the ontological implications of castration anxiety, disavowal, and splitting of the ego. Lacan's theory both derives from and develops Freud's late work on the narcissistic origins of conflict within the ego.

Treatment of postmenopausal hyperparathyroidism with norethindrone. Effects on biochemistry and forearm mineral density

The effects of norethindrone (5 mg daily) on biochemical variables and forearm mineral density were assessed in 20 postmenopausal women with mild primary hyperparathyroidism. Norethindrone produced a significant fall in plasma calcium levels and the fasting urinary calcium-creatinine and hydroxyproline-creatinine ratios after three months of treatment. There was no change in the plasma parathyroid hormone concentrations. The forearm mineral density before treatment was low in 16 of the 20 patients and there was a significant increase in forearm mineral density after norethindrone treatment. No side effects were reported. We conclude that norethindrone is an effective treatment for mild hyperparathyroidism in postmenopausal women.

The source of 'paradoxical lateralization' of cortical evoked potentials to posterior tibial nerve stimulation

We report the potentials elicited by posterior tibial nerve stimulation and recorded simultaneously from the scalp and from electrodes within the interhemispheric fissure. The primary cortical potential was recorded from cortex contralateral but from scalp ipsilateral to the stimulated nerve. The scalp recordings thus demonstrated "paradoxical lateralization" as reported previously, and the similar morphology of the scalp and contralateral cortical recordings confirm that this "paradoxical lateralization" is most likely the result of a horizontal dipole located within the interhemispheric fissure.

Transitional object use and borderline psychopathology

The authors examined whether transitional object use distinguishes borderline patients from patients with other personality disorders or schizophrenia and from normal subjects. One hundred five subjects were given a structured interview to assess present and past transitional object use. The borderline group had the highest scores on the interview, and the group with nonborderline axis II diagnoses the lowest. Although transitional object use was not specific to the borderline diagnosis, it did emerge as a potentially useful developmental and psychodynamic marker for borderline persons.

The effect of serum dexamethasone concentrations in the dexamethasone suppression test

Serum dexamethasone and cortisol concentrations were measured in a sample of 98 psychiatric inpatients during the course of the 1-mg oral overnight Dexamethasone Suppression Test (DST). Suppressors were found to have significantly higher serum dexamethasone concentrations than nonsuppressors at each time of sampling (8:00 AM, 4:00 PM, and 11:00 PM). There was a significant inverse curvilinear relationship between serum dexamethasone and cortisol concentrations at each sample time. Although serum dexamethasone concentration was a potent determinant of postdexamethasone serum cortisol concentration, there were still significantly higher serum concentrations of cortisol in patients with major depression compared with patients with other disorders when dexamethasone concentrations were statistically controlled. By taking serum dexamethasone concentrations into account in defining DST suppression status, a modest increase in diagnostic specificity was achieved, but no substantial change in sensitivity.

Basal temporal language area demonstrated by electrical stimulation

We report on a 38-year-old patient with intractable complex partial seizures originating in the dominant left medial temporal region. In the work-up for seizure surgery, arrays of subdural electrodes were placed, and electrical stimulation revealed marked language interference in a 2 X 2-cm area in the left basal temporal fusiform gyrus (3.5 to 5.5 cm posterior to the temporal tip). Complete receptive and expressive aphasia, inability to repeat, agraphia, and alexia were elicited, but visual memory was preserved, and no constructional apraxia was noted. Stimulation of the basal temporal gyrus at lower stimulus intensities produced a relatively selective and severe anomia.

Langerhans' cells, papillomaviruses and oesophageal carcinoma. A hypothesis

A hypothesis linking the concept of mucosal immune surveillance (Langerhans' cells and intra-epithelial lymphocytes) with recent evidence of human papillomavirus (HPV) infection of the oesophagus in a sequence of events which leads to squamous dysplasia and invasive carcinoma is presented. It is believed that the essential pathway to squamous carcinoma involves an aberration of the Langerhans' cell/lymphocyte network and its symbiotic relationship with squamous cells as a result of persistent HPV infection in the epithelium. Neoplastic transformation may occur when this 'at-risk' mucosa is exposed to one or several co-carcinogenic factors present in the environment. This hypothesis is supported by morphological changes present in acanthotic lesions of the oesophagus and by immunocytochemical evidence of HPV infection of the mucosa. In addition, this viewpoint offers a possible explanation for the regional variation of oesophageal carcinoma, the rising incidence of the disease, and the association with multifocal squamous carcinomas of the upper aerodigestive tract.

Lymphoid tissue of the normal fallopian tube--a form of mucosal-associated lymphoid tissue (MALT)?

Mucosal-associated lymphoid tissue (MALT) is a specialized form of peripheral lymphoid tissue which is found in mucosal surfaces directly or indirectly exposed to the environment. Using immunohistological labeling techniques and electron microscopy, we have explored the possibility that MALT exists in the normal fallopian tube. Immunohistological analysis has demonstrated a striking degree of uniformity in the phenotype of intraepithelial lymphocytes with a predominance of T-lymphocytes of T-cytotoxic/suppressor subtype. Occasional intraepithelial macrophages are also present, but B-cells, T-helper cells, and natural killer cells are absent or are rarely found in the epithelium. Electron microscopy has provided morphological evidence of an interaction between epithelial cells and intraepithelial lymphocytes. The opposing plasma membranes of these two cell types are arranged in the form of complex interdigitations and laminations. These striking arrangements substantially increase the total area of contact between the two cell types. We conclude that MALT does exist in the fallopian tube and that epithelial cells form an integral part of the system. A hypothetical view of the relationship between these cell types is presented.

Dexamethasone concentrations and the dexamethasone suppression test in psychiatric disorders

The dexamethasone suppression test (DST) has been widely used in psychiatry as a laboratory aid for the diagnosis of endogenous depression; failure to suppress serum cortisol levels is interpreted as confirming a clinical diagnosis of endogenous depression. We found that serum dexamethasone concentrations in this test vary widely and are determinants of the DST response: non-suppression of serum cortisol levels is associated with low serum dexamethasone concentrations, and suppression is associated with high concentrations.

Competitive solid-phase enzyme immunoassay for measuring digoxin in serum

In this clinically useful enzyme immunoassay of digoxin in serum, we mix sample, beta-galactosidase-labeled digoxin, and anti-digoxin Fab fragments for 30 min at room temperature, then use Sepharose-bound second antibody for phase separation, and measure the unbound enzyme activity directly in the supernate of the equilibrium reaction mixture. The immunoassay buffer--phosphate-buffered isotonic saline with added rabbit globulin (4 g/L), hydrolyzed gelatin (2 g/L), Brij 96 detergent (5 g/L), glycerol (0.25 mol/L), and N-acetyl-8-anilinonaphthalene-1-sulfonic acid (2 mmol/L)--minimizes serum matrix effects for convenient measuring of unbound enzyme--digoxin conjugate. The immunoassay developed with Fab fragments has better displacement characteristics than that with intact antibody. Performance of the assay compares favorably with that of other manual digoxin immunoassays; in comparison studies with EMIT involving 110 clinical specimens, the coefficient of correlation was 0.97.

Competitive solid-phase enzyme immunoassay for measuring digoxin in serum

In this clinically useful enzyme immunoassay of digoxin in serum, we mix sample, beta-galactosidase-labeled digoxin, and anti-digoxin Fab fragments for 30 min at room temperature, then use Sepharose-bound second antibody for phase separation, and measure the unbound enzyme activity directly in the supernate of the equilibrium reaction mixture. The immunoassay buffer--phosphate-buffered isotonic saline with added rabbit globulin (4 g/L), hydrolyzed gelatin (2 g/L), Brij 96 detergent (5 g/L), glycerol (0.25 mol/L), and N-acetyl-8-anilinonaphthalene-1-sulfonic acid (2 mmol/L)--minimizes serum matrix effects for convenient measuring of unbound enzyme--digoxin conjugate. The immunoassay developed with Fab fragments has better displacement characteristics than that with intact antibody. Performance of the assay compares favorably with that of other manual digoxin immunoassays; in comparison studies with EMIT involving 110 clinical specimens, the coefficient of correlation was 0.97.

Endometrial lymphoid tissue: an immunohistological study

Lymphoid tissue of the endometrium was analysed by histological, immunohistological, and electron microscopical methods in 10 healthy uteri. A panel of monoclonal antibodies recognising macrophages (OKMI), HLA-DR antigen, B lymphocytes, T lymphocytes and their subsets, and dendritic reticulum cells was used in a two stage indirect immunoperoxidase labelling technique. Endometrial lymphoid tissue showed a remarkably consistent pattern of labelling in all cases. Lymphoid tissue was present in three sites: namely, (i) intraepithelial lymphocytes (predominantly T lymphocytes with occasional macrophages) associated with periglandular and sub-epithelial HLA-DR+, OKMI+ macrophages; (ii) interstitial lymphocytes and macrophages; (iii) lymphoid aggregates in the stratum basalis. These were composed mainly of T lymphocytes with a few B lymphocytes. Dendritic reticulum cells were found in those occasional lymphoid aggregates in which germinal centres were present. These features suggest that endometrial lymphoid tissue has many of the hallmarks of mucosal associated lymphoid tissue as found elsewhere in the body--for example, the bronchus and intestine. Endometrial lymphoid tissue appears to be unique, however, in that most of the stratum functionalis in which it is situated shows cyclical shedding during the menstrual cycle.