Corticospinal and corticoreticulospinal projections benefit motor behaviors in chronic stroke

After corticospinal tract (CST) stroke, several motor deficits in the upper extremity (UE) emerge, including diminished muscle strength, motor control, and muscle individuation. Both the ipsilesional CST and contralesional corticoreticulospinal tract (CReST) innervate the paretic UE and may have different innervation patterns for the proximal and distal UE segments. These patterns may underpin distinct pathway relationships to separable motor behaviors. In this cross-sectional study of 15 chronic stroke patients and 28 healthy subjects, we examined two key questions: (1) whether segmental motor behaviors differentially relate to ipsilesional CST and contralesional CReST projection strengths, and (2) whether motor behaviors segmentally differ in the paretic UE. We measured strength, motor control, and muscle individuation in a proximal (biceps, BIC) and distal muscle (first dorsal interosseous, FDI) of the paretic UE. We measured the projection strengths of the ipsilesional CST and contralesional CReST to these muscles using transcranial magnetic stimulation (TMS). Stroke subjects had abnormal motor control and muscle individuation despite strength comparable to healthy subjects. In stroke subjects, stronger ipsilesional CST projections were linked to superior motor control in both UE segments, whereas stronger contralesional CReST projections were linked to superior muscle strength and individuation in both UE segments. Notably, both pathways also shared associations with behaviors in the proximal segment. Motor control deficits were segmentally comparable, but muscle individuation was worse for distal motor performance. These results suggest that each pathway has specialized contributions to chronic motor behaviors but also work together, with varying levels of success in supporting chronic deficits.

Key points summary

Individuals with chronic stroke typically have deficits in strength, motor control, and muscle individuation in their paretic upper extremity (UE). It remains unclear how these altered behaviors relate to descending motor pathways and whether they differ by proximal and distal UE segment.In this study, we used transcranial magnetic stimulation (TMS) to examine projection strengths of the ipsilesional corticospinal tract (CST) and contralesional corticoreticulospinal tract (CReST) with respect to quantitated motor behaviors in chronic stroke.We found that stronger ipsilesional CST projections were associated with better motor control in both UE segments, whereas stronger contralesional CReST projections were associated with better strength and individuation in both UE segments. In addition, projections of both pathways shared associations with motor behaviors in the proximal UE segment.We also found that deficits in strength and motor control were comparable across UE segments, but muscle individuation was worse with controlled movement in the distal UE segment.These results suggest that the CST and CReST have specialized contributions to chronic motor behaviors and also work together, although with different degrees of efficacy.

Using Wearable Sensors to Assess Freezing of Gait in the Real World

Freezing of gait (FOG) is a debilitating symptom of Parkinson's disease (PD) that remains difficult to assess. Wearable movement sensors and associated algorithms can be used to quantify FOG in laboratory settings, but the utility of such methods for real world use is unclear. We aimed to determine the suitability of our wearable sensor-based FOG assessment method for real world use by assessing its performance during in-clinic simulated real world activities. Accuracy of the sensor-based method during simulated real-world tasks was calculated using expert rated video as the gold standard. To determine feasibility for unsupervised home use, we also determined correlations between the percent of active time spent freezing (%ATSF) during unsupervised home use and in-clinic activities. Nineteen people with PD and FOG participated in this study. Results from our sensor-based method demonstrated an accuracy above 90% compared to gold-standard expert review during simulated real-world tasks. Additionally, %ATSF from our sensor-based method during unsupervised home use correlated strongly with %ATSF from our sensor-based method during in-clinic simulated real-world activities (ρ = 0.73). Accuracy values and correlation patterns suggest our method may be useful for FOG assessment in the real world.

Transductive Learning Models for Accurate Ambulatory Gait Analysis in Elderly Residents of Assisted Living Facilities

Instrumented footwear represents a promising technology for spatiotemporal gait analysis in out-of-the-lab conditions. However, moderate accuracy impacts this technology's ability to capture subtle, but clinically meaningful, changes in gait patterns that may indicate adverse outcomes or underlying neurological conditions. This limitation hampers the use of instrumented footwear to aid functional assessments and clinical decision making. This paper introduces new transductive-learning inference models that substantially reduce measurement errors relative to conventional data processing techniques, without requiring subject-specific labelled data. The proposed models use subject-optimized input features and hyperparameters to adjust the spatiotemporal gait metrics (i.e., stride time, length, and velocity, swing time, and double support time) obtained with conventional techniques, resulting in computationally simpler models compared to end-to-end machine learning approaches. Model validity and reliability were evaluated against a gold-standard electronic walkway during a clinical gait performance test (6-minute walk test) administered to N=95 senior residents of assisted living facilities with diverse levels of gait and balance impairments. Average reductions in absolute errors relative to conventional techniques were -42.0% and -33.5% for spatial and gait-phase parameters, respectively, indicating the potential of transductive learning models for improving the accuracy of instrumented footwear for ambulatory gait analysis.

Design of the WHIP-PD study: a phase II, twelve-month, dual-site, randomized controlled trial evaluating the effects of a cognitive-behavioral approach for promoting enhanced walking activity using mobile health technology in people with Parkinson-disease

Background

Parkinson disease (PD) is a debilitating and chronic neurodegenerative disease resulting in ambulation difficulties. Natural walking activity often declines early in disease progression despite the relative stability of motor impairments. In this study, we propose a paradigm shift with a “connected behavioral approach” that targets real-world walking using cognitive-behavioral training and mobile health (mHealth) technology.

Methods/design

The Walking and mHealth to Increase Participation in Parkinson Disease (WHIP-PD) study is a twelve-month, dual site, two-arm, randomized controlled trial recruiting 148 participants with early to mid-stage PD. Participants will be randomly assigned to connected behavioral or active control conditions. Both conditions will include a customized program of goal-oriented walking, walking-enhancing strengthening exercises, and eight in-person visits with a physical therapist. Participants in the connected behavioral condition also will (1) receive cognitive-behavioral training to promote self-efficacy for routine walking behavior and (2) use a mHealth software application to manage their program and communicate remotely with their physical therapist. Active control participants will receive no cognitive-behavioral training and manage their program on paper. Evaluations will occur at baseline, three-, six-, and twelve-months and include walking assessments, self-efficacy questionnaires, and seven days of activity monitoring. Primary outcomes will include the change between baseline and twelve months in overall amount of walking activity (mean number of steps per day) and amount of moderate intensity walking activity (mean number of minutes per day in which > 100 steps were accumulated). Secondary outcomes will include change in walking capacity as measured by the six-minute walk test and ten-meter walk test. We also will examine if self-efficacy mediates change in amount of walking activity and if change in amount of walking activity mediates change in walking capacity.

Discussion

We expect this study to show the connected behavioral approach will be more effective than the active control condition in increasing the amount and intensity of real-world walking activity and improving walking capacity. Determining effective physical activity interventions for persons with PD is important for preserving mobility and essential for maintaining quality of life. Clinical trials registration NCT03517371, May 7, 2018.

Trial registration

ClinicalTrials.gov: NCT03517371. Date of registration: May 7, 2018. Protocol version: Original.

Gait Cycle Validation and Segmentation Using Inertial Sensors

In this paper, we develop an algorithm to automatically validate and segment a gait cycle in real time into three gait events, namely midstance, toe-off, and heel-strike, using inertial sensors. We first use the physical models of sensor data obtained from a foot-mounted inertial system to differentiate stationary and moving segments of the sensor data. Next, we develop an optimization routine called sparsity-assisted wavelet denoising (SAWD), which simultaneously combines linear time invariant filters, orthogonal multiresolution representations such as wavelets, and sparsity-based methods, to generate a sparse template of the moving segments of the gyroscope measurements in the sagittal plane for valid gait cycles. Thereafter, to validate any moving segment as a gait cycle, we compute the root-mean-square error between the generated sparse template and the sparse representation of the moving segment of the gyroscope data in the sagittal plane obtained using SAWD. Finally, we find the local minima for the stationary and moving segments of a valid gait cycle to detect the gait events. We compare our proposed method with existing methods, for a fixed threshold, using real data obtained from three groups, namely controls, participants with Parkinson disease, and geriatric participants. Our proposed method demonstrates an average F1 score of 87.78% across all groups for a fixed sampling rate, and an average F1 score of 92.44% across all Parkinson disease participants for a variable sampling rate.

Predicting Cognitive Improvement in Normal Pressure Hydrocephalus Patients Using Preoperative Neuropsychological Testing and Cerebrospinal Fluid Biomarkers

BACKGROUND

Though it is well known that normal pressure hydrocephalus (NPH) patients can cognitively improve after ventriculoperitoneal shunting (VPS), one of the major dilemmas in NPH is the ability to prospectively predict which patients will improve.

OBJECTIVE

To prospectively assess preoperative predictors of postshunt cognitive improvement.

METHODS

This was a prospective observational cohort including 52 consecutive patients with approximately 1-yr follow-up. Patients underwent neuropsychological testing at baseline, postlumbar drainage, and postshunt. Cerebrospinal fluid (CSF) biomarkers and cortical biopsies were also collected to examine their relationship with postshunt cognitive improvement.

RESULTS

Rey Auditory Verbal Learning Test-L (RAVLT-L) was the only neuropsychological test to demonstrate statistically significant improvement both postlumbar drain and postshunt. Improvement on the RAVLT-L postlumbar drain predicted improvement on the RAVLT-L postshunt. Patients with biopsies demonstrating Aβ+ Tau+ had lower ventricular CSF Aβ42 and higher lumbar CSF pTau compared to Aβ– Tau– patients. A receiver operating curve analysis using lumbar pTau predicted Aβ+ Tau+ biopsy status but was not related to neuropsychological test outcome.

CONCLUSION

The RAVLT can be a useful preoperative predictor of postoperative cognitive improvement, and thus, we recommend using the RAVLT to evaluate NPH patients. CSF biomarkers could not be related to neuropsychological test outcome. Future research in a larger patient sample will help determine the prospective utility of CSF biomarkers in the evaluation of NPH patients.

A Single, Continuously Applied Control Policy for Modeling Reaching Movements with and without Perturbation

It has been debated whether kinematic features, such as the number of peaks or decomposed submovements in a velocity profile, indicate the number of discrete motor impulses or result from a continuous control process. The debate is particularly relevant for tasks involving target perturbation, which can alter movement kinematics. To simulate such tasks, finite-horizon models require two preset movement durations to compute two control policies before and after the perturbation. Another model employs infinite- and finite-horizon formulations to determine, respectively, movement durations and control policies, which are updated every time step. We adopted an infinite-horizon optimal feedback control model that, unlike previous approaches, does not preset movement durations or use multiple control policies. It contains both control-dependent and independent noises in system dynamics, state-dependent and independent noises in sensory feedbacks, and different delays and noise levels for visual and proprioceptive feedbacks. We analytically derived an optimal solution that can be applied continuously to move an effector toward a target regardless of whether, when, or where the target jumps. This single policy produces different numbers of peaks and “submovements” in velocity profiles for different conditions and trials. Movements that are slower or perturbed later appear to have more submovements. The model is also consistent with the observation that subjects can perform the perturbation task even without detecting the target jump or seeing their hands during reaching. Finally, because the model incorporates Weber's law via a state representation relative to the target, it explains why initial and terminal visual feedback are, respectively, less and more effective in improving end-point accuracy. Our work suggests that the number of peaks or submovements in a velocity profile does not necessarily reflect the number of motor impulses and that the difference between initial and terminal feedback does not necessarily imply a transition between open- and closed-loop strategies.

DYT1 dystonia increases risk taking in humans

It has been difficult to link synaptic modification to overt behavioral changes. Rodent models of DYT1 dystonia, a motor disorder caused by a single gene mutation, demonstrate increased long-term potentiation and decreased long-term depression in corticostriatal synapses. Computationally, such asymmetric learning predicts risk taking in probabilistic tasks. Here we demonstrate abnormal risk taking in DYT1 dystonia patients, which is correlated with disease severity, thereby supporting striatal plasticity in shaping choice behavior in humans.

DOI:http://dx.doi.org/10.7554/eLife.14155.001

We learn to choose better options and avoid worse ones through trial and error, but exactly how this happens is still unclear. One idea is that we learn 'values' for options: whenever we choose an option and get more reward than originally expected (for example, if an unappetizing-looking food turns out to be very tasty), the value of that option increases. Likewise, if we get less reward than expected, the chosen option’s value decreases.

This learning process is hypothesized to work via the strengthening and weakening of connections between neurons in two parts of the brain: the cortex and the striatum. In this model, the activity of the neurons in the cortex represents the options, and the value of these options is represented by the activity of neurons in the striatum. Strengthening the connections is thought to increase the value of the stimulus, but this theory has been difficult to test.

In humans, a single genetic mutation causes a movement disorder called DYT1 dystonia, in which muscles contract involuntarily. In rodents, the same mutation causes the connections between the neurons in the cortex and the striatum to become too strong. If the theory about value learning is true, this strengthening should affect the decisions of patients that have DYT1 dystonia.

Arkadir et al. got healthy people and people with DYT1 dystonia to play a game where they had to choose between a 'sure' option and a 'risky' option. Picking the sure option guaranteed the player would receive a small amount of money, whereas the risky option gave either double this amount or nothing. The theory predicts that the double rewards should cause the patients to learn abnormally high values, which would lure them into making risky choices. Indeed, Arkadir et al. found that players with DYT1 dystonia were more likely to choose the risky option, with the people who had more severe symptoms of dystonia having a greater tendency towards taking risks.

Arkadir et al. showed that these results correspond with a model that suggests that people with DYT1 dystonia learn excessively from unexpected wins but show weakened learning after losses, causing them to over-estimate the value of risky choices. This imbalance mirrors the previous results that showed an inappropriate strengthening of the connections between neurons in rodents, and so suggests that similar changes occur in the brains of humans. Thus it appears that the changes in the strength of the connections between neurons translate into changes in behavior.

This pattern of results might also mean that the movement problems seen in people with DYT1 dystonia may be because they over-learn movements that previously led to a desired outcome and cannot sufficiently suppress movements that are no longer useful. Testing this idea will require further experiments.

DOI:http://dx.doi.org/10.7554/eLife.14155.002

Motor fluctuations due to interaction between dietary protein and levodopa in Parkinson's disease

Background

The modulation of levodopa transport across the blood brain barrier by large neutral amino acids is well documented. Protein limitation and protein redistribution diets may improve motor fluctuations in patients with Parkinson’s disease but the pharmacokinetics and pharmacodynamics of levodopa and amino acids are highly variable.

Methods

Clinical records of 1037 Parkinson’s disease patients were analyzed to determine the proportion of patients with motor fluctuations related to protein interaction with levodopa. Motor fluctuations due to protein interaction with levodopa were defined as dietary protein being associated with (i) longer time to levodopa effectiveness, (ii) reduced benefit or duration of benefit, (iii) dose failures or (iv) earlier wearing off from a previously effective dose. Dose failures, sudden, painful or behavioral wearing-off periods, gait freezing, nausea, hallucinations, orthostasis, and dyskinesias were taken as markers of motor fluctuations, disease severity, and levodopa side effects potentially influenced by protein.

Results

5.9 % of Parkinson’s disease patients on levodopa, and 12.4 % with motor fluctuations on levodopa correlated their fluctuations with the relative timing of levodopa and protein intake. These patients were younger at disease onset, had worse motor fluctuations and had a higher incidence of family members with Parkinson’s disease. Early wearing off or decreased dose efficacy were most commonly associated with protein interaction. 60 % of patients who modified their diets had weight loss.

Conclusions

This study suggests that clinically significant protein interaction with levodopa may occur mostly in a subset of Parkinson’s disease patients with earlier disease onset and those with familial disease.

Robotic therapy for chronic stroke: general recovery of impairment or improved task-specific skill?

There is a great need to develop new approaches for rehabilitation of the upper limb after stroke. Robotic therapy is a promising form of neurorehabilitation that can be delivered in higher doses than conventional therapy. Here we sought to determine whether the reported effects of robotic therapy, which have been based on clinical measures of impairment and function, are accompanied by improved motor control. Patients with chronic hemiparesis were trained for 3 wk, 3 days a week, with titrated assistive robotic therapy in two and three dimensions. Motor control improvements (i.e., skill) in both arms were assessed with a separate untrained visually guided reaching task. We devised a novel PCA-based analysis of arm trajectories that is sensitive to changes in the quality of entire movement trajectories without needing to prespecify particular kinematic features. Robotic therapy led to skill improvements in the contralesional arm. These changes were not accompanied by changes in clinical measures of impairment or function. There are two possible interpretations of these results. One is that robotic therapy only leads to small task-specific improvements in motor control via normal skill-learning mechanisms. The other is that kinematic assays are more sensitive than clinical measures to a small general improvement in motor control.

Glucocerebrosidase activity in Parkinson's disease with and without GBA mutations

Glucocerebrosidase (GBA) mutations have been associated with Parkinson's disease in numerous studies. However, it is unknown whether the increased risk of Parkinson's disease in GBA carriers is due to a loss of glucocerebrosidase enzymatic activity. We measured glucocerebrosidase enzymatic activity in dried blood spots in patients with Parkinson's disease (n = 517) and controls (n = 252) with and without GBA mutations. Participants were recruited from Columbia University, New York, and fully sequenced for GBA mutations and genotyped for the LRRK2 G2019S mutation, the most common autosomal dominant mutation in the Ashkenazi Jewish population. Glucocerebrosidase enzymatic activity in dried blood spots was measured by a mass spectrometry-based assay and compared among participants categorized by GBA mutation status and Parkinson's disease diagnosis. Parkinson's disease patients were more likely than controls to carry the LRRK2 G2019S mutation (n = 39, 7.5% versus n = 2, 0.8%, P < 0.001) and GBA mutations or variants (seven homozygotes and compound heterozygotes and 81 heterozygotes, 17.0% versus 17 heterozygotes, 6.7%, P < 0.001). GBA homozygotes/compound heterozygotes had lower enzymatic activity than GBA heterozygotes (0.85 µmol/l/h versus 7.88 µmol/l/h, P < 0.001), and GBA heterozygotes had lower enzymatic activity than GBA and LRRK2 non-carriers (7.88 µmol/l/h versus 11.93 µmol/l/h, P < 0.001). Glucocerebrosidase activity was reduced in heterozygotes compared to non-carriers when each mutation was compared independently (N370S, P < 0.001; L444P, P < 0.001; 84GG, P = 0.003; R496H, P = 0.018) and also reduced in GBA variants associated with Parkinson's risk but not with Gaucher disease (E326K, P = 0.009; T369M, P < 0.001). When all patients with Parkinson's disease were considered, they had lower mean glucocerebrosidase enzymatic activity than controls (11.14 µmol/l/h versus 11.85 µmol/l/h, P = 0.011). Difference compared to controls persisted in patients with idiopathic Parkinson's disease (after exclusion of all GBA and LRRK2 carriers; 11.53 µmol/l/h, versus 12.11 µmol/l/h, P = 0.036) and after adjustment for age and gender (P = 0.012). Interestingly, LRRK2 G2019S carriers (n = 36), most of whom had Parkinson's disease, had higher enzymatic activity than non-carriers (13.69 µmol/l/h versus 11.93 µmol/l/h, P = 0.002). In patients with idiopathic Parkinson's, higher glucocerebrosidase enzymatic activity was associated with longer disease duration (P = 0.002) in adjusted models, suggesting a milder disease course. We conclude that lower glucocerebrosidase enzymatic activity is strongly associated with GBA mutations, and modestly with idiopathic Parkinson's disease. The association of lower glucocerebrosidase activity in both GBA mutation carriers and Parkinson's patients without GBA mutations suggests that loss of glucocerebrosidase function contributes to the pathogenesis of Parkinson's disease. High glucocerebrosidase enzymatic activity in LRRK2 G2019S carriers may reflect a distinct pathogenic mechanism. Taken together, these data suggest that glucocerebrosidase enzymatic activity could be a modifiable therapeutic target.

The neural correlates of learned motor acuity

We recently defined a component of motor skill learning as "motor acuity," quantified as a shift in the speed-accuracy trade-off function for a task. These shifts are primarily driven by reductions in movement variability. To determine the neural correlates of improvement in motor acuity, we devised a motor task compatible with magnetic resonance brain imaging that required subjects to make finely controlled wrist movements under visual guidance. Subjects were imaged on day 1 and day 5 while they performed this task and were trained outside the scanner on intervening days 2, 3, and 4. The potential confound of performance changes between days 1 and 5 was avoided by constraining movement time to a fixed duration. After training, subjects showed a marked increase in success rate and a reduction in trial-by-trial variability for the trained task but not for an untrained control task, without changes in mean trajectory. The decrease in variability for the trained task was associated with increased activation in contralateral primary motor and premotor cortical areas and in ipsilateral cerebellum. A global nonlocalizing multivariate analysis confirmed that learning was associated with increased overall brain activation. We suggest that motor acuity is acquired through increases in the number of neurons recruited in contralateral motor cortical areas and in ipsilateral cerebellum, which could reflect increased signal-to-noise ratio in motor output and improved state estimation for feedback corrections, respectively.

Learning fast accurate movements requires intact frontostriatal circuits

The basal ganglia are known to play a crucial role in movement execution, but their importance for motor skill learning remains unclear. Obstacles to our understanding include the lack of a universally accepted definition of motor skill learning (definition confound), and difficulties in distinguishing learning deficits from execution impairments (performance confound). We studied how healthy subjects and subjects with a basal ganglia disorder learn fast accurate reaching movements. We addressed the definition and performance confounds by: (1) focusing on an operationally defined core element of motor skill learning (speed-accuracy learning), and (2) using normal variation in initial performance to separate movement execution impairment from motor learning abnormalities. We measured motor skill learning as performance improvement in a reaching task with a speed-accuracy trade-off. We compared the performance of subjects with Huntington's disease (HD), a neurodegenerative basal ganglia disorder, to that of premanifest carriers of the HD mutation and of control subjects. The initial movements of HD subjects were less skilled (slower and/or less accurate) than those of control subjects. To factor out these differences in initial execution, we modeled the relationship between learning and baseline performance in control subjects. Subjects with HD exhibited a clear learning impairment that was not explained by differences in initial performance. These results support a role for the basal ganglia in both movement execution and motor skill learning.

Clinical characteristics of patients with spinocerebellar ataxias 1, 2, 3 and 6 in the US; a prospective observational study

Background

All spinocerebellar ataxias (SCAs) are rare diseases. SCA1, 2, 3 and 6 are the four most common SCAs, all caused by expanded polyglutamine-coding CAG repeats. Their pathomechanisms are becoming increasingly clear and well-designed clinical trials will be needed.

Methods

To characterize the clinical manifestations of spinocerebellar ataxia (SCA) 1, 2, 3 and 6 and their natural histories in the United States (US), we conducted a prospective multicenter study utilized a protocol identical to the European consortium study, using the Scale for the Assessment and Rating of Ataxia (SARA) score as the primary outcome, with follow-ups every 6 months up to 2 years.

Results

We enrolled 345 patients (60 SCA1, 75 SCA2, 138 SCA3 and 72 SCA6) at 12 US centers. SCA6 patients had a significantly later onset, and SCA2 patients showed greater upper-body ataxia than patients with the remaining SCAs. The annual increase of SARA score was greater in SCA1 patients (mean ± SE: 1.61 ± 0.41) than in SCA2 (0.71 ± 0.31), SCA3 (0.65 ± 0.24) and SCA6 (0.87 ± 0.28) patients (p = 0.049). The functional stage also worsened faster in SCA1 than in SCA2, 3 and 6 (p = 0.002).

Conclusions

The proportions of different SCA patients in US differ from those in the European consortium study, but as in the European patients, SCA1 progress faster than those with SCA2, 3 and 6. Later onset in SCA6 and greater upper body ataxia in SCA2 were noted. We conclude that progression rates of these SCAs were comparable between US and Europe cohorts, suggesting the feasibility of international collaborative clinical studies.

Parkinson disease phenotype in Ashkenazi Jews with and without LRRK2 G2019S mutations

The phenotype of Parkinson's disease (PD) in patients with and without leucine-rich repeat kinase 2 (LRRK2) G2019S mutations reportedly is similar; however, large, uniformly evaluated series are lacking. The objective of this study was to characterize the clinical phenotype of Ashkenazi Jewish (AJ) PD carriers of the LRRK2 G2019S mutation. We studied 553 AJ PD patients, including 65 patients who were previously reported, from three sites (two in New York and one in Tel-Aviv). Glucocerebrosidase (GBA) mutation carriers were excluded. Evaluations included the Montreal Cognitive Assessment (MoCA), the Unified Parkinson's Disease Rating Scale (UPDRS), the Geriatric Depression Scale (GDS) and the Non-Motor Symptoms (NMS) questionnaire. Regression models were constructed to test the association between clinical and demographic features and LRRK2 status (outcome) in 488 newly recruited participants. LRRK2 G2019S carriers (n = 97) and non-carriers (n = 391) were similar in age and age at onset of PD. Carriers had longer disease duration (8.6 years vs. 6.1 years; P < 0.001), were more likely to be women (51.5% vs. 37.9%; P = 0.015), and more often reported first symptoms in the lower extremities (40.0% vs. 19.2%; P < 0.001). In logistic models that were adjusted for age, disease duration, sex, education, and site, carriers were more likely to have lower extremity onset (P < 0.001), postural instability and gait difficulty (PIGD) (P = 0.043), and a persistent levodopa response for >5 years (P = 0.042). Performance on the UPDRS, MoCA, GDS, and NMS did not differ by mutation status. PD in AJ LRRK2 G2019S mutation carriers is similar to idiopathic PD but is characterized by more frequent lower extremity involvement at onset and PIGD without the associated cognitive impairment.

Motor control abnormalities in Parkinson's disease

The primary manifestations of Parkinson's disease are abnormalities of movement, including movement slowness, difficulties with gait and balance, and tremor. We know a considerable amount about the abnormalities of neuronal and muscle activity that correlate with these symptoms. Motor symptoms can also be described in terms of motor control, a level of description that explains how movement variables, such as a limb's position and speed, are controlled and coordinated. Understanding motor symptoms as motor control abnormalities means to identify how the disease disrupts normal control processes. In the case of Parkinson's disease, movement slowness, for example, would be explained by a disruption of the control processes that determine normal movement speed. Two long-term benefits of understanding the motor control basis of motor symptoms include the future design of neural prostheses to replace the function of damaged basal ganglia circuits, and the rational design of rehabilitation strategies. This type of understanding, however, remains limited, partly because of limitations in our knowledge of normal motor control. In this article, we review the concept of motor control and describe a few motor symptoms that illustrate the challenges in understanding such symptoms as motor control abnormalities.

Unlearning versus savings in visuomotor adaptation: comparing effects of washout, passage of time, and removal of errors on motor memory

Humans are able to rapidly adapt their movements when a visuomotor or other systematic perturbation is imposed. However, the adaptation is forgotten or unlearned equally rapidly once the perturbation is removed. The ultimate cause of this unlearning remains poorly understood. Unlearning is often considered to be a passive process due to inability to retain an internal model. However, we have recently suggested that it may instead be a process of reversion to habit, without necessarily any forgetting per se. We compared the timecourse and nature of unlearning across a variety of protocols where unlearning is known to occur: error-clamp trials, removal of visual feedback, removal of the perturbation, or simply a period of inactivity. We found that, in agreement with mathematical models, there was no significant difference in the rate of decay between subject who experienced zero-error clamp trials, and subjects who made movements with no visual feedback. Time alone did lead to partial unlearning (over the duration we tested), but the amount of unlearning was inconsistent across subjects. Upon re-exposure to the same perturbation, subjects who unlearned through time or by reverting to veridical feedback exhibited savings. By contrast, no savings was observed in subjects who unlearned by having visual feedback removed or by being placed in a series of error-clamp trials. Thus although these various forms of unlearning can all revert subjects back to baseline behavior, they have markedly different effects on whether long-term memory for the adaptation is spared or is also unlearned. On the basis of these and previous findings, we suggest that unlearning is not due to passive forgetting of an internal model, but is instead an active process whereby adapted behavior gradually reverts to baseline habits.

The role of neuroplasticity in dopaminergic therapy for Parkinson disease

Dopamine replacement is a mainstay of therapeutic strategies for Parkinson disease (PD). The motor response to therapy involves an immediate improvement in motor function, known as the short-duration response (SDR), followed by a long-duration response (LDR) that develops more slowly, over weeks. Here, we review evidence in patients and animal models suggesting that dopamine-dependent corticostriatal plasticity, and retention of such plasticity in the absence of dopamine, are the mechanisms underlying the LDR. Conversely, experience-dependent aberrant plasticity that develops slowly under reduced dopamine levels could contribute substantially to PD motor symptoms before initiation of dopamine replacement therapy. We place these findings in the context of the role of dopamine in basal ganglia function and corticostriatal plasticity, and provide a new framework suggesting that therapies that enhance the LDR could be more effective than those targeting the SDR. We further propose that changes in neuroplasticity constitute a form of disease modification that is distinct from prevention of degeneration, and could be responsible for some of the unexplained disease-modifying effects of certain therapies. Understanding such plasticity could provide novel therapeutic approaches that combine rehabilitation and pharmacotherapy for treatment of neurological and psychiatric disorders involving basal ganglia dysfunction.

Movement duration, Fitts's law, and an infinite-horizon optimal feedback control model for biological motor systems

Optimization models explain many aspects of biological goal-directed movements. However, most such models use a finite-horizon formulation, which requires a prefixed movement duration to define a cost function and solve the optimization problem. To predict movement duration, these models have to be run multiple times with different prefixed durations until an appropriate duration is found by trial and error. The constrained minimum time model directly predicts movement duration; however, it does not consider sensory feedback and is thus applicable only to open-loop movements. To address these problems, we analyzed and simulated an infinite-horizon optimal feedback control model, with linear plants, that contains both control-dependent and control-independent noise and optimizes steady-state accuracy and energetic costs per unit time. The model applies the steady-state estimator and controller continuously to guide an effector to, and keep it at, target position. As such, it integrates movement control and posture maintenance without artificially dividing them with a precise, prefixed time boundary. Movement pace is determined by the model parameters, and the duration is an emergent property with trial-to-trial variability. By considering the mean duration, we derived both the log and power forms of Fitts's law as different approximations of the model. Moreover, the model reproduces typically observed velocity profiles and occasional transient overshoots. For unbiased sensory feedback, the effector reaches the target without bias, in contrast to finite-horizon models that systematically undershoot target when energetic cost is considered. Finally, the model does not involve backward and forward sweeps in time, its stability is easily checked, and the same solution applies to movements of different initial conditions and distances. We argue that biological systems could use steady-state solutions as default control mechanisms and might seek additional optimization of transient costs when justified or demanded by task or context.

Improvement after constraint-induced movement therapy: recovery of normal motor control or task-specific compensation?

BACKGROUND

Constraint-induced movement therapy (CIMT) has proven effective in increasing functional use of the affected arm in patients with chronic stroke. The mechanism of CIMT is not well understood.

OBJECTIVE

To demonstrate, in a proof-of-concept study, the feasibility of using kinematic measures in conjunction with clinical outcome measures to better understand the mechanism of recovery in chronic stroke patients with mild to moderate motor impairments who undergo CIMT.

METHODS

A total of 10 patients with chronic stroke were enrolled in a modified CIMT protocol over 2 weeks. Treatment response was assessed with the Action Research Arm Test (ARAT), the Upper-Extremity Fugl-Meyer score (FM-UE), and kinematic analysis of visually guided arm and wrist movements. All assessments were performed twice before the therapeutic intervention and once afterward.

RESULTS

There was a clinically meaningful improvement in ARAT from the second pre-CIMT session to the post-CIMT session compared with the change between the 2 pre-CIMT sessions. In contrast, FM-UE and kinematic measures showed no meaningful improvements.

CONCLUSIONS

Functional improvement in the affected arm after CIMT in patients with chronic stroke appears to be mediated through compensatory strategies rather than a decrease in impairment or return to more normal motor control. We suggest that future large-scale studies of new interventions for neurorehabilitation track performance using kinematic analyses as well as clinical scales.

How is a motor skill learned? Change and invariance at the levels of task success and trajectory control

The public pays large sums of money to watch skilled motor performance. Notably, however, in recent decades motor skill learning (performance improvement beyond baseline levels) has received less experimental attention than motor adaptation (return to baseline performance in the setting of an external perturbation). Motor skill can be assessed at the levels of task success and movement quality, but the link between these levels remains poorly understood. We devised a motor skill task that required visually guided curved movements of the wrist without a perturbation, and we defined skill learning at the task level as a change in the speed-accuracy trade-off function (SAF). Practice in restricted speed ranges led to a global shift of the SAF. We asked how the SAF shift maps onto changes in trajectory kinematics, to establish a link between task-level performance and fine motor control. Although there were small changes in mean trajectory, improved performance largely consisted of reduction in trial-to-trial variability and increase in movement smoothness. We found evidence for improved feedback control, which could explain the reduction in variability but does not preclude other explanations such as an increased signal-to-noise ratio in cortical representations. Interestingly, submovement structure remained learning invariant. The global generalization of the SAF across a wide range of difficulty suggests that skill for this task is represented in a temporally scalable network. We propose that motor skill acquisition can be characterized as a slow reduction in movement variability, which is distinct from faster model-based learning that reduces systematic error in adaptation paradigms.

Longitudinal Change in Gait and Motor Function in Pre-manifest Huntington's Disease

The purpose of this study was to examine longitudinal change in gait and motor function in pre-manifest Huntington's disease (HD).We examined ten pre-manifest subjects at baseline, one and five years. Quantitative gait data were collected with an electronic mat (GAITRite®). We analyzed measures related to speed (velocity, step length, cadence), asymmetry (step length difference), dynamic balance (percent time in double support, support base) and variability in stride length and swing time. Motor function was assessed with the motor component of the Unified Huntington's Disease Rating Scale.Gait velocity decreased (p=0.001), whereas step length difference (p=0.006), stride length variability (p=0.0001) and swing time variability increased (p=0.0001) from baseline to year five. Step length difference (p<0.05) and swing time variability (p<0.05) increased marginally in one year from baseline. UHDRS Total motor score increased over five years (p=0.003), though the increase in one year was not significant (p=0.053). Of the individual motor domain scores (eye, hand movements, gait and balance, chorea) only dystonia worsened over five years (p=0.02). Total motor score (r2= 0.49, p<0.001) and swing time variability (r2= 0.22, p<0.009) were correlated with estimated years to diagnosis.Our results present the longest longitudinal follow up of gait in pre-manifest HD thus far. Despite the small sample size, quantitative gait analysis was able to detect changes in gait speed, symmetry and variability. Swing time variability was particularly important because it increased in one year from baseline and was correlated with estimated time to diagnosis. Our results highlight the importance of predictive outcomes such as gait variability using quantitative analysis.

Human sensorimotor learning: adaptation, skill, and beyond

Recent studies of upper limb movements have provided insights into the computations, mechanisms, and taxonomy of human sensorimotor learning. Motor tasks differ with respect to how they weight different learning processes. These include adaptation, an internal-model based process that reduces sensory-prediction errors in order to return performance to pre-perturbation levels, use-dependent plasticity, and operant reinforcement. Visuomotor rotation and force-field tasks impose systematic errors and thereby emphasize adaptation. In skill learning tasks, which for the most part do not involve a perturbation, improved performance is manifest as reduced motor variability and probably depends less on adaptation and more on success-based exploration. Explicit awareness and declarative memory contribute, to varying degrees, to motor learning. The modularity of motor learning processes maps, at least to some extent, onto distinct brain structures.

How do Symptoms and Level of Functioning Affect the Quality of Life in Schizophrenia? a Study on the Community Mental Health Centre of Ferrara (Italy)

Introduction

A specific interest regarding quality of life(QoL) of patients with schizophrenia dates back to the de-institutionalisation process. Italy worked on decentralising its mental health services since 1978. It was apparent that capturing psychopathological symptoms alone was not sufficient to reflect relevant outcomes. In particular, information on the social functioning and quality of life is regarded as essential for evaluating long-term outcomes.

Objective

The relationship between Quality of life and global functioning and symptoms in outpatients with Schizophrenia.

Method

In the present study we examined all the subjects with a diagnosis of schizophrenia attending a same Community Mental Health Centre in Northern Italy, in 2008. Each patient completed the WHO QoL Instrument - Brief and was administerd the Brief Psychiatric Rating Scale-24 to assess psychiatric symptoms and the VADO Personal and social Functioning Scale to assess the level of functioning.

Results

The population studied subjects showed an intermediate satisfaction on the overall QoL and health; these data can be juxtaposed to the national standard sample rates. QoL resulted positively associated to personal and social functioning, while it was negatively related to psychiatric symptoms.

Conclusion

The QoL in our study is not extremely negative, though schizophrenia is an often an impairing chronic illness. Furthermore, the present research on social functioning, psychiatric symptoms and QoL in people with schizophrenia suggest that symptoms, but, above all, personal and social functioning are important elements to determine QoL. These studies point to the importance of looking beyond symptom-reduction strategies for improving QoL in schizophrenia.

Learning not to generalize: modular adaptation of visuomotor gain

When a new sensorimotor mapping is learned through practice, learning commonly transfers to unpracticed regions of task space, that is, generalization ensues. Does generalization reflect fixed properties of movement representations in the nervous system and thereby limit what visuomotor mappings can and cannot be learned? Or does what needs to be learned determine the shape of generalization? We used the broad generalization properties of visuomotor gain adaptation to address these questions. Adaptation to a single gain for reaching movements is known to generalize broadly across movement directions. By training subjects on two different gains in two directions, we set up a potential conflict between generalization patterns: if generalization of gain adaptation indicates fixed properties of movement amplitude encoding, then learning two different gains in different directions should not be possible. Conversely, if generalization is flexible, then it should be possible to learn two gains. We found that subjects were able to learn two gains simultaneously, although more slowly than when they adapted to a single gain. Analysis of the resulting double-gain generalization patterns, however, unexpectedly revealed that generalization around each training direction did not arise de novo, but could be explained by a weighted combination of single-gain generalization patterns, in which the weighting takes into account the relative angular separation between training directions. Our findings therefore demonstrate that the mappings to each training target can be fully learned through reweighting of single-gain generalization patterns and not through a categorical alteration of these functions. These results are consistent with a modular decomposition approach to visuomotor adaptation, in which a complex mapping results from a combination of simpler mappings in a "mixture-of-experts" architecture.

Historical underpinnings of the term essential tremor in the late 19th century

BACKGROUND

The term essential tremor has been in regular use since the second half of the 20th century. To modern neurologists, the word "essential" may seem cryptic. The historical underpinnings of this term have not been examined.

OBJECTIVES

To bring to attention early medical reports using the term essential tremor and examine the characteristics of the disorder that contributed to the proposed use of the term.

METHODS

Review of 19th and early 20th century medical literature on essential tremor.

RESULTS

The term tremore semplice essenziale (simple essential tremor) was first used by Burresi (Italy, 1874) to describe an 18-year-old man with severe, isolated action tremor. Several years later, Maragliano (Italy, 1879), Nagy (Austria, 1890), and Raymond (France, 1892) described similar cases and proposed the terms tremore essenziale congenito (essential congenital tremor), essentieller Tremor (essential tremor), and tremblement essentiel héréditaire (hereditary essential tremor) to define the illness. Mirroring contemporaneous views of constitutional and inherited disease, the key ingredients of the disorder were viewed as the constant presence of tremor in the absence of other neurologic signs and its heritable nature. By the early 20th century, the term began to appear in the medical literature with greater frequency.

CONCLUSIONS

Toward the end of the 19th century, several clinicians attempted to provide a nosologic separation for a tremor diathesis that was often familial and occurred in isolation of other neurologic signs. This disorder, which was termed essential tremor, was later recognized as one of the most common neurologic disorders.

Explaining savings for visuomotor adaptation: linear time-invariant state-space models are not sufficient

Adaptation of the motor system to sensorimotor perturbations is a type of learning relevant for tool use and coping with an ever-changing body. Memory for motor adaptation can take the form of savings: an increase in the apparent rate constant of readaptation compared with that of initial adaptation. The assessment of savings is simplified if the sensory errors a subject experiences at the beginning of initial adaptation and the beginning of readaptation are the same. This can be accomplished by introducing either 1) a sufficiently small number of counterperturbation trials (counterperturbation paradigm [CP]) or 2) a sufficiently large number of zero-perturbation trials (washout paradigm [WO]) between initial adaptation and readaptation. A two-rate, linear time-invariant state-space model (SSM(LTI,2)) was recently shown to theoretically produce savings for CP. However, we reasoned from superposition that this model would be unable to explain savings for WO. Using the same task (planar reaching) and type of perturbation (visuomotor rotation), we found comparable savings for both CP and WO paradigms. Although SSM(LTI,2) explained some degree of savings for CP it failed completely for WO. We conclude that for visuomotor rotation, savings in general is not simply a consequence of LTI dynamics. Instead savings for visuomotor rotation involves metalearning, which we show can be modeled as changes in system parameters across the phases of an adaptation experiment.

Why don't we move faster? Parkinson's disease, movement vigor, and implicit motivation

People generally select a similar speed for a given motor task, such as reaching for a cup. One well established determinant of movement time is the speed-accuracy trade-off: movement time increases with the accuracy requirement. A second possible determinant is the energetic cost of making a movement. Parkinson's disease (PD), a condition characterized by generalized movement slowing (bradykinesia), provides the opportunity to directly explore this second possibility. We compared reaching movements of patients with PD with those of control subjects in a speed-accuracy trade-off task comprising conditions of increasing difficulty. Subjects completed as many trials as necessary to make 20 movements within a required speed range (trials to criterion, N(c)). Difficulty was reflected in endpoint accuracy and N(c). Patients were as accurate as control subjects in all conditions (i.e., PD did not affect the speed-accuracy trade-off). However, N(c) was consistently higher in patients, indicating reluctance to move fast although accuracy was not compromised. Specifically, the dependence of N(c) on movement energy cost (slope S(N)) was steeper in patients than in control subjects. This difference in S(N) suggests that bradykinesia represents an implicit decision not to move fast because of a shift in the cost/benefit ratio of the energy expenditure needed to move at normal speed. S(N) was less steep, but statistically significant, in control subjects, which demonstrates a role for energetic cost in the normal control of movement speed. We propose that, analogous to the established role of dopamine in explicit reward-seeking behavior, the dopaminergic projection to the striatum provides a signal for implicit "motor motivation."

Generalization of motor learning depends on the history of prior action

Generalization of motor learning refers to our ability to apply what has been learned in one context to other contexts. When generalization is beneficial, it is termed transfer, and when it is detrimental, it is termed interference. Insight into the mechanism of generalization may be acquired from understanding why training transfers in some contexts but not others. However, identifying relevant contextual cues has proven surprisingly difficult, perhaps because the search has mainly been for cues that are explicit. We hypothesized instead that a relevant contextual cue is an implicit memory of action with a particular body part. To test this hypothesis we considered a task in which participants learned to control motion of a cursor under visuomotor rotation in two contexts: by moving their hand through motion of their shoulder and elbow, or through motion of their wrist. Use of these contextual cues led to three observations: First, in naive participants, learning in the wrist context was much faster than in the arm context. Second, generalization was asymmetric so that arm training benefited subsequent wrist training, but not vice versa. Third, in people who had prior wrist training, generalization from the arm to the wrist was blocked. That is, prior wrist training appeared to prevent both the interference and transfer that subsequent arm training should have caused. To explain the data, we posited that the learner collected statistics of contextual history: all upper arm movements also move the hand, but occasionally we move our hands without moving the upper arm. In a Bayesian framework, history of limb segment use strongly affects parameter uncertainty, which is a measure of the covariance of the contextual cues. This simple Bayesian prior dictated a generalization pattern that largely reproduced all three findings. For motor learning, generalization depends on context, which is determined by the statistics of how we have previously used the various parts of our limbs.

Cross-fixation transfer of motion aftereffects with expansion motion

It has been shown that motion aftereffect (MAE) not only is present at the adapted location but also partially transfers to nearby non-adapted locations. However, it is not clear whether MAE transfers across the fixation point. Since cells in area MSTd have receptive fields that cover both sides of the fixation point and since many MSTd cells, but not cells in earlier visual areas, prefer complex motion patterns such as expansion, we tested cross-fixation transfer of MAE induced by expanding random-dots stimuli. We also used rightward translational motion for comparison. Subjects adapted to motion patterns on a fixed side of the fixation point. Dynamic MAE was then measured with a nulling procedure at both the adapted site and the mirror site across the fixation point. Subjects' eye fixation during stimulus presentation was monitored with an infrared eye tracker. At the adapted site, both the expansion and the translation patterns generated strong MAEs, as expected. However, only the expansion pattern, but not translation pattern, generated significant MAE at the mirror site. This remained true even after we adjusted stimulus parameters to equate the strengths of the expansion MAE and translation MAE at the adapted site. We conclude that there is cross-fixation transfer of MAE for expansion motion but not for translational motion.

An implicit plan overrides an explicit strategy during visuomotor adaptation

The relationship between implicit and explicit processes during motor learning, and for visuomotor adaptation in particular, is poorly understood. We set up a conflict between implicit and explicit processes by instructing subjects to counter a visuomotor rotation using a cognitive strategy in a pointing task. Specifically, they were told the exact nature of the directional perturbation, a rotation that directed them 45 degrees counterclockwise from the desired target, and they were instructed to counter it by aiming for the neighboring clockwise target, 45 degrees away. Subjects were initially successful in completely negating the rotation with this strategy. Surprisingly, however, they were unable to sustain explicit control and made increasingly large errors to the desired target. The cognitive strategy failed because subjects simultaneously adapted unconsciously to the rotation to the neighboring target. Notably, the rate of implicit adaptation to the neighboring target was not significantly different from rotation adaptation in the absence of an opposing explicit strategy. These results indicate that explicit strategies cannot substitute for implicit adaptation to a visuomotor rotation and are in fact overridden by the motor planning system. This suggests that the motor system requires that planned and executed trajectories remain congruous in visual space, and enforces this correspondence even at the expense of an opposing explicit task goal.

Huntington's disease

In this case study, we describe the symptoms, neurological exam, neuropsychological test results, and brain pathology of a man who died with Huntington's disease (HD). HD is a rare neurodegenerative disease. Like other movement disorders involving the basal ganglia, HD affects motor, cognitive, and psychiatric functioning. The disease follows an autosomal dominant pattern of inheritance, with onset of symptoms most commonly occurring in the late 30s or early 40s, as in this patient. HD is caused by an unstable expansion of the trinucleotide CAG, coding for glutamine, on chromosome 4. Despite knowledge of the gene mutation responsible for HD, no definitive treatment is currently available to slow or halt progression of the disease. However, symptomatic treatment can significantly improve the quality of life for patients with HD.

Amoxicillin/clavulanic acid versus cefotaxime for antimicrobial prophylaxis in abdominal surgery: a randomized trial

Amoxicillin/clavulanic acid (amoxicillin 2 g/clavulanic acid 200 mg) has been administered in comparison to cefotaxime (2 g) for antimicrobial prophylaxis in 476 evaluable patients undergoing abdominal surgery at high risk of septic complications. Both antibiotics were administered as a single infusion. 205 evaluable patients (110 in amoxicillin/clavulanic acid group and 95 in cefotaxime group) underwent upper gastrointestinal surgery (including gastroduodenal and biliary surgery). The wound infection rate was 4.5% for amoxicillin/clavulanic acid and 7.4% for cefotaxime, with no significant differences. Intra-abdominal abscesses were observed in 3 patients in the amoxicillin/clavulanic acid group and in 1 patient in the cefotaxime group. 271 evaluable patients (135 in amoxicillin/clavulanic acid group and 136 in cefotaxime group) underwent lower gastrointestinal surgery (including colorectal surgery). The wound infection rate was 11% for amoxicillin/clavulanic acid and 13% for cefotaxime, with no significant differences. A purulent discharge was present in 3 patients in both groups. Intra-abdominal abscesses were observed in 3 patients in the amoxicillin/clavulanic acid group and in 4 patients in the cefotaxime group. No serious adverse events and no cases of diarrhea were observed. In conclusion, in our experience amoxicillin/clavulanic acid proved to be as effective as cefotaxime in protecting patients from surgical infections in abdominal surgery. Its use in surgical prophylaxis may help decrease the cost of treatment and reduce the risk of resistance to antibiotics and superinfections.

Intracerebral aneurysms in human immunodeficiency virus infection: case report and literature review

We describe a child with human immunodeficiency virus infection who presented with a large subarachnoid hemorrhage. She had multiple saccular and fusiform aneurysms in the proximal cerebral arterial circulation and no evidence of bacterial or fungal infection. The arteriopathy coincided with a high human immunodeficiency virus RNA load. Human immunodeficiency virus may cause cerebral arteriopathy with potentially life-threatening complications.

Marked variation of thymidylate synthase and folylpolyglutamate synthetase gene expression in human colorectal tumors

Patients with advanced colorectal cancer are currently being treated with 5-fluorouracil (5-FU)-based chemotherapy. A growing number of patients with resectable disease receive adjuvant therapy with 5-FU/levamisole (LEV) or 5-FU/folinic acid (LV). However, many patients still fail on these treatments, due to occurrence of natural or acquired tumor resistance. Among clinically relevant mechanisms of resistance to fluoropyrimidines, increased expression of thymidylate synthase (TS) has been emphasized. Another potentially relevant mechanism involves a decrease in folylpolyglutamate synthetase (FPGS) expression. To establish the value of these genes as prognostic factors and predictors of the outcome of 5-FU-based chemotherapy in colorectal cancer, we measured their expression in colorectal tumors from patients undergoing surgery and postoperative chemotherapy and compared it with that in normal colonic mucosa. This was done by a semi quantitative, nonradioisotopic polymerase chain reaction (PCR) method using beta-actin as an internal standard and expressed as a TS/beta-actin or a FPGS/beta-actin mRNA ratio. In tumor samples from 21 colorectal cancer patients, TS gene expression varied 118-fold. The median TS/beta-actin ratio was, in fact, 41.36 x 10(-3) (range 2.49 x 10(-3) to 294.54 x 10(-3)). Little variation in TS gene expression was observed in corresponding normal colic mucosa; the TS/beta-actin gene ratio was lower (median 26.16 x 10(-3); range 8.49 x 10(-3) to 69.49 x 10(-3)). Among tumor explants from 20 patients, FPGS expression varied over 161-fold. A similar marked variation was also observed in normal colonic mucosal samples (over 185-fold). Overall and disease-free survival data suggest an inverse association between the level of tumor TS and FPGS expression and clinical prognosis. The availability of this sensitive and accurate assay for gene expression should now make it possible to extend these laboratory/clinical correlations to larger populations.

Effect of reversible inactivation of macaque lateral intraparietal area on visual and memory saccades

Previous studies from our laboratory identified a parietal eye field in the primate lateral intraparietal sulcus, the lateral intraparietal area (area LIP). Here we further explore the role of area LIP in processing saccadic eye movements by observing the effects of reversible inactivation of this area. One to 2 microl of muscimol (8 mg/ml) were injected at locations where saccade-related activities were recorded for each lesion experiment. After the muscimol injection we observed in two macaque monkeys consistent effects on both the metrics and dynamics of saccadic eye movements at many injection sites. These effects usually took place within 10-30 min and disappeared after 5-6 h in most cases and certainly when tested the next day. After muscimol injection memory saccades directed toward the contralesional and upper space became hypometric, and in one monkey those to the ipsilesional space were slightly but significantly hypermetric. In some cases, the scatter of the end points of memory saccades was also increased. On the other hand, the metrics of visual saccades remained relatively intact. Latency for both visual and memory saccades toward the contralesional space was increased and in many cases displayed a higher variance after muscimol lesion. At many injection sites we also observed an increase of latency for visual and memory saccades toward the upper space. The peak velocities for memory saccades toward the contralesional space were decreased after muscimol injection. The peak velocities of visual saccades were not significantly different from those of the controls. The duration of saccadic eye movements either to the ipsilesional or contralesional space remained relatively the same for both visual and memory saccades. Overall these results demonstrated that we were able to selectively inactivate area LIP and observe effects on saccadic eye movements. Together with our previous recording studies these results futher support the view that area LIP plays a direct role in processing incoming sensory information to program saccadic eye movements. The results are consistent with our unit recording data and microstimulation studies, which suggest that area LIP represents contralateral space and also has a bias for the upper visual field.

Lower left temporal lobe MRI volumes in patients with first-episode schizophrenia compared with psychotic patients with first-episode affective disorder and normal subjects

OBJECTIVE

Magnetic resonance imaging (MRI) studies of schizophrenic patients have revealed structural brain abnormalities, with low volumes of gray matter in the left posterior superior temporal gyrus and in medial temporal lobe structures. However, the specificity to schizophrenia and the roles of chronic morbidity and neuroleptic treatment in these abnormalities remain unclear.

METHOD

Magnetic resonance (1.5-T) scans were obtained from 33 patients with first-episode psychosis and 18 age-matched normal comparison subjects, all right-handed. Sixteen of the patients were diagnosed with affective disorder and 17 with schizophrenia.

RESULTS

Quantitative volumetric analysis showed that the patients with first-episode schizophrenia had significantly smaller gray matter volume in the left posterior superior temporal gyrus than did the patients with first-episode affective psychosis or the comparison subjects, with a significant left-less-than-right asymmetry. The schizophrenic patients also showed a smaller gray matter volume of the left posterior amygdala-hippocampal complex than the comparison subjects. Both the patients with schizophrenia and those with affective psychosis had significant left-less-than-right asymmetry of the posterior amygdala-hippocampal complex.

CONCLUSIONS

These findings suggest that temporal lobe abnormalities are present at the first hospitalization for schizophrenia and that low volume of the left posterior superior temporal gyrus gray matter is specific to schizophrenia compared with affective disorder.