Outcome in patients with religious delusions

We read with interest the recent report on the definition, diagnosis, and clinical implications of religious delusions (RD).1 In our sample of 929 delusional schizophrenia patients who had been admitted to two psychiatric hospitals in Germany between 2010 and 2014, 138 patients (15%) reported RD. In 569 cases, information on religious affiliation was available. Patients with religious affiliation did not differ from patients without religious affiliation in the frequency of RD [χ2(1,569)= 0.02, p= 0.885]. Furthermore, patients with RD did not differ from patients with other types of delusion (OD) in the duration of hospitalisation [t(924)= -0.39, p= 0.695], or the number of hospitalisations [t(927)= -0.92, p= 0.358]. Additionally, in 185 cases, information on Clinical Global Impressions (CGI) and Global Assessment of Functioning (GAF) was available at the beginning and end of the hospital stay. By CGI-scores, no difference was seen in morbidity of subjects with RD relative to subjects with OD on admission [t(183)= -0.78, p= 0.437] and discharge t(183)= -1.10, p= .273 . Likewise, GAF-scores on admission did not differ in these groups [t(183)= 1.50, p= 0.135]. However, a trend was noted for lower GAF-scores on discharge in subjects with RD [t(183)= 1.91, p= .057, d= 0.39, CI 95% (-0.12-0.78)]. While RD have often been associated with a poorer prognosis in schizophrenia,2,3 we argue that this need not apply to all domains. Mohr et al4 reported that patients with RD were less likely to maintain psychiatric treatment, but did not have a more severe clinical status than patients with OD. Iyassu et al5 found higher levels of positive, but also lower levels of negative symptoms in patients with RD compared to patients with OD. Groups did not differ in terms of length of illness or level of medication. Siddle et al6 reported higher symptom scores in patients with RD at their first presentation, but a similar response to treatment when compared to patients with OD after 4 weeks of treatment. Furthermore, Ellersgaard et al7 iindicated that first-episode psychosis patients with RD at baseline were more likely to be non-delusional at follow-ups conducted after years 1, 2 and 5 when compared to patients with OD at baseline. We conclude that RD may thus interfere with short-term clinical outcome. With regard to long-term effects more favourable observations exist8 and the interplay of psychotic delusions with non-psychotic beliefs still warrants further research.

Which tinnitus patients benefit from transcranial magnetic stimulation?

Objectives

Chronic tinnitus is associated with hyperactivity of the central auditory system. Low-frequency repetitive transcra-nial magnetic stimulation (rTMS) of the temporal cortex has been proposed as a treatment for chronic tinnitus. This study determined the factors that predict a beneficial outcome with rTMS treatment.

Study Design

Forty-five patients with chronic tinnitus underwent 10 sessions of low-frequency rTMS to their left auditory cortex. The treatment outcome was assessed with a tinnitus questionnaire. Therapeutic success was related to the patients' clinical characteristics.

Results

A significant reduction in tinnitus complaints occurred after rTMS. In the questionnaire, 40% of the patients improved by five points or more. Treatment responders were characterized by shorter duration of tinnitus complaints and no hearing impairment.

Conclusion

Tinnitus-related neuroplastic changes might be less pronounced in patients with normal hearing and a short history of complaints. This could explain why those patients benefitted more from rTMS treatment.

Durable improvements in urinary incontinence and positive treatment response in patients with idiopathic overactive bladder syndrome following long-term onabotulinumtoxinA treatment: Final results of 3.5-year study

OBJECTIVES

Here we present the final results from an extension study assessing long-term onabotulinumtoxinA treatment (3.5 years) in patients with idiopathic overactive bladder.

METHODS

Patients who completed either of 2 Phase III trials were eligible to enter a 3-year extension study in which they received multiple onabotulinumtoxinA (100 U) treatments. Data were analyzed for the overall population of patients who received 100 U in any treatment cycle (n=829) and within discrete subgroups of patients who received exactly 1 (n=105), 2 (n=118), 3 (n=117), 4 (n=83), 5 (n=46), or 6 (n=33) treatments of the 100 U dose throughout the study (n=502).

RESULTS

Of the 829 patients enrolled, 51.7 % completed the study. Discontinuations due to AEs/lack of efficacy were low (5.1/5.7 %); other reasons were not treatment-related. Mean reductions from baseline in urinary incontinence (UI) episodes/day (week 12; co-primary endpoint) were consistent among discrete subgroups who received 1 (-3.1), 2 (-2.9, -3.2), 3 (-4.1 to -4.5), 4 (-3.4 to -3.8), 5 (-3.0 to -3.6), or 6 (-3.1 to -4.1) treatments. A consistently high proportion of patients reported improvement/great improvement on the Treatment Benefit Scale (week 12; co-primary endpoint) in the discrete subgroups across all treatments (70.0-93.5 %). Median time to request retreatment was ≤6 months for 34.2 %, >6-≤12 months for 37.2 %, and >12 months for 28.5 % of patients. Most common AE was UTI, with no changes in safety profile over time.

CONCLUSION

Long-term onabotulinumtoxinA treatment resulted in consistent reductions in UI and high proportions of patients reporting improvement after each treatment, with no new safety findings.

Health-related quality of life in preschool children with Type 1 diabetes

AIMS

To describe health-related quality of life in children aged < 7 years with Type 1 diabetes mellitus compared with healthy children of the same age, and to investigate how health-related quality of life was correlated with aspects of insulin treatment and glycaemic control.

METHODS

The participants in this study were 24 children with diabetes (12 girls, mean age 4.5 years) and 27 healthy children (14 girls, mean age 4.6 years). All participants completed the Pediatric Quality of Life Inventory 4.0 Generic Core Scales and the participants with diabetes also completed the Pediatric Quality of Life Inventory 3.0 Type 1 Diabetes Module Scales. HbA1c levels were measured in children with diabetes and the plasma glucose meter memories were uploaded.

RESULTS

Children aged <7 years with diabetes had lower parent-rated generic health-related quality of life compared with healthy children (score: 80 vs 91; P = 0.003). The difference was largest in children aged < 5 years (score: 79 vs 93; P = 0.004). Among the parents of children with Type 1 diabetes, 22% rated their child's generic health-related quality of life to be at a level of concern (- 1 sd of a general population). Of the children with Type 1 diabetes aged between 5 and 7 years, 40% rated their own generic health-related quality of life at the same level of concern.

CONCLUSION

This study shows a significantly lower level of generic health-related quality of life in very young children with diabetes in comparison with healthy children. We suggest screening for health-related quality of life in children of all ages with Type 1 diabetes mellitus.

A multicenter, prospective trial to evaluate mesh-augmented sacrospinous hysteropexy for uterovaginal prolapse

Introduction and hypothesis

Hysterectomy is often part of pelvic organ prolapse repair. However, this may offer no benefit when compared to uterine preservation. We aimed to prospectively evaluate a minimally invasive bilateral sacrospinous hysteropexy using polypropylene mesh. We hypothesized that anatomic success and patient satisfaction can be achieved with this technique.

Methods

Women with uterovaginal prolapse desiring surgery who had completed childbearing were enrolled. Preoperative assessment included standardized prolapse examination and validated symptom and pain scale questionnaires. Women with prior pelvic organ prolapse repair or any contraindication to uterine preservation were excluded. Data including demographic, operative and postoperative information was collected on patients for 1 year following surgery. Continuous variables are summarized as means (standard deviation) and categorical variables are summarized as frequencies and percentages. A mixed-effects model was used to evaluate the changes in questionnaire scores and outcomes at 6 months and 12 months after surgery with random effects accounting for the center effect with adjustment for age.

Results

The study group comprised 99 women from three female pelvic medicine and reconstructive surgery (urogynecology) centers. The average age of the participants was 67.0 years (11.32 years), BMI 26.04 kg/m² (3.56 kg/m²), and the majority were multiparous (98.9 %) and menopausal (90.9 %). Overall success at 12 months, as measured by composite outcome was 97.7 % (with the Ba point as the anatomic landmark) and 96.6 % (with the C point as the anatomic landmark). The overall exposure rate was 6.52 % and reoperation rate was 7.53 %. All subjective questionnaire scores and anatomic outcomes had improved at 12 months.

Conclusions

Sacrospinous hysteropexy using a minimally invasive polypropylene mesh kit is an effective and safe technique for addressing uterovaginal prolapse as an alternative to hysterectomy at the time of pelvic reconstructive surgery.

Thyroid hormone receptor alpha can control action potential duration in mouse ventricular myocytes through the KCNE1 ion channel subunit

AIMS

The reduced heart rate and prolonged QT(end) duration in mice deficient in thyroid hormone receptor (TR) alpha1 may involve aberrant expression of the K(+) channel alpha-subunit KCNQ1 and its regulatory beta-subunit KCNE1. Here we focus on KCNE1 and study whether increased KCNE1 expression can explain changes in cardiac function observed in TRalpha1-deficient mice.

METHODS

TR-deficient, KCNE1-overexpressing and their respective wildtype (wt) mice were used. mRNA and protein expression were assessed with Northern and Western blot respectively. Telemetry was used to record electrocardiogram and temperature in freely moving mice. Patch-clamp was used to measure action potentials (APs) in isolated cardiomyocytes and ion currents in Chinese hamster ovary (CHO) cells.

RESULTS

KCNE1 was four to 10-fold overexpressed in mice deficient in TRalpha1. Overexpression of KCNE1 with a heart-specific promoter in transgenic mice resulted in a cardiac phenotype similar to that in TRalpha1-deficient mice, including a lower heart rate and prolonged QT(end) time. Cardiomyocytes from KCNE1-overexpressing mice displayed increased AP duration. CHO cells transfected with expression plasmids for KCNQ1 and KCNE1 showed an outward rectifying current that was maximal at equimolar plasmids for KCNQ1-KCNE1 and decreased at higher KCNE1 levels.

CONCLUSION

The bradycardia and prolonged QT(end) time in hypothyroid states can be explained by altered K(+) channel function due to decreased TRalpha1-dependent repression of KCNE1 expression.

Allelic variation in the serotonin transporter promoter modulates cortical excitability

BACKGROUND

Transcranial magnetic stimulation (TMS) is a noninvasive procedure that may be used to study individual differences in motor cortex excitability. Such differences are assumed to reflect serotonergic and other inputs to the motor cortex.

METHODS

Here we investigate the impact of a functional polymorphism in the promoter region of the 5-hydroxytryptamine transporter gene (5-HTTLPR) on measures of motor cortex excitability.

RESULTS

Sixty healthy subjects carrying one or two copies of the short 5-HTTLPR allele (s/s and s/l) showed a significant reduction in short intracortical inhibition (SICI, p = .012) and an increased cortical silent period (p = .042) compared with 60 age- and sex-matched individuals homozygous for the long allele (l/l). In contrast, motor threshold and intracortical facilitation did not differ significantly between groups.

CONCLUSIONS

These results provide further evidence of a role for serotonergic transmission in the modulation of cortical excitability. Differential effects on the measures under study suggest a pattern of prioritization in bioamine regulation of cortical inhibition.

Controversy: Does repetitive transcranial magnetic stimulation/ transcranial direct current stimulation show efficacy in treating tinnitus patients?

BACKGROUND

Tinnitus affects 10% of the population, its pathophysiology remains incompletely understood, and treatment is elusive. Functional imaging has demonstrated a relationship between the intensity of tinnitus and the degree of reorganization in the auditory cortex. Experimental studies have further shown that tinnitus is associated with synchronized hyperactivity in the auditory cortex. Therefore, targeted modulation of auditory cortex has been proposed as a new therapeutic approach for chronic tinnitus.

METHODS

Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are noninvasive methods that can modulate cortical activity. These techniques have been applied in different ways in patients with chronic tinnitus. Single sessions of high-frequency rTMS over the temporal cortex have been successful in reducing the intensity of tinnitus during the time of stimulation and could be predictive for treatment outcome of chronic epidural stimulation using implanted electrodes.

RESULTS

Another approach that uses rTMS as a treatment for tinnitus is application of low-frequency rTMS in repeated sessions, to induce a lasting change of neuronal activity in the auditory cortex beyond the duration of stimulation. Beneficial effects of this treatment have been consistently demonstrated in several small controlled studies. However, results are characterized by high interindividual variability and only a moderate decrease of the tinnitus. The role of patient-related (for example, hearing loss, tinnitus duration, age) and stimulation-related (for example, stimulation site, stimulation protocols) factors still remains to be elucidated.

CONCLUSIONS

Even in this early stage of investigation, there is a convincing body of evidence that rTMS represents a promising tool for pathophysiological assessment and therapeutic management of tinnitus. Further development of this technique will depend on a more detailed understanding of the neurobiological effects mediating the benefit of TMS on tinnitus perception. Moreover clinical studies with larger sample sizes and longer follow-up periods are needed.

Modulation of human motor cortex excitability by the cholinesterase inhibitor rivastigmine

Acetylcholine exerts strong neuromodulating action at cortical and subcortical neurons and networks. Alterations of cortical excitability, induced by acute and repeated administration of the acetylcholinesterase inhibitor rivastigmine were investigated with transcranial magnetic stimulation in healthy volunteers. It was found that rivastigmine had an overall significant effect on the stimulus-response curve with mean values suggesting an enhancement 1.5 and 3 h after a single loading dose of 3 mg rivastigmine and a reduction after 7 days of daily administration of 3 mg rivastigmine. Motor threshold, intracortical inhibition, intracortical facilitation, cortical silent period, M-wave, F-wave and peripheral silent period remained unaffected either by acute or repeated administration of rivastigmine. Our results demonstrate that effects of acetylcholine on motor cortex excitability in healthy subjects are reflected by alterations of the stimulus-response curve. The differential effect between acute and chronic administration of rivastigmine may reflect dynamic properties of different receptor subtypes.

Cerebellar and thalamic metabolic changes visualized by [18]-FDG-PET in olanzapine-induced acute akathisia

OBJECTIVES

Akathisia is a clinical important symptom, frequently induced by neuroleptic treatment. Despite its clinical importance, less is known about its pathophysiology.

METHODS

Using [18]-FDG-PET, imaging patterns of cortical metabolic activity were obtained in a patient during olanzapine-induced akathisia and after recovery.

RESULTS

Akathisia was characterized by a reduced metabolic activity in thalamus and cerebellum. After discontinuing medication akathisia disappeared, reflected by a recovery of metabolic activity in these brain areas.

CONCLUSION

[18]-FDG-PET may be useful to identify cortical regions mediating clinical aspects of drug-induced akathisia, thereby offering a deeper insight into the pathophysiology of this serious side effect.

The impact of auditory cortex activity on characterizing and treating patients with chronic tinnitus--first results from a PET study

CONCLUSION

Unilaterally increased metabolic activity within the primary auditory cortex (PAC) represents a robust finding in tinnitus patients. Targeting these hyperactive areas with image-guided low frequency repetitive transcranial magnetic stimulation (rTMS) results in subjective tinnitus reduction. More pronounced activation of the PAC predicted higher resistance to rTMS.

OBJECTIVES

[18F]deoxyglucose (FDG)-positron emission tomography (PET) was used to assess metabolic activity within the central auditory system in tinnitus. The study investigated whether patterns of neuronal activity correlate with clinical features or may be used for the prediction of treatment outcome.

PATIENTS AND METHODS

Twenty patients with chronic tinnitus underwent PET imaging followed by low frequency rTMS treatment. Neuroimaging data were compared with clinical parameters and treatment outcome.

RESULTS

PET data demonstrated an asymmetric activation of the central auditory system. Seventeen patients revealed increased activity of the primary auditory cortex on the left side, three on the right side. The extent of hypermetabolic activity prior to treatment correlated significantly with tinnitus reduction after rTMS, but not with clinical characteristics such as tinnitus severity, tinnitus laterality or tinnitus duration.

Repetitive transcranial magnetic stimulation and chronic tinnitus

CONCLUSION

There is a good theoretical basis and early research evidence suggesting that transcranial magnetic stimulation (TMS) may have treatment potential in tinnitus. Further studies with larger sample sizes and additional assessment of neurobiological effects are necessary.

OBJECTIVES

Tinnitus is a common and often severely disabling disorder for which there is no satisfactory treatment. TMS is a new, non-invasive method of modifying the excitability of the cerebral cortex, which has proven effective in auditory hallucinations and other disorders. Some early studies have been published in which TMS has been used in the treatment of tinnitus. The objective of this paper is to examine the literature and consider the potential for TMS as a therapy in tinnitus.

METHODS

A thorough search of the tinnitus and TMS literature was conducted, and all available relevant material was examined.

RESULTS

Tinnitus is common, with a prevalence of 8.2% in subjects aged 50 years and over, and may be associated with great distress (tinnitus sufferers). There are no effective treatments. Tinnitus is frequently associated with deafness, and may be the result of a pathological plasticity process. Neuroimaging studies demonstrate increased activity within the central auditory system. TMS is a non-invasive method of modulating excitability in cerebral cortex. It uses electromagnetic principles and has been successfully employed in the treatment of other conditions associated with increased activity of the cerebral cortex. Meanwhile, a growing number of studies suggest that repetitive TMS may be effective in the treatment of chronic tinnitus.

Transcranial Magnetic Stimulation for the Treatment of Tinnitus: A New Coil Positioning Method and First Results

Auditory phantom perceptions are associated with hyperactivity of the central auditory system. Neuronavigation guided repetitive transcranial magnetic stimulation (rTMS) of the area of increased activity was demonstrated to reduce tinnitus perception. The study aimed at developing an easy applicable standard procedure for transcranial magnetic stimulation of the primary auditory cortex and to investigate this coil positioning strategy for the treatment of chronic tinnitus in clinical practice. The left gyrus of Heschl was targeted in 25 healthy subjects using a frameless stereotactical system. Based on individual scalp coordinates of the coil, a positioning strategy with reference to the 10--20-EEG system was developed. Using this coil positioning approach we started an open treatment trial. 28 patients with chronic tinnitus received 10 sessions of rTMS (intensity 110% of motor threshold, 1 Hz, 2000 Stimuli/day). Being within a range of about 20 mm diameter, the scalp coordinates for stimulating the primary auditory cortex allowed to determine a standard procedure for coil positioning. Clinical validation of this coil positioning method resulted in a significant improvement of tinnitus complaints (p<0.001). The newly developed coil positioning strategy may have the potential to offer a more easy-to-use stimulation approach for treating chronic tinnitus as compared with highly sophisticated, imaging guided treatment methods.

The novel brain-specific tryptophan hydroxylase-2 gene in panic disorder

Panic disorder is a common psychiatric disorder characterized by recurrent anxiety attacks and anticipatory anxiety. Due to the severity of the symptoms of the panic attacks and the frequent additional occurrence of agoraphobia, panic disorder is an often debilitating disease. Elevation of central serotonin levels by drugs such as clomipramine represents one of the most effective treatment options for panic disorder. This points to an important role of dysregulation of the serotonergic system in the genetic etiology of panic disorder. The novel brain-specific 5-HT synthesizing enzyme, tryptophan hydroxylase-2 (TPH2), which represents the rate-limiting enzyme of 5-HT production in the brain, may therefore be of particular importance in panic disorder. We focused on the putative transcriptional control region of TPH2 and identified two novel common single nucleotide polymorphisms (SNPs) of TPH2 in and close to this region. Moreover, a recently described loss-of-function mutation of TPH2 which results in an 80% reduction of serotonin production, was assessed. In an analysis of the putative transcriptional control region SNPs in a sample of panic disorder patients and controls no association of the disorder with the TPH2 SNPs or haplotypes was found. Moreover, the loss-of-function R441H mutation of TPH2 was not present in the panic disorder patients. The results of this first study of TPH2 in panic disorder argue against an importance of allelic variation of TPH2 in the pathogenesis of panic disorder with or without agoraphobia.

Interaction of serotonergic and noradrenergic gene variants in panic disorder

OBJECTIVE

Panic disorder is an anxiety disorder with an estimated heritability of 48%. Associations findings have been obtained with candidate genes from both serotonergic and noradrenergic pathways including regulatory and coding variants of the serotonin receptor 1A gene, the monoamine oxidase A gene, the catechol-O-methyltransferase gene and the norepinephrine transporter gene.

METHODS

In the present study, an analysis of interactions between the functional serotonin receptor 1A polymorphism, the norepinephrine transporter variants and the other respective polymorphisms of the above-mentioned genes is reported. The analysis is based on genotype results from 115 cases and 115 age and sex-matched controls.

RESULTS

A nominally significant (P=0.04) interaction between the serotonin receptor 1A and the catechol-O-methyltransferase polymorphisms was observed. Stratified analysis revealed that the odds ratio of each polymorphism was highest in the presence of the low-risk genotype(s) of the other polymorphism and low in the presence of the high-risk genotype(s) of the other polymorphism.

CONCLUSIONS

This is the first possible interaction of genetic variations in panic disorder that has been observed. As the sample size was small and no adjustment for multiple testing was made, the assessment of the interacting risk alleles needs replication in a larger sample with higher power.

[GABA-B-associated neuropsychiatric disorders]

OBJECTIVE

Disturbed GABA-B mediated inhibitory cortical processes are discussed to be involved both in schizophrenia as well as in chronic tinnitus. Transcranial magnetic stimulation (TMS) provides an intriguing in vivo method to investigate GABA-B associated aspects of cortical inhibition, thus allowing to detect disease-related cortical inhibitory processes.

METHOD

Parameters of cortical excitability were measured by TMS in drug-naive first-episode schizophrenic patients and in patients suffering from chronic tinnitus.

RESULTS

The cortical silent period as measured by TMS indicated a dysfunctional GABA-B mediated cortical inhibition in both groups of patients.

CONCLUSIONS

TMS offers new insights into the pathophysiology of neuropsychiatric disorders. Parameters of this technique point to changes in GABA-B associated inhibitory processes within thalamocortial circuits both in schizophrenia and chronic tinnitus. These data are in line with current models of disturbed thalamic gating in phantom perceptions like auditory hallucinations, chronic tinnitus and central pain.

Evidence of a role for the 5-HTTLPR genotype in the modulation of motor response to antidepressant treatment

RATIONALE

Serotonergic mechanisms are thought to play an important role in the regulation of mood, motor activity and sleep patterns. Serotonin reuptake is controlled by the serotonin transporter (5-HTT) and by a common functional insertion/deletion polymorphism in the corresponding gene's promoter region (5-HTTLPR). Homozygosity for the long variant may confer a favourable response to treatment with serotonin reuptake inhibitors (SSRIs), and to sleep deprivation.

OBJECTIVES

The study assessed the role of the 5-HTTLPR genotype in determining motor side effects of antidepressant medication.

METHODS

Motor activity patterns of 62 patients with major depression who were being treated with either SSRIs or tricyclic antidepressants (TCAs) were monitored over a 24-h period using a wrist-actograph. Additionally, motor activity was rated in a semi-structured interview using the motor agitation and retardation scale (MARS).

RESULTS

Night-time motor activity was significantly increased in homozygous carriers of the long 5-HTTLPR allele (LL-genotype) who were being treated with SSRIs in comparison to short allele carriers (LS-genotype and SS-genotype), regardless of the type of antidepressant treatment (P<0.001). It was also significantly increased in comparison to patients with the LL-genotype who were being treated with TCAs (P<0.01). Differences in actographic motor activity were most prominent between 11 p.m. and 4 a.m. Clinical ratings of motor activity also showed a trend toward higher agitation scores in patients with the LL-genotype who received SSRI treatment.

CONCLUSIONS

Homozygosity for the long variant of the 5-HTTLPR may cause a predisposition to increased night-time motor activity in conjunction with SSRI treatment.

The flavone hispidulin, a benzodiazepine receptor ligand with positive allosteric properties, traverses the blood-brain barrier and exhibits anticonvulsive effects

The functional characterization of hispidulin (4',5,7-trihydroxy-6-methoxyflavone), a potent benzodiazepine (BZD) receptor ligand, was initiated to determine its potential as a modulator of central nervous system activity. After chemical synthesis, hispidulin was investigated at recombinant GABA(A)/BZD receptors expressed by Xenopus laevis oocytes. Concentrations of 50 nm and higher stimulated the GABA-induced chloride currents at tested receptor subtypes (alpha(1-3,5,6)beta(2)gamma(2)S) indicating positive allosteric properties. Maximal stimulation at alpha(1)beta(2)gamma(2)S was observed with 10 microm hispidulin. In contrast to diazepam, hispidulin modulated the alpha(6)beta(2)gamma(2)S-GABA(A) receptor subtype. When fed to seizure-prone Mongolian gerbils (Meriones unguiculatus) in a model of epilepsy, hispidulin (10 mg kg(-1) body weight (BW) per day) and diazepam (2 mg kg(-1) BW per day) markedly reduced the number of animals suffering from seizures after 7 days of treatment (30 and 25% of animals in the respective treatment groups, vs 80% in the vehicle group). Permeability across the blood-brain barrier for the chemically synthesized, (14)C-labelled hispidulin was confirmed by a rat in situ perfusion model. With an uptake rate (K(in)) of 1.14 ml min(-1) g(-1), measurements approached the values obtained with highly penetrating compounds such as diazepam. Experiments with Caco-2 cells predict that orally administered hispidulin enters circulation in its intact form. At a concentration of 30 microm, the flavone crossed the monolayer without degradation as verified by the absence of glucuronidated metabolites.

Altered motor cortex excitability in tinnitus patients: a hint at crossmodal plasticity

Idiopathic tinnitus is a frequent and often debilitating auditory phantom perception of largely unknown pathological conditions. In electrophysiological and functional neuroimaging studies, affected subjects have shown excessive spontaneous activity in the central auditory system. To further investigate the underlying central nervous component, we assessed motor cortex excitability in 19 patients with chronic tinnitus by means of transcranial magnetic stimulation (TMS). When results were compared with data from 19 healthy controls matched for age and sex, we found significantly enhanced intracortical facilitation in tinnitus patients. These findings parallel excitability changes after limb amputation and experimental deafferentation. Our results give further support to crossmodal interactions involving neuroplastic changes in some forms of tinnitus and may help to better understand mechanisms of maladaptive cortical reorganisation involved in phantom perceptions.

Norepinephrine transporter (NET) promoter and 5'-UTR polymorphisms: association analysis in panic disorder

Several biochemical and pharmacological studies suggest that the catecholaminergic system involving the norepinephrine transporter (NET) is relevant for the pathogenesis of panic disorder. Three single nucleotide polymorphisms in the promoter or untranslated 5' region of the NET gene were investigated by means of RFLP analysis in a sample of 115 German patients with panic disorder and 115 matched controls. Statistical analysis failed to show association with the overall diagnosis of panic disorder. In the subgroup of patients with panic disorder without agoraphobia, however, two polymorphisms were found to be associated with the disease (G/C (rs2397771): p < 0.05; T/C (rs2242446): p < 0.01). While our data do not support a major function of the NET gene in the development of panic disorder, it may play a role in the subgroup of panic disorder without agoraphobia.

Hypotonic stress activates an intermediate conductance K+ channel in human colonic crypt cells

AIM

To investigate the effect of hypotonic stress on human colonic crypts cells in terms of ion channel activity and intracellular Ca2+ concentration.

METHODS

Single crypts were isolated from biopsies taken during colonoscopy. The patch clamp technique was used (in the cell-attached mode) to observe the activity of ion channels during hypotonic stress. Calcium measurements were made using the fluophores Fluo 3 or 4.

RESULTS

The intermediate conductance (29 pS), Ca2+ -sensitive, K+ channel (also known as KCNN4) previously described (Sandle et al. 1994) was seen in 54 of 149 patches (36%) when the crypts were bathed in normal extracellular solution (290 mOsm kg(-1)). Forty-one patches could be used for further analysis. Activation of one or several 29 pS channels was seen in 15 of 41 patches (39%) after 30 s to 4 min of exposure to hypotonic solution (160 mOsm kg(-1)). The open probability increased from 0.0043 in control solution to 0.44 at 5 min of hypotonic stress. When the crypts were exposed to hypotonic solution, an increase in intracellular Ca2+ could be seen. The increase in intracellular Ca2+ emanates mainly from intracellular stores.

CONCLUSION

The 29 pS K+ channel takes part in volume regulation in human colonic crypt cells. The activation of this channel is mediated through an increase in intracellular Ca2+.

[No evidence for gender-specific sharing of COMT alleles in schizophrenia]

Catechol-o-methyltransferase (COMT) plays a major role in dopamine metabolism and has been the object of extensive investigations in subjects affected by schizophrenia. Interest in the enzyme has grown in recent years following positive linkage findings for schizophrenia in the chromosomal region surrounding the COMT gene locus on 22q. In several studies, a gender-specific association of COMT polymorphisms with schizophrenia has been reported and has given rise to speculations on transmission ratio distortions. The present investigation addressed allelic distributions in 307 men and women with respect to the rs165599 A > G polymorphism. No evidence was obtained for gender bias in allelic patterns, nor did we observe association with schizophrenia (p = 0.4). While studies involving same-sex siblings are lacking, gender-specific sharing of alleles does not appear to be a consistent feature of the COMT variant investigated.

Behandlung von chronischem Tinnitus mit niedrigfrequenter repetitiver transkranieller Magnetstimulation (rTMS) - gibt es Langzeiteffekte?

OBJECTIVE

Clinical, neurophysiological and neuroimaging data suggest that chronic tinnitus resembles neuropsychiatric syndromes characterised by focal brain activation. Low frequency repetitive transcranial magnetic stimulation (rTMS) has been proposed as an efficient method in treating brain hyperexcitability disorders.

METHODS

Patients suffering from chronic tinnitus underwent a [ (18)F]deoxyglucose-PET (positron emission tomography). Fusioning of the individual PET scan with the structural MRI-scan (magnetic resonance imaging, T1, MPRAGE) revealed an increased metabolic activation in the primary auditory cortex as target point for rTMS. A neuronavigational system enabled the positioning of the figure of eight coil in relation to the target area. rTMS (110 % motor threshold; 1 Hz; 2000 stimuli/day over 5 days) was performed using a placebo controlled cross-over design.

RESULTS

Following active rTMS there was a moderate improvement of tinnitus perception. Treatment effects lasted up to six months in some patients.

CONCLUSIONS

Neuronavigated rTMS offers new possibilities in the understanding and treatment of chronic tinnitus.

Association of a functional 1019C>G 5-HT1A receptor gene polymorphism with panic disorder with agoraphobia

Panic disorder is a common anxiety disorder which frequently co-occurs with agoraphobia. A functional promoter polymorphism in the serotonin receptor 1A (5-HT1A) gene has been found to be associated with major depression as well as anxiety- and depression-related personality traits. We investigated a possible association between this 5-HT1A gene promoter polymorphism and panic disorder by genotyping the 1019C>G single nucleotide polymorphism in 134 panic-disorder patients with and without agoraphobia and matched 134 controls. In our sample no significant evidence of allelic association in the combined panic-disorder group was found. However, our results show a significant association with the G allele in patients with panic disorder with agoraphobia (p=0.03, n=101). In conclusion, our findings do not support a major contribution of this polymorphism to the pathogenesis of panic disorder, but provide evidence for a possible role in the subgroup with agoraphobia.

Association of the functional V158M catechol-O-methyl-transferase polymorphism with panic disorder in women

Panic disorder is an anxiety disorder with an estimated heritability of up to 48%. Pharmacological and genetic studies suggest that genes coding for proteins involved in the catecholaminergic system might be relevant for the pathogenesis of the disease. In the present study, we genotyped a single nucleotide polymorphism (472G/A=V158M) in the coding region of the catechol-O-methyl-transferase (COMT) gene in 115 patients with panic disorder and age- and sex-matched controls. Association analysis revealed a significant excess of the more active COMT allele (472G=V158) in patients with panic disorder (p=0.04), particularly in female patients (p=0.01), but not in male patients (p=1.0). The assessment of a possible interaction of the COMT polymorphism with a previously reported functional 30-bp VNTR in the monoamine oxidase A promoter (MAOALPR) in female patients did not yield significant results. Our data support a role of the 472G/A (V158M) COMT polymorphism or a nearby locus in the pathogenesis of panic disorder in women.

Cholecystokinin- and cholecystokinin-B-receptor gene polymorphisms in panic disorder

Panic disorder like other neuropsychiatric disorders is believed to be caused by multiple psychosocial and biological factors. Several lines of evidence point to a role for the peptide neurotransmitter cholecystokinin in the pathogenesis of panic disorder. We therefore determined the allele and genotype frequencies of a single nucleotide polymorphism in the CCK gene (-36C>T) and one CT repeat polymorphism in the CCK-B-receptor gene in a German panic disorder sample (n = 115 for CCK gene polymorphism, n = 111 for CCK-B-receptor polymorphism) and compared them with gender and age matched controls. The length of the polymorphic CT repeat alleles varies between 146 bp and 180 bp. We first analysed the results by a permutation test which provided evidence for heterogeneity between patients and controls (p=0.002). We then analysed the data as a di-allelic polymorphism with a short (146-162bp) and a long (164-180bp) allele and as a tetra-allelic polymorphism with 4 alleles (146-154bp, 156-162bp, 164-170bp, 172-180bp). In the di-allelic analysis as well as in the tetra-allelic analysis there was an excess of the longer allele (p = 0.001) or the two longer alleles (p = 0.041) respectively in patients with panic disorder. No difference between groups was observed for the -36C > T polymorphism. Our findings are consistent with the notion that genetic variation in the CCK neurotransmitter system contributes to the pathogenesis of panic disorder.

Association between A2a receptor gene polymorphisms and caffeine-induced anxiety

The adenosine receptor system, which mediates the psychoactive effects of caffeine, is also thought to be involved in the regulation of anxiety. In this study, we examined the association between variations in anxiogenic responses to caffeine and polymorphisms in the A1 and A2a adenosine receptor genes. Healthy, infrequent caffeine users (N=94) recorded their subjective mood states following a 150 mg oral dose of caffeine freebase or placebo in a double-blind study. We found a significant association between self-reported anxiety after caffeine administration and two linked polymorphisms on the A2a receptor gene, the 1976C>T and 2592C>Tins polymorphisms. Individuals with the 1976T/T and the 2592Tins/Tins genotypes reported greater increases in anxiety after caffeine administration than the other genotypic groups. The study shows that an adenosine receptor gene polymorphism that has been associated with Panic Disorder is also associated with anxiogenic responses to an acute dose of caffeine.

Human nuclear transcription factor gene CREM: genomic organization, mutation screening, and association analysis in panic disorder

Panic disorder is an anxiety disorder with an estimated heritability of 48%. Variation in the gene of the nuclear transcription factor "cAMP-responsive element modulator" (CREM) might contribute to its pathogenesis. CREM knock-out mice exhibit significantly less anxiety behavior than wild-type mice and the alternative CREM gene product "inducible cAMP early repressor" (ICER) plays a pivotal role in the hypothalamo-pituitary-adrenal (HPA) axis, which is disturbed in panic disorder. We characterized the genomic organization of the human CREM gene and performed a systematic mutation screening by means of single stranded conformational analysis (SSCA) in a sample of 40 German patients with panic disorder (DSM-III-R). Four novel single nucleotide polymorphisms in CREM promoters P 1 and P 4, one trinucleotide (ATT)-repeat polymorphism in CREM promoter P 2-generating the ICER isoform-and a rare amino acid substitution in CREM exon glut 2 were identified. Association analysis in an extended sample of German patients (n = 88) revealed a significant excess of the shorter CREM P 2 promoter eight-repeat trinucleotide allele and of genotypes containing the eight-repeat trinucleotide allele in panic disorder (P = 0.02), in particular in panic disorder without agoraphobia (P = 0.001). A replication study in independent Italian (n = 76) and Spanish (n = 62) samples, however, failed to confirm this observation. This suggests that the CREM P 2 promoter trinucleotide polymorphism is not a major susceptibility factor in the pathogenesis of panic disorder. Functional analysis of the observed CREM P 2 promoter polymorphism as well as studies in independent panic disorder samples are necessary.

Constituents of sage (Salvia officinalis) with in vitro affinity to human brain benzodiazepine receptor

Benzodiazepine receptor binding assay-guided fractionation of the methanol extract from sage leaves ( Salvia officinalis L.) revealed three flavones and two abietane diterpenes functioning as benzodiazepine receptor-active components. Structural elucidation of the isolated pure compounds was performed by UV, EI-MS, ESI(pos)-MS/MS, as well as 1H- and 13C-NMR techniques. The flavones apigenin, hispidulin and cirsimaritin competitively inhibited 3H-flumazenil binding to the benzodiazepine receptor with IC50 values of 30, 1.3 and 350 microM, respectively. In addition, the affinities of the newly discovered diterpene receptor ligands, i. e., 7-methoxyrosmanol and galdosol, were characterized. 7-Methoxyrosmanol exhibited an IC50 value of 7.2 microM and galdosol showed the strongest binding activity to the benzodiazepine receptor with an IC50 value of 0.8 microM.

Olfactory reference syndrome manifests in a variety of psychiatric disorders

Olfactory reference syndrome (ORS) is a rare psychiatric condition characterized by isolated olfactory hallucinations or illusionary misinterpretations of odours with delusional self-reference and a typical contrite reaction. The aetiopathology of the disorder is unclear. Three cases of ORS are presented, which show the typical clinical symptom constellation, while pointing to various underlying psychiatric illnesses and differing treatment responses. Nosological aspects are discussed on the basis of the available literature.

Untangling the human estrogen receptor gene structure

Awareness of estrogen's neuroprotective and behavioral effects is broadening rapidly and has served as an incentive to investigate estrogen signaling in central nervous system disorders. The present analysis focuses on two human nuclear estrogen receptors, ER alpha and ER beta, which have been shown to play key roles in the complex integration of estrogen's genomic and non-genomic modes of action. The corresponding genes are estimated to have diverged from an ancestral ER gene over 450 million years ago and are candidate genes for a variety of brain disorders. Recent progress in the Human Genome Project has greatly aided our understanding of the molecular blueprint and provides the means for reassessing both genes' genomic organization. Analyses of multiple alternatively spliced transcripts, large untranslated sequences and neighbouring genes reveal several novel features which suggest an increasingly versatile transcriptional machinery. We outline additional exons in the genes' 5'- and 3'-untranslated regions, a new polymorphic ER alpha microsatellite and a nested gene which lend themselves to further evolutionary and functional studies.

Naturally occurring benzodiazepines may codetermine chronotypes

Determinants of individual differences in sleep-wake cycles and vigilance are being recognized as major factors of influence in both physical and mental health. Alterations of an accustomed circadian sleep-wake rhythm are commonly seen in the early stages of the majority of psychiatric disorders and, by themselves, predispose to significant morbidity even in the absence of an underlying illness. While it is well known that disruptions of sleep respond favourably to benzodiazepines, agents which have been prescribed for insomnia since their industrial synthesis in the early 1960s, little attention has been paid to putative central nervous system effects of naturally occurring benzodiazepines. These molecules were found in various nutritive plants and have been quantified in human brain and peripheral blood of drug-naive individuals at trace amounts. There is agreement that elevated concentrations of naturally occurring benzodiazepines participate in the complex pathophysiology of hepatic encephalopathy, a condition asssociated with progressive impairment of consciousness and, ultimately, coma. In the present study, we address the relationship between naturally occurring benzodiazepines and time-of-day effects on the behavior of healthy subjects.

Transvaginal bladder neck suspension to Cooper's ligament

Numerous surgeries have been proposed for the treatment of genuine stress incontinence, with the goals to improve functional outcome and decrease complications and their associated morbidity. Two new, minimally invasive procedures, transvaginal retropubic urethropexy and transvaginal Cooper's ligament sling, are reviewed in this article. These procedures provide a completely transvaginal approach, without the use of abdominal incisions or bone anchors. The anterior point of suspension is Cooper's ligament. The transvaginal retropubic urethropexy is used for the treatment of genuine stress incontinence with urethral hypermobility, and the transvaginal sling also may be used in the presence of intrinsic sphincteric deficiency. The procedures are described and the recent outcomes discussed.

Prospective randomized controlled trial of extended-release oxybutynin chloride and tolterodine tartrate in the treatment of overactive bladder: results of the OBJECT Study

OBJECTIVE

To compare the efficacy and tolerability of extended-release oxybutynin chloride and tolterodine tartrate at 12 weeks in participants with overactive bladder.

SUBJECTS AND METHODS

The OBJECT (Overactive Bladder: Judging Effective Control and Treatment) study was a prospective, randomized, double-blind, parallel-group study conducted between March and October 2000 at 37 US study sites. Participants who had between 7 and 50 episodes of urge incontinence per week and 10 or more voids in 24 hours received extended-release oxybutynin, 10 mg/d, or tolterodine, 2 mg twice daily. The outcome measures were the number of episodes of urge incontinence, total incontinence, and micturition frequency at 12 weeks adjusted for baseline.

RESULTS

A total of 315 women and 63 men were randomized and treated, and 332 participants (276 women, 56 men) completed the study. At the end of the study, extended-release oxybutynin was significantly more effective than tolterodine in each of the main outcome measures: weekly urge incontinence (P=.03), total incontinence (P=.02), and micturition frequency episodes (P=.02) adjusted for baseline. Both drugs improved symptoms of overactive bladder significantly from baseline to the end of the study as assessed by the 3 main outcome measures (P<.001). Dry mouth, the most common adverse event, was reported by 28.1% and 33.2% of participants taking extended-release oxybutynin and tolterodine, respectively (P=.32). Rates of central nervous system and other adverse events were low and similar in both groups.

CONCLUSIONS

Extended-release oxybutynin was more effective than tolterodine as measured by end-of-study urge incontinence, total incontinence, and micturition frequency episodes. Both groups had similar rates of dry mouth and other adverse events.