Multimodal approach of advanced gastric cancer: based therapeutic algorithm

Gastric cancer (GC) is the third leading cause of cancer death in both sexes worldwide, with the highest estimated mortality rates in Eastern Asia and the lowest in Northern America. However, the availability of modern treatment has improved the survival and the prognosis is often poor due to biological characteristics of the disease. In oncology, we are living in the "Era" of target treatment and, to know biological aspects, prognostic factors and predictive response informations to therapy in GC is mandatory to apply the best strategy of treatment.The purpose of this review, according to the recently published English literature, is to summarize existing data on prognostic aspects and predictive factors to response to therapy in GC and to analyze also others therapeutic approaches (surgery and radiotherapy) in locally, locally advanced and advanced GC. Moreover, the multidisciplinary approach (chemotherapy, surgery and radiotherapy) can improve the prognosis of GC. The purpose of this review, according to the recently published English literature, is to summarize existing data on prognostic aspects and predictive factors to response to therapy in GC and to analyze also others therapeutic approaches (surgery and radiotherapy) in locally, locally advanced and advanced GC. Moreover, the multidisciplinary approach (chemotherapy, surgery and radiotherapy) can improve the prognosis of GC.

Feasibility of intraperitoneal Trastuzumab treatment in a patient with peritoneal carcinomatosis from gastric cancer

OBJECTIVES

This case report evaluates the feasibility and efficacy of intraperitoneal (IP) trastuzumab administration in gastric cancer (GC) patients with peritoneal carcinomatoses.

METHODS

Peritoneal metastasis is a common sign of advanced tumor stage, tumor progression or disease recurrence in patients with GC. Recently, the role of HER2 overexpression in GC, occurring in about 20% of cases, is correlated with a worse prognosis. We report the case of 61-years old female, admitted to our Hospital after curative surgery for GC with over-expression of HER2. Seven months after the start of first line chemotherapy treatment a pleuro-peritoneal disease progression occurred, documented by cytological exam; according to HER2 status, we decided to treat the patient with IP trastuzumab administration.

RESULTS

Between September and October 2012, the patient (ECOG performance status was 0), underwent to 6 cycles of IP trastuzumab. Trastuzumab was administered weekly at a dose of 150 mg for each cycle after paracentesis. The safety was good, no local complications (e.g. abdominal pain, peritonitis) occurred. The clinical revaluation evidenced a stable peritoneal disease.

CONCLUSIONS

To our knowledge this is the first report on Trastuzumab use to treat IP metastases from GC, with acceptable toxicity and local disease control.

Kidney disease in HIV-infected patients

The introduction of highly active antiretroviral therapy (HAART) has reduced mortality and improved life expectancy of HIV-positive patients. However, increased survival is associated with increased prevalence of comorbidities, such as cardiovascular disease, hepatic and renal disease. Kidney disease, including HIV-associated nephropathy, acute renal failure and chronic kidney disease, represents one of the main causes of morbidity and mortality, especially if associated to other risk factors, i.e. hypertension, diabetes, older age, black race and hepatitis C coinfection. Careful evaluation of renal function may help identifying kidney disease in its early stages. In addition, proper management of hypertension and diabetes is recommended. Even if HAART has changed the natural course of HIV-associated nephropathy, reducing the risk of End-stage Renal Disease (ERDS), some antiretroviral regimens have been related with the development of acute or chronic kidney disease. Further studies are needed to optimize the management of renal disease among HIV-infected patients.

Dysphonia as an Unusual Toxic Event of Oxaliplatin-Based Chemotherapy

Oxaliplatin is a new, third-generation platinum complex. It has a good safety profile characterized by low hematological-gastrointestinal toxicity. No significant nephro-ototoxicity has been observed. Acute peripheral neuropathy is a common event affecting, as grade 1 or 2, 85-95% of patients. Recently, data on dysphonia toxicity, after the administration of oxaliplatin, has been reported in literature. This toxicity with acute onset can be misunderstood if not carefully looked for. However, it is self-limiting and a non-permanent (grade 1-2) neurotoxic phenomenon, which impairs transiently the quality of life of a percentage of oxaliplatin-treated patients. We report our experience in consecutive patients affected by advanced colorectal cancer treated with oxaliplatin-based chemotherapy. Overall, we observed 13 (16%) cases of dysphonia out of 81 consecutive patients treated with oxaliplatin-based chemotherapy. This toxic effect was self-limiting and all patients recovered rapidly. Nonetheless, a deeper understanding of this phenomenon is essential to give correct information to the patients.

Cetuximab/Targeted Chemotherapy in an HIV-Positive Patient with Metastatic Colorectal Cancer in the HAART Era: a Case Report

Recent data have shown the efficacy of cetuximab/Folfiri regimen in patients with chemotherapy-resistant metastatic colorectal cancer. In the literature there are no data about this treatment in HIV-positive patients with metastatic colorectal cancer. At the Aviano Cancer Center, we used the cetuximab/Folfiri regimen and concomitant HAART in an HIV-positive patient with metastatic colorectal cancer. The patient experienced acceptable non-hematological toxicity, without any opportunistic infection and his HIV infection was kept under control. This case suggests that, in the HAART era, a multidisciplinary approach can be offered to HIV patients with advanced cancer when they have good performance status, resulting in efficacious control of the HIV infection.

Dissemination metastasis after laparoscopic colorectal surgery versus conventional open surgery for colorectal cancer: a metanalysis

PURPOSE

The purpose of this systematic review is to evaluate and compare the risk of dissemination metastasis (wound, port-side metastases and peritoneal seeding) after laparoscopic colorectal surgery and conventional open surgery for colorectal cancer.

MATERIALS AND METHODS

The Authors searched relevant randomized controlled trials between January 1998 and July 2012.

RESULTS

Wound, port-site metastases and peritoneal seeding were rare and no significant differences occurred between the two groups. The port-site and extraction site recurrence were likely to be the results of suboptimal surgical techniques and occurred in the early phase of the learning curve. The authors also found no significant differences in overall, local and distant recurrences. No significant differences between laparoscopic and open surgery were found in cancer-related mortality during the follow up period of the study (7 RCTs, 3525 patients, 12.8% vs. 14.00%; OR (fixed) 0.83, 95% CI 0.68-1.02), with no significant heterogeneity (p = 0.35).

CONCLUSIONS

The literature supports the implementation of laparoscopic surgery into daily practice. Laparoscopic surgery can be used for safe and radical resection of cancer in the right, left, sigmoid colon and rectum. However further studies should address whether laparoscopic surgery is superior to open surgery in this setting.

Hepatocellular carcinoma in HIV positive patients

Highly active antiretroviral therapy (HAART) has dramatically changed the natural history of HIV-1-infected patients leading to increased survival and a better quality of life. Hepatitis C virus (HCV) and hepatitis B virus (HBV) infections are common among HIV-1-infected subjects and represent the most important risk factors for hepatocellular carcinoma (HCC). Whether HIV plays a direct role in hepatocellular carcinoma (HCC) pathogenesis remains to be established.HCC clinical course depends on stage of cancer disease, performance status and comorbidities. Therapeutic options include liver transplantation, local antiblastic chemotherapy and biological drugs. In the HIV setting few data are available about treatment options. The increased longevity of patients with HIV imposes new strategies for prevention and therapeutic management of patients. The aim of this article is to provide an up-to-date review of HIV-related HCC in the HAART era.

A phase III study of VMPT versus VMP in newly diagnosed elderly myeloma patients

8515

Background: In MM patients VMP is superior to MP. In relapsed-refractory patients the 4 drug combination VMPT induced a high proportion of complete responses (CR). Methods: 500 newly diagnosed MM patients ≥ 65 years were randomly assigned to receive VMPT (N=247) or VMP (N=253). Patients were treated with nine 5-week cycles of VMPT (bortezomib 1.3 mg/m2 days 1, 8, 15, 22; melphalan 9 mg/m2 days 1–4; prednisone 60 mg/m2 days 1–4 and thalidomide 50 mg days 1–35) or VMP (bortezomib, melphalan and prednisone at the same doses and schedules previously described). Primary end-point was progression-free survival (PFS). Assuming the hazard ratio (VMP vs VMPT) of 1.35, the total sample size is 500 (250/arm) subjects (power 80%, 2-side alpha 0.05). Results: 354 patients (median age 71 years), who received at least 1 cycle were evaluated: 177 VMPT and 177 VMP. Data were analyzed in intention-to-treat. The VGPR rate was 55% in the VMPT group and 45% in the VMP group (p<0.001). After a median follow-up of 14.5 months, the 3-year PFS was 74% in the VMPT group and 70% in the VMP group (HR=0.75, 95% CI 0.45–1.26, p=0.28). The 3-year overall survival (OS) was 88% in the VMPT group and 87% in the VMP group (HR=0.89, 95% CI 0.42–1.87, p=0.75). Subgroup analyses did not show any statistical difference between responses/PFS and either ISS or chromosomal abnormalities (t(4;14) or t(14;16) or del17) in both groups. Age > 75 years was associated with lower VGPR rate (p=0.02) in VMPT but not in VMP. Factors predictive of longer PFS were age ≤ 75 years (p=0.003) and the achievement of VGPR (p=0.0005) in VMPT but not in VMP. The incidence of grade 3–4 adverse events (AEs) was similar in both groups. In the VMPT patients and in the VMP patients, the more frequent AEs were neutropenia (36% vs 31%), thrombocytopenia (20% vs 19%), peripheral neuropathy (18% vs 12%) and infections (14% vs 10%), respectively. Conclusions: VMPT is superior to VMP in terms of response rates. Longer follow-up is needed to assess their effects on PFS and OS. Both regimens appeared to overcome the poor prognosis of ISS and chromosomal abnormalities. An update of these data will be presented.

[Table: see text]

Metastatic angiosarcoma of the kidney: a case report with treatment approach and review of the literature

Angiosarcomas are rare soft tissue malignancies. Typically they originate from the skin of the scalp or face, whereas visceral sarcomas are very rare. We report the case of a 67-year-old man affected by a large angiosarcoma of the kidney. After surgical removal, a rapid peritoneal, visceral and cutaneous diffusion developed. Palliative chemotherapy, based on anthracycline and ifosfamide, which are normally used to treat all other high-grade spindle cell sarcomas, was totally inactive. On the basis of these results and of the biological characteristics of these rare neoplasms it is mandatory to develop other therapeutic approaches. Antiangiogenetic agents are of interest for this disease due to the peculiar origin of the cells of these sarcomas.

Infralimbic cortex activation increases c-Fos expression in intercalated neurons of the amygdala

Recently, it was reported that stimulation of the infralimbic cortex produces a feedforward inhibition of central amygdala neurons. The interest of this observation comes from the fact that the central nucleus is the main output station of the amygdala for conditioned fear responses and evidence that the infralimbic cortex plays a critical role in the extinction of conditioned fear. However, the identity of the neurons mediating this infralimbic-evoked inhibition of the central nucleus remains unknown. Likely candidates are intercalated amygdala neurons. Indeed, these cells receive glutamatergic afferents from the infralimbic cortex, use GABA as a transmitter, and project to the central amygdala. Thus, the present study was undertaken to test whether, in adult rats, the infralimbic cortex can affect the activity of intercalated neurons. To this end, disinhibition of the infralimbic cortex was induced by local infusion of the non-competitive GABA-A receptor antagonist picrotoxin. Subsequently, neuronal activation was determined bilaterally within the amygdala using induction of the immediate early gene Fos. Infralimbic disinhibition produced a significant increase in the number of Fos-immunoreactive intercalated cells bilaterally whereas no change was detected in the central nucleus. In the basolateral amygdaloid complex, increases in the number of Fos-immunoreactive cells only reached significance in the contralateral lateral nucleus. These results suggest that glutamatergic inputs from the infralimbic cortex directly activate intercalated neurons. Thus, our findings raise the possibility that the infralimbic cortex inhibits conditioned fear via the excitation of intercalated cells and the consequent inhibition of central amygdala neurons.

Acute amygdalar activation induces an upregulation of multiple monoamine G protein coupled pathways in rat hippocampus

A "partial" rodent model for schizophrenia has been used to characterize the regulation of hippocampal genes in response to amygdalar activation. At 96 h after the administration of picrotoxin into the basolateral nucleus, we have observed an increase in the expression of genes associated with 18 different monoamine (ie adrenergic alpha 1, alpha 2 and beta 2, serotonergic 5HT5b and 5HT6, dopamine D4 and muscarinic m1, m2 and m3) and peptide (CCK A and B, angiotensin 1A, mu and kappa opiate, FSH, TSH, LH, GNRH, and neuropeptide Y) G-protein coupled receptors (GPCRs). These latter receptors are associated with three different G protein signaling pathways (Gq, Gs, and Gi) in which significant changes in gene expression were also noted for adenylate cyclase (AC4), phosphodiesterase (PDE4D), protein kinase A (PKA), and protein kinase C (PKC). Quantitative RT-PCR was used to validate the results and demonstrated that there were predictable increases of three GPCRs selected for this analysis, including the dopamine D4, alpha 1b, and CCK-B receptors. Eight out of the nine monoamine receptors showing these changes have moderate to high affinity for the atypical antipsychotic, clozapine. Taken together, these results suggest that amygdalar activation may play a role in the pathophysiology and treatment of psychosis by regulating the activity of multiple GPCR and metabolic pathways in hippocampal cells.

[Tension-free prosthetic videolaparoscopic repair of adult Morgagni-Larrey hernia]

A symptomatic case of diaphragmatic hernia through the foramen of Morgagni-Larrey in an adult patient is presented. Etiology, diagnosis and particularly, indications of differences between open and laparoscopic repair of diaphragmatic hernia are discussed. In the case presented laparoscopic technique was carried out by means of tension-free closure of the defect using extraperitoneal prolene-mesh. The recovery was quick and uneventful. Four years after surgery no compliants were noticed.

[Frantz's solid cystic papillary pancreatic carcinoma]

The authors report their own case of a young woman recently operated for a rare form of pancreatic tumor of exocrine origin, so-called Frantz's solid-cystic-papillary carcinoma, for which only a little more than 300 cases have been reported in the world literature. The authors discuss the pathogenesis (it is possible that Frantz's tumor is related to female sex hormones that may play a role in its growth but not in its genesis), clinical (the presentation is not specific and, despite the aid of modern diagnostic imaging, the preoperative diagnosis may be very difficult and this unusual tumor should be considered in the differential diagnosis of large abdominal masses, especially in young females), histological, radiological and surgical features of this tumor. The recommended treatment, given the low grade of malignancy of the tumor and the excellent overall prognosis, has to be as conservative as possible, with respect to the oncological radicality, but every attempt should be made for complete excision since surgical curability is high and radio-chemo-therapy is of no use for its treatment. Since regrowth of the tumor may occur, prolonged follow-up is mandatory.

GABAergic interneurons: implications for understanding schizophrenia and bipolar disorder

A core component to corticolimbic circuitry is the GABAergic interneuron. Neuroanatomic studies conducted over the past century have demonstrated several subtypes of interneuron defined by characteristic morphological appearances in Golgi-stained preparations. More recently, both cytochemical and electrophysiological techniques have defined various subtypes of GABA neuron according to synaptic connections, electrophysiological properties and neuropeptide content. These cells provide both inhibitory and disinhibitory modulation of cortical and hippocampal circuits and contribute to the generation of oscillatory rhythms, discriminative information processing and gating of sensory information within the corticolimbic system. All of these functions are abnormal in schizophrenia. Recent postmortem studies have provided consistent evidence that a defect of GABAergic neurotransmission probably plays a role in both schizophrenia and bipolar disorder. Many now believe that such a disturbance may be related to a perturbation of early development, one that may result in a disturbance of cell migration and the formation of normal lamination. The ingrowth of extrinsic afferents, such as the mesocortical dopamine projections, may "trigger" the appearance of a defective GABA system, particularly under stressful conditions when the modulation of the dopamine system is likely to be altered. Based on the regional and subregional distribution of changes in GABA cells in schizophrenia and bipolar disorder, it has been postulated that the basolateral nucleus of the amygdala may contribute to these abnormalities through an increased flow of excitatory activity. By using "partial" modeling, changes in the GABA system remarkably similar to those seen in schizophrenia and bipolar disorder have been induced in rat hippocampus. In the years to come, continued investigations of the GABA system in rodent, primate and human brain and the characterization of changes in specific phenotypic subclasses of interneurons in schizophrenia and bipolar disorder will undoubtedly provide important new insights into how the integration of this transmitter system may be altered in neuropsychiatric disease.

Amygdalar activation alters the hippocampal GABA system: "partial" modelling for postmortem changes in schizophrenia

Abnormalities in amygdala and hippocampus have been shown to coexist in schizophrenia (SZ). In the hippocampus, compelling evidence suggests that a disruption of GABA neurotransmission is present mainly in sectors CA4, CA3, and CA2. The amygdala sends important inputs to the hippocampus and is also believed to have a defective GABA system in schizophrenia. To explore the possibility that changes in the hippocampal GABAergic system could be related to an increased inflow of activity originating in the amygdala, a "partial" animal model has been developed. In awake, freely moving, rats a GABA(A) receptor antagonist was infused locally into the basolateral nuclear complex of the amygdala (BLn). Within 2 hours, a decreased density of both the 65- and 67-kDa isoforms of glutamate decarboxylase (GAD(65) and GAD(67)) -immunoreactive (IR) terminals was detected on neuron somata in sectors CA3 and CA2, but not in CA1, CA3, or dentate gyrus. An increase of GAD(67)-IR somata was also found in the dentate gyrus and CA4. In anterograde tracer studies, amygdalo-hippocampal projection fibers were exclusively found in CA3 and CA2, but not CA1. Taken together, these results indicate that activation of amygdalo-hippocampal afferents is associated with the induction of significant changes in the GABA system of the hippocampus, with a subregional distribution that is remarkably similar to that found in SZ. Under pathologic conditions, an excessive discharge of excitatory activity emanating from the amygdala could be capable of altering inhibitory modulation along the trisynaptic pathway. This mechanism may potentially contribute to disturbances of GABAergic function in the major psychoses. Such "partial" rodent modelling provides an important strategy for deciphering the effect of altered cortico-limbic circuits in SZ.

Ranitidine in the prevention of gastroduodenal damage during antiblastic polychemotherapy

BACKGROUND

The authors report their personal experience of the use of ranitidine in the prevention of gastroduodenal damage induced by antiblastic drugs during antiblastic polychemotherapy.

METHODS

A heterogeneous group of cancer patients was monitored from January 1984 to December 1999 (293 males and 204 females), aged between 36 and 80 years old, a11 of whom were undergoing antineoplastic polychemotherapy. Preventive treatment with ranitidine at a dose of 300 mg/die per os in a single evening bolus continued through the entire period of antiblastic treatment ranging from a minimum of six months to one year or more. The study was carried out in the General Surgery Department of Valdichiana Senese, Local Health Unit 7 in Siena and in the Department of Surgical Oncology at the University of Catania. The study consisted of a clinical and instrumental follow-up using esophagogastroduodenoscopy at the time patients were enrolled and at 3, 6 and 12 months, or at the end of treatment if longer.

RESULTS

Ranitidine was useful and could significantly reduce the harmful gastric effects of antiblastic drugs, as has been extensively shown by the literature. These drugs can lead to the suspension of treatment owing to intolerance or even death. In this study ranitidine reduced the damaging effects on the upper digestive tract in respectively 78% of the cases treated compared to 22% of non-responders.

CONCLUSIONS

The action of ranitidine made antiblastic treatment more acceptable by mitigating or even blocking the damaging effects on the stomach and duodenum, leading to an improved quality of life for cancer patients.

Amygdalo-entorhinal inputs to the hippocampal formation in relation to schizophrenia

This chapter reviews recent postmortem studies of schizophrenic brain and discusses the potential role of the amygdala in the induction of hippocampal abnormalities in this disorder. Based on available evidence, sectors CA4, CA3, and CA2, but not CA1, show preferential changes in schizophrenic subjects, although the most pronounced changes have been found in CA3 and CA2. It seems likely that the amygdala would contribute in some way to the induction of abnormalities along the trisynaptic pathway via its direct input to sectors CA3 and CA2, as well as an indirect one that involves the entorhinal cortex and its perforant path projection to the area dentata. The postmortem findings reported to date have been integrated into a working model in which decreases of inhibitory GABAergic modulation are invoked to explain the observation from a recent PET scan study (Heckers et al., 1999) that baseline metabolic activity in the hippocampus of schizophrenics is increased. In addition, however, the apparent inability of schizophrenics to increase metabolic activity in the hippocampus when challenged with a memory retrieval task may reflect a disturbance of disinhibitory modulation postulated herein to occur in sector CA3, a key relay point along the trisynaptic pathway. Overall, it seems plausible that an increase of excitatory activity entering the hippocampus from the basolateral complex via both direct and indirect pathways may make a significant contribution to the pathophysiology of schizophrenia.

[Our experience with the Hartmann's operation in colorectal emergencies]

BACKGROUND

The role of Hartmann's operation has been revised during the past few years in the context of emergency colorectal surgery: it represents an obligatory choice that enables the simultaneous treatment of the primary disorder and the complication. This study aims to emphasise the importance of this unique surgical choice and to stress that surgeons should not underestimate it.

METHODS

The authors review the literature on the subject and make a retrospective analysis of 228 cases of colorectal surgery from 1988 to 1997 in which Hartmann's operation was performed in 16 patients with the following indications: Hinchey's stage III and IV peritonitis secondary to perforating diverticulitis of the sigma (elective indication) or occlusion of the left colon when preparation could not be accomplished in spite of intraoperative washout.

RESULTS

Post-Hartmann recanalisation was successfully performed in 14 patients.

CONCLUSIONS

The authors' experience and these results concord with the general view that this operation should be reserved for selected cases, in particular colorectal emergencies of a perforating nature; it is less appropriate for intestinal occlusion, although it is always preferable to be too prudent by resorting to Hartmann's operation or protective colostomy rather than risk anastomotic dehiscence.

Cortically driven Fos induction in the striatum is amplified by local dopamine D2-class receptor blockade

Dopamine D2-class receptors have been shown to control the excitability of striatal neurons in response to cortical activation. It has been unclear, however, whether such receptors could regulate the number of striatal neurons activated by cortical stimulation, and thus affect the population response of the striatum to its cortical inputs. We used Fos induction as a readout to measure the ensemble response of striatal neurons to localized stimulation of the frontal cortex and tested for the effects of D2-class dopamine receptor blockade on this response. In freely moving rats, we stimulated the frontal cortex by local epidural application of a dose of a GABAA receptor antagonist (picrotoxin) just threshold for inducing Fos in the striatum. We combined this treatment with D2-class dopamine receptor antagonist treatments at dose levels also just threshold for inducing Fos, using either (i) systemic haloperidol or (ii) intrastriatal (-)sulpiride. Both systemic and intrastriatal blockade of D2-class receptors sharply increased the numbers of striatal neurons exhibiting cortically evoked Fos induction. These findings suggest that local activation of intrastriatal D2-class dopamine receptors can regulate the number of striatal neurons responsive to cortical inputs, thus dynamically shaping the flow of information through the striatum.

[Post-thymectomy extrathymic tumors]

The Authors report the case of a 78 year old woman affected with two synchronous primary cancers (epidermoid bronchial and rectal adenocarcinoma); 16 years previously, after the discovery of a thymoma, she underwent thymectomy. Thus, the discussion issue is if post-thymectomy extra-thymic malignancies are to be considered just a simple coincidence or a true syndrome.

Local release of GABAergic inhibition in the motor cortex induces immediate-early gene expression in indirect pathway neurons of the striatum

The neocortex is thought to exert a powerful influence over the functions of the basal ganglia via its projection to the striatum. It is not known, however, whether corticostriatal effects are similar across different types of striatal projection neurons and interneurons or are unique for cells having different functions within striatal networks. To examine this question, we developed a method for focal synchronous activation of the primary motor cortex (MI) of freely moving rats by local release of GABAergic inhibition. With this method, we monitored cortically evoked activation of two immediate-early gene protein products, c-Fos and JunB, in phenotypically identified striatal neurons. We further studied the influence of glutamate receptor antagonists on the stimulated expression of c-Fos, JunB, FosB, and NGFI-A. Local disinhibition of MI elicited remarkably selective induction of c-Fos and JunB in enkephalinergic projection neurons. These indirect pathway neurons, through their projections to the globus pallidus, can inhibit thalamocortical motor circuits. The dynorphin-containing projection neurons of the direct pathway, with opposite effects on the thalamocortical circuits, showed very little induction of c-Fos or JunB. The gene response of striatal interneurons was also highly selective, affecting principally parvalbumin- and NADPH diaphorase-expressing interneurons. The glutamate NMDA receptor antagonist MK-801 strongly reduced the cortically evoked striatal gene expression in all cell types for each gene examined. Because the gene induction that we found followed known corticostriatal somatotopy, was dose-dependent, and was selectively sensitive to glutamate receptor antagonists, we suggest that the differential activation patterns reflect functional specialization of cortical inputs to the direct and indirect pathways of the basal ganglia and functional plasticity within these circuits.

[Sialolithiasis of the submandibular gland: therapeutic options and technical notes]

The Authors report their experience in the surgical treatment of submandibular sialolithiasis, particularly as far as simple sialolithotomy of Wharton's duct and submandibular gland resection are concerned. Care must be taken to minimize the risk of nerve damage (marginal mandibular branch of the facial nerve; lingual nerve; hypoglossal nerve).

Cerebellar influences on accessory oculomotor nuclei of the rat: a neuroanatomical, immunohistochemical, and electrophysiological study

With the aim to evaluate a possible neocerebellar control on eye movements, the projections from the cerebellar lateral nucleus (LN) to the accessory oculomotor nuclei (i.e., the nucleus of posterior commissure, the nucleus of Darkschewitsch, and the interstitial nucleus of Cajal), the putative neurotransmitters subserving this pathway, and the nature of the synaptic influences exerted by these projections were studied in adult rats. We used the orthograde transport of horseradish peroxidase conjugated with wheat germ agglutinin (WGA-HRP) to identify the mesencephalic areas where cerebellofugal fibers terminate, and retrograde labeling with the fluorescent dye fluoro-gold to estimate the incidence of cerebellar neurons projecting to the accessory oculomotor nuclei. Orthograde labeling showed that only a small contingent of cerebellofugal fibers reaches the contralateral accessory oculomotor nuclei. The retrogradely labeled cells were located primarily in the small-celled part of LN. By immunohistochemistry, we observed that all the cells retrogradely labeled from the accessory oculomotor area were also stained by using glutamate or aspartate antisera, but none of them were double-stained with a GABA antiserum. Electrical stimulation of the contralateral LN elicited changes in firing rate of a significant fraction of cells belonging to the accessory oculomotor nuclei (36.4% in the nucleus of posterior commissure, 47.1% in the nucleus of Darkschewitsch, and 44.6% in the interstitial nucleus of Cajal). In 57.8% of the cases, the responses were excitations, most of which had latencies and response characteristics compatible with a monosynaptic linkage. The remaining 42.2% of the cases were inhibitions with latencies ranging between 5 and 22 ms. Extracellular field potential recordings within the contralateral accessory oculomotor nuclei were interpreted as arising from impulses propagating along excitatory axons projecting in a bundle from the cerebellum. Stimulation of LN area in rats following intranuclear injection of kainic acid was not capable of evoking short latency excitations, so these responses can be considered to depend on the activation of LN efferents. The LN projection on accessory oculomotor nuclei could be part of the final precise control exerted by the neocerebellum on those brain structures concerned with movements of the eyes.

Dopamine and glutamate agonists stimulate neuron-specific expression of Fos-like protein in the striatum

1. The monoamine dopamine and the amino acid glutamate are major neurotransmitters in the basal ganglia implicated in the normal functions of the striatum and in extrapyramidal disease states. To study the effects of these neurotransmitters on gene transcription in striatal neurons, we treated rats with dopamine (monoamine) agonists and with glutamate agonists and monitored the induction of Fos-like protein in striatal neurons. We administered the indirect monoamine agonists cocaine and amphetamine intraperitoneally and gave the glutamate agonist quinolinic acid by direct intrastriatal injection. We identified the phenotypes of the responsive neurons by immunohistochemistry and by enzyme histochemistry in double staining protocols. 2. Both the indirect monoamine agonists and the glutamate receptor agonist stimulated rapid nuclear expression of Fos-like protein in specific classes of striatal neurons. The induction by cocaine and amphetamine was blocked by pretreatment with the dopamine D1-like receptor antagonist SCH23390, and the induction by quinolinic acid was blocked by pretreatment with MK-801, a noncompetitive antagonist of the N-methyl-D-aspartate (NMDA) glutamate receptor. 3. The monoamine and glutamate agonists both induced Fos-like protein exclusively in striatal neurons that constitutively expressed the protein phosphatase inhibitor DARPP-32 (dopamine and cAMP-regulated phosphoprotein). 4. The dopamine agonists failed to induce detectable Fos-like protein in striatal neurons expressing enkephalin, even though many such neurons expressed DARPP-32. By contrast, many enkephalinergic neurons did express Fos-like protein in response to glutamatergic stimulation. 5. Glutamate agonist stimulation, but not dopamine agonist stimulation, induced Fos-like protein in a subpopulation of striatal interneurons, namely, a group of neurons exhibiting NADPH-diaphorase activity. 6. These findings suggest that stimulation of dopamine D1-like receptors (or related monoamine receptors) and glutamate NMDA receptors activates neuron-specific programs of immediate-early gene expression in the striatum. Our findings further suggest that monoamine and glutamate may act cooperatively at the transcriptional level on a functionally defined subset of striatal neurons.

The cerebellopontine system: an electrophysiological study in the rat

We examined the effects of electric stimulation of the cerebellar lateral nucleus (LN) in the rat on the activity of single pontocerebellar neurons in the basilar pontine nuclei (BPN) and the reticulotegmental nucleus (RtTg). We found that about half of the cells of these nuclei that were influenced by LN stimulation were inhibited. A significant fraction of both excitatory and inhibitory responses had latencies of less than 4 ms and were able to follow high frequency stimulation, compatible with a monosynaptic linkage. Extracellular field potential recordings within the BPN and RtTg were interpreted as arising from impulses propagating along inhibitory axons projecting in a bundle from the cerebellum to these pontine structures. Microiontophoretic administration of GABA antagonists bicuculline or picrotoxin abolished or attenuated most inhibitory effects. Therefore, we conclude that LN-induced inhibition is most likely mediated by cerebellopontine GABAergic fibers. The functional significance of this cerebellopontine inhibitory circuit is discussed.

Origin of cuneate projections to the anterior and posterior lobes of the rat cerebellum

The present study was carried out to analyze the topography of projections from external cuneate nucleus to the anterior and posterior lobes of the cerebellum and to investigate whether projections to the two lobes come from different cuneocerebellar neurons or from branching axons of the same cells. We used retrograde double-labeling techniques to estimate the incidence of cuneocerebellar neurons projecting to both anterior and posterior lobes via axon collaterals. Cells sending their axons to the lobus anterior were about twice the number of those projecting to the posterior lobe. The double-labeled cells were about 1/7 of all labeled neurons and were located mainly in the more lateral half of the nucleus. Therefore, the two lobes of the cerebellum are likely to receive common information from these cells, but different information from the separate populations of cuneocerebellar neurons that project only to one lobe or the other.

Origin of spinal projections to the anterior and posterior lobes of the rat cerebellum

The present study was carried out to analyze the topography of spinal projections to the anterior and posterior lobes of the cerebellum and to investigate whether projections to the two lobes come from different spinocerebellar neurons or from branching axons of the same cells. We used orthograde transport of horseradish peroxidase conjugated with wheat germ agglutinin (WGA-HRP) to identify the cerebellar areas where spinocerebellar axons terminate and retrograde double-labeling techniques to estimate the incidence of spinocerebellar neurons projecting to both anterior and posterior lobes via axon collaterals. Orthograde labeling confirmed that the rat, like other mammalian species, has spinocerebellar projections to two different regions of cerebellar cortex, i.e., lobules I-V of the anterior lobe and lobule VIII of the posterior lobe, with the highest incidence in lobules II, III, and VIII. We did not observe a clear difference in the distribution of afferents coming from different spinal segments to either of the two lobes. The double-labeled cells were located primarily in the lower thoracic and upper lumbar segments, almost exclusively in Clarke's column and in the dorso-lateral part of lamina 7 (in the region of the spinal border cells). It is likely that most or all of the spinocerebellar neurons in these structures project to both anterior and posterior lobes. Therefore, the two lobes of the cerebellum are likely to receive common information from these cells, but different information from the separate populations of spinocerebellar neurons that project only to one lobe or the other.

Influence of play on creative thinking

The immediate influence of flexible and highly structured play on the creative thinking of 184 fourth-grade boys and girls was investigated. Following either flexible or highly structured art, drama, and playground activities, children's performances on the Torrance Tests of Creative Thinking were evaluated. Children who participated in flexible play experiences showed significantly greater creative thinking than children participating in the highly structured play experiences. No significant differences were found between boys and girls related to effects of flexible and structured play on creative thinking. Implications for curriculum are explored.