DTI-MR tractography of white matter damage in stroke patients with neglect.

Left visual neglect is a dramatic neurological condition that impairs awareness of left-sided events. Neglect has been classically reported after strokes in the territory of the right middle cerebral artery. However, the precise lesional correlates of neglect within this territory remain discussed. Recent evidence strongly suggests an implication of dysfunction of large-scale perisylvian networks in chronic neglect, but the quantitative relationships between neglect signs and damage to white matter (WM) tracts have never been explored. In this prospective study, we used diffusion tensor imaging (DTI) tractography in twelve patients with a vascular stroke in the right hemisphere. Six of these patients showed signs of neglect. Nonparametric voxel-based comparisons between neglect and controls on fractional anisotropy maps revealed clusters in the perisylvian WM and in the external capsule. Individual DTI tractography identified specific disconnections of the fronto-parietal and fronto-occipital pathways in the neglect group. Voxel-based correlation statistics highlighted correlations between patients' performance on two visual search tasks and damage to WM clusters. These clusters were located in the anterior limb of the internal capsule and in the WM underlying the inferior frontal gyrus, along the trajectory of the anterior segment of the arcuate fasciculus (asAF). These results indicate that chronic visual neglect can result from, and correlate with, damage to fronto-parietal connections in the right hemisphere, within large-scale cortical networks important for orienting of spatial attention, arousal and spatial working memory.

A narrative review of family members' experience of organ donation request after brain death in the critical care setting.

INTRODUCTION: Family members of critically ill patients suffer from high levels of anxiety and depression in the ICU, and are at risk of developing post-ICU syndrome following ICU discharge. In the case of brain death, and potential organ donation, the family is at the center of the decision process: within a limited time frame, the family will be informed that the patient is brain-dead and will be approached about potential organ donation. MATERIALS AND METHODS: Family experience with organ donation has been the topic of several research papers allowing one to gain knowledge about family members' experience of organ donation, emphasizing specific needs, adequate support, and pointing out gaps in current delivery of family-centered care. In this narrative review, experts, clinicians, and researchers present the various legal systems regarding family implication in organ donation decisions; describe factors that influence the decision-making process; highlight family perspectives of care and respect for potential donors in the ICU environment; describe the impact of organ donation discussions and decisions on post-ICU syndrome; and suggest communication skills and support to be developed in the future. A research agenda for the next decade is also encouraged. CONCLUSION: Overall, challenges remain and concern all persons involved in the process, ICU doctors and nurses, the organ procurement organization, family members, and, in some cases, the patients themselves. Looking at the big picture will provide opportunities for further improvements.

Brain networks of spatial awareness: evidence from diffusion tensor imaging tractography.

Left unilateral neglect, a dramatic condition which impairs awareness of left-sided events, has been classically reported after right hemisphere cortical lesions involving the inferior parietal region. More recently, the involvement of long range white matter tracts has been highlighted, consistent with the idea that awareness of events occurring in space depends on the coordinated activity of anatomically distributed brain regions. Damage to the superior longitudinal fasciculus (SLF), linking parietal to frontal cortical regions, or to the inferior longitudinal fasciculus (ILF), connecting occipital and temporal lobes, has been described in neglect patients. In this study, four right-handed patients with right hemisphere strokes underwent a high definition anatomical MRI with diffusion tensor imaging (DTI) sequences and a pencil and paper neglect battery of tests. We used DTI tractography to visualise the SLF, ILF and the inferior fronto-occipital fasciculus (IFOF), a pathway running the depth of the temporal lobe, not hitherto associated with neglect. Two patients with cortical involvement of the inferior parietal and superior temporal regions, but intact and symmetrical fasciculi, showed no signs of neglect. The other two patients with signs of left neglect had superficial damage to the inferior parietal cortex and white matter damage involving the IFOF. These findings suggest that superficial damage to the inferior parietal cortex per se may not be sufficient to produce visual neglect. In some cases, a lesion to the direct connections between ventral occipital and frontal regions (ie, IFOF) may contribute to the manifestation of neglect by impairing the top down modulation of visual areas from the frontal cortex.

[Unilateral spatial neglect: a dramatic but often neglected consequence of right hemisphere damage]. / Négligence spatiale unilatérale: une conséquence dramatique mais souvent négligée des lésions de l'hémisphère droit.

INTRODUCTION: Unilateral Spatial Neglect (USN) is a common consequence of right brain damage. In the most severe cases, behavioral signs of USN can last several years and compromise patients' autonomy and social rehabilitation. These clinical facts stress the need for reliable procedures of diagnosis and rehabilitation. STATE OF THE ART: The last 3 decades have witnessed an explosion of studies on USN, which raises issues related to complex cognitive activities such as mental representation, spatial attention and consciousness. USN is probably a heterogeneous syndrome, but some of its underlying mechanisms might be understood as an association of disorders of spatial attention. A bias of automatic orienting towards right-sided objects seems typical of left USN. Afterwards, patients find it difficult to disengage their attention in order to explore the rest of the visual scene. Neglected objects are sometimes processed in an "implicit" way. PERSPECTIVES: The development of behavioural paradigms and of neuroimaging techniques and their application to the study of USN has advanced our understanding of the functional mechanisms of attention and spatial awareness, as well as of their neural bases. A number of new procedures for rehabilitation have recently been proposed. CONCLUSION: The present review describes the clinical presentation of USN, its anatomical basis and some of possible accounts of different aspects of neglect behavior. Results of computer simulations and of rehabilitation techniques are also presented with implications for the functioning of normal neurocognitive systems.

Atlasing the frontal lobe connections and their variability due to age and education: a spherical deconvolution tractography study.

In neuroscience, there is a growing consensus that higher cognitive functions may be supported by distributed networks involving different cerebral regions, rather than by single brain areas. Communication within these networks is mediated by white matter tracts and is particularly prominent in the frontal lobes for the control and integration of information. However, the detailed mapping of frontal connections remains incomplete, albeit crucial to an increased understanding of these cognitive functions. Based on 47 high-resolution diffusion-weighted imaging datasets (age range 22-71 years), we built a statistical normative atlas of the frontal lobe connections in stereotaxic space, using state-of-the-art spherical deconvolution tractography. We dissected 55 tracts including U-shaped fibers. We further characterized these tracts by measuring their correlation with age and education level. We reported age-related differences in the microstructural organization of several, specific frontal fiber tracts, but found no correlation with education level. Future voxel-based analyses, such as voxel-based morphometry or tract-based spatial statistics studies, may benefit from our atlas by identifying the tracts and networks involved in frontal functions. Our atlas will also build the capacity of clinicians to further understand the mechanisms involved in brain recovery and plasticity, as well as assist clinicians in the diagnosis of disconnection or abnormality within specific tracts of individual patients with various brain diseases.

Specific antigen binding by proteins secreted by an antigen-specific T cell hybrid.

Antigen-specific molecules secreted by a murine T cell hybrid specific for azobenzene arsonate (ABA) were purified from ascites fluid by ion exchange chromatography and affinity for antigen. The antigen-specific proteins were purified 250 fold and were resolved predominantly as Mr 110,000 polypeptides by reduction and SDS-polyacrylamide gel electrophoresis. The ability of these molecules to bind antigen was analyzed by an ELISA using antigen-coated microtiter trays. Binding of the T cell proteins to antigen was detected with antisera specific for the proteins. Antigen binding to ABA-ovalbumin but not ovalbumin was optimal at 37 degrees C and protein derived from another T cell hybrid did not bind ABA-ovalbumin. Solid phase antigen binding was inhibited specifically by soluble ABA-ovalbumin, indicating that these T cell-derived proteins bind nominal antigen in the solid or liquid phase. It is suggested that these proteins represent a soluble, antigen specific manifestation of some T cell function.

Synthesis of (aryloxy)alkylamines. 2. Novel imidazo-fused heterocycles with calcium channel blocking and local anesthetic activity.

A series of imidazo-fused heterocycles substituted with an aryloxy)alkylamine side chain were prepared as modifications to butoprozine (I) and found to possess calcium channel blocking activity similar in potency to that of bepridil in trachea smooth muscle and similar to that of verapamil in nitrendipine binding affinity in rabbit cardiac muscle. Of the various imidazo-fused heterocycles prepared, the imidazo[1,2-a]pyridines were also found to be potent local anesthetic agents. While most compounds in this series were equipotent to lidocaine in our initial screen, compounds 2 and 35 showed local anesthetic activity approximately 100 times more potent than lidocaine in our preliminary assays. These compounds represent a novel structural class of local anesthetic agents, and compound 2 is under further investigation.

Synthesis of (aryloxy)alkylamines. 1. Novel antisecretory agents with H+K+-ATPase inhibitory activity.

A series of heterocyclic (aryloxy)alkylamines of structures II and III were prepared and found to possess gastric antisecretory activity. Of the variety of substituted thiazoles, benzoxazoles, and benzothiazoles prepared, thiazole 18, benzoxazole 32, and benzothiazole 47 exhibited gastric antisecretory potency comparable to that of ranitidine in vivo in the pylorous ligated rat model. In an isolated rabbit parietal system, the series of thiazoles, benzoxazoles, and benzothiazoles also demonstrated similar potency to that of ranitidine toward the inhibition of both histamine-stimulated and dcAMP-stimulated uptake of amino[14C]pyrine. These compounds inhibited the H+K+-sensitive ATPase enzyme in isolated gastric microsomes. A direct correlation existed between inhibition of 14C uptake, in vivo antisecretory activity, and inhibition of the H+K+-ATPase enzyme. The more potent antisecretory compounds 18, 32, and 47 were also the more potent enzyme inhibitors. These data suggest that the mechanism responsible for the observed in vitro and in vivo gastric antisecretory activity, in these series of compounds, is a consequence of the inhibition of the H+K+-sensitive ATPase enzyme.

Novel thiazole-based heterocycles as selective inhibitors of fibrinogen-mediated platelet aggregation.

The synthesis and biological activity of novel thiazole-based heterocycles as inhibitors of thrombin-induced human platelet aggregation are described. Further evaluation of selected compounds show they inhibit platelet aggregation as stimulated by a variety of agonists. The more active compounds also were found to inhibit fibrinogen binding to platelets. To further delineate the mechanism of action of these compounds, direct binding studies with the purified glycoprotein (GP) IIb/IIIa receptor were performed. Flow cytometry analyses of 24 and 32 indicate that these compounds block the activation process of the GPIIb/IIIa receptor without denaturing the integrin receptor. On the basis of these studies, 32 exhibited the best profile as a novel nonpeptide inhibitor of fibrinogen-mediated platelet aggregation.

Thiophene systems. 14. Synthesis and antihypertensive activity of novel 7-(cyclic amido)-6-hydroxythieno[3,2-b]pyrans and related compounds as new potassium channel activators.

The synthesis and antihypertensive activity of novel 7-(cyclic amido)-6-hydroxy-5,5-dimethylthieno[3,2-b]pyrans and related compounds are described. The compounds were tested for oral antihypertensive activity in spontaneously hypertensive rats (SHR) and selected compounds were evaluated in vitro for increases in 86Rb efflux in rabbit isolated mesenteric arteries. The effects on activity in SHR of lactam ring size, the presence of heteroatoms in the lactam ring, the relative stereochemistry at C-6 and C-7, and the substituents on the thiophene ring are examined. The best racemic compound in this series is 32, trans-5,6-dihydro-6-hydroxy-5,5-dimethyl-2-nitro-7-(2-oxopiperidin -1-yl)-5H- thieno[3,2-b]pyran, which is 10-fold more potent than cromakalim with an ED30 = 0.015 mg/kg in SHR. Compound 32 could be resolved and the antihypertensive activity determined to reside primarily in the (6S,7S)-(-)-enantiomer 41. Surprisingly, the elimination of water to give the enamides 50-52, thiophene isosteres of bimakalim, diminishes activity significantly.

Endocannabinoid-mediated synaptically evoked suppression of GABAergic transmission in the cerebellar cortex.

Presynaptic CB(1) cannabinoid receptors are frequently targets of endogenous cannabinoids (endocannabinoids) released from postsynaptic neurons. It is known that the glutamatergic afferent input to a neuron can trigger endocannabinoid production and that the released endocannabinoid can suppress the glutamatergic input. We tested the hypothesis that activation of the glutamatergic input to a neuron leads to an endocannabinoid-mediated suppression of the GABAergic afferent input to the same neuron. Spontaneous postsynaptic currents (sPSCs) were recorded with patch-clamp techniques in Purkinje cells in mouse cerebellar brain slices. Activation of the climbing fiber-mediated glutamatergic input to Purkinje cells led to a suppression of the sPSCs by 34+/-3%. This suppression was mostly due to suppression of GABAergic spontaneous inhibitory postsynaptic current (sIPSCs), because 93% of the sPSCs recorded in Purkinje cells were GABAergic sIPSCs. Blockade of ionotropic, but not metabotropic glutamate receptors, prevented the suppression. The climbing fiber activation led to an increase in calcium concentration in the Purkinje cells, and this increase was necessary for the suppression of sPSCs, because the suppression did not occur when the calcium increase was prevented by BAPTA. No sPSC suppression was observed in the presence of the CB(1) antagonist rimonabant or the diacylglycerol lipase inhibitor orlistat. In a further series of experiments GABAergic sIPSCs were recorded: these sIPSCs were also suppressed after climbing fiber activation, and the suppression was sensitive to the CB(1) antagonist SLV319. Finally, the GABAergic synaptic transmission between molecular layer interneurons and Purkinje cells was directly studied on simultaneously patch-clamped neuron pairs. Climbing fiber activation led to suppression of the interneuron --> Purkinje cell synaptic transmission. The results point to a novel form of endocannabinoid-mediated heterosynaptic plasticity. The endocannabinoid production in a neuron is triggered by its glutamatergic synaptic input and is dependent on an increase in intracellular calcium concentration. The produced endocannabinoid, in turn, suppresses the GABAergic synaptic input to the neuron by activating CB(1) cannabinoid receptors.

Regulation of the extracellular signal-regulated kinases following acute and chronic opioid treatment.

The adaptations in extracellular signal-regulated kinase (ERK) pathway activity result in alterations in transcription of several genes that can be essential for development of both opioid tolerance and dependence. In this study, we investigated the effect of acute and prolonged opioid treatment on ERK pathway activity in SH-SY5Y cells. Acute administration of morphine and DAMGO stimulated ERK activity and this stimulation required activation of Ca(2+)/calmodulindependent kinase II (CaMKII) and protein kinase C (PKC). In contrast, prolonged morphine treatment decreased the level of phosphorylated ERK. The pr ecipitation of withdrawal further decreased the ERK1/2 activity. The principal finding of these studies is demonstration that the activation of CaMKII and PKC is required for ERK stimulation following acute opioid treatment while in a chronic morphine treatment and withdrawal, the up-regulation of PKC and CaMKII pathways seems to be engaged in the ERK inhibition. These results provide evidence that both opioid administration and opioid withdrawal, affecting similar intracellular pathways, can exert different effects on ERK activity.

Appearance of T lymphocyte-derived proteins specific for the immunizing antigen in serum during a humoral immune response.

Some T lymphocytes produce extracellular proteins that bind nominal antigen specifically (TABM), and these proteins exhibit potent immunoregulatory activity. We have utilized an ELISA for Ag binding by Ag-specific TABM to detect and quantitate the appearance of Ag-specific TABM in murine serum during a humoral Ir to protein Ag. The TABM response was specific for the inducing Ag, stronger and more rapid during a secondary response, and temporally distinct from the appearance of Ig. The non-Ig serum TABM were bound by mAb specific for TCR-alpha chains and isolated by affinity for Ag were Mr 110,000 polypeptides. The TABM response did not occur in scid/scid mice unless the mice were reconstituted with thymocytes and thymocyte-reconstituted scid/scid mice produced TABM, but did not produce Ig. The results suggest that soluble TABM are an Ag-specific humoral manifestation of the Ir of some T lymphocytes.

T cell-derived antigen-specific humoral immune response. II. Further characterization of the response and the antigen binding T cell immunoproteins.

Murine T lymphocyte-derived proteins which bind nominal antigen specifically (TABM) were detected in serum during a humoral immune response to bovine serum albumin. The TABM response was observed only when the adjuvants polyadenylic:polyuridylic acid complex (poly(A: U)), Freund's complete adjuvant or Titermax were used concurrently with antigen to immunize. When poly(A:U) was used, higher doses of antigen were optimal to stimulate TABM production than those required to stimulate immunoglobulin production. The binding of TABM in the serum of BSA-immunized mice to BSA in solid phase was inhibited specifically by 10-fold more BSA than that required to inhibit BSA-specific immunoglobulins suggesting that TABM have much less affinity for antigen than immunoglobulins. Immunoblotting of TABM in serum from BSA-immune mice, which bind BSA, demonstrated that these serum TABM are comprised of M(r) 110,000 polypeptides linked by disulfide bonds. Antigen-specific proteins in a lysate of an NP-specific T cell hybrid inhibited the recognition of serum TABM by anti-TABM antiserum while a lysate of a B cell hybridoma was not inhibitory, and serum TABM were adsorbed by monoclonal antibodies to TCR-C beta. These results provide more evidence that serum TABM may be a soluble analogue of the T cell receptor for antigen.

Microgenia as a factor making endotracheal intubation impossible.

The authors report a case of microgenia which made endotracheal intubation impossible in a patient with pharyngeal stenosis. It is suggested that laryngological examination should precede the operation and when endotracheal intubation is impossible tracheostomy should be performed.

Discovery of the first non-peptide antagonist of the motilin receptor.

A first-in-class non-peptide antagonist of the motilin receptor was identified through electronic screening of our corporate database against a 3D pharmacophore. The pharmacophore was developed from the motilin 22 residue endogenous peptide using NMR structural data, principles of peptide folding, and peptide structure activity relationships. The NMR data supported helical content within the peptide, and both the hydrophobic staple and N-capping box motifs were identified in the motilin sequence. The conformational features of these motifs were imposed on the peptide structure, providing a constrained conformer as a starting point for database searching. A trisubstituted cyclopentene lead was identified directly from the electronic search. Compounds in this series inhibit the binding of 125I-motilin to human antral smooth muscle membrane and antagonize motilin-induced intracellular calcium mobilization in cells expressing the human motilin receptor. A potent compound developed through optimization, RWJ 68023, is active in binding and cell-based functional assays and is also effective in inhibiting motilin-induced contractility in segments of rabbit duodenum. This orally active compound is currently undergoing clinical evaluation for the treatment of gastrointestinal disorders associated with altered motility.