An exploratory study of the neural mechanisms of decision making in compulsive hoarding.

BACKGROUND: Prior studies have suggested unique patterns of neural activity associated with compulsive hoarding. However, to date no studies have examined the process of making actual decisions about whether to keep or discard possessions in patients with hoarding symptoms. An increasing body of clinical data and experimental psychopathology research suggests that hoarding is associated with impaired decision making; therefore, it is important to understand the neural underpinnings of decision-making abnormalities in hoarding patients. METHOD: Twelve adult patients diagnosed with compulsive hoarding, 17% of whom also met criteria for obsessive-compulsive disorder (OCD), and 12 matched healthy controls underwent functional magnetic resonance imaging (fMRI) while making decisions about whether or not to discard personal paper items (e.g. junk mail) brought to the laboratory as well as control items that did not belong to them. Items were either saved or destroyed following each decision. RESULTS: When deciding about whether to keep or discard personal possessions, compulsive hoarding participants displayed excessive hemodynamic activity in lateral orbitofrontal cortex and parahippocampal gyrus. Among hoarding participants, decisions to keep personal possessions were associated with greater activity in superior temporal gyrus, middle temporal gyrus, medial frontal gyrus, anterior cingulate cortex, precentral gyrus, and cerebellum than were decisions to discard personal possessions. CONCLUSIONS: These results provide partial support for an emerging model of compulsive hoarding based on complications of the decision-making process. They also suggest that compulsive hoarding may be characterized by focal deficits in the processing of reward and changes in reward contingencies, particularly when these are perceived to be punishing.

Efficacy of tacrine and lecithin in mild to moderate Alzheimer's disease: double blind trial.

OBJECTIVE: To assess the efficacy of tacrine and lecithin in treating Alzheimer's disease over nine months. DESIGN: Double blind randomised controlled trial. SETTING: Outpatients clinic of university department of geriatric medicine. SUBJECTS: 53 subjects (26 women, 27 men) with probable Alzheimer's disease. 41 completed the dose finding phase and were randomised to treatment. 32 (14 tacrine, 18 placebo) completed nine months' treatment. INTERVENTIONS: Lecithin and tacrine or lecithin and placebo for 36 weeks. MAIN OUTCOME MEASURES: Scores on neuropsychological tests sensitive to deficits in the cholinergic system; mini-mental state score; behaviour change; mood; functional state; and stress in carers. RESULTS: The tacrine and placebo groups were similar except that the tacrine group had a longer duration of disease (mean 5.4 v 2.5 years in placebo group; P = 0.003). Only 17 of the 32 patients could tolerate the maximum dose of tacrine (100 mg). No significant difference was found between the groups for any of the tests after nine months' treatment except for the digit backwards test, which is insensitive to cholinergic deficit. Analysis of subjects taking the maximum dose of tacrine and of subjects with mild dementia also found no differences. CONCLUSIONS: Tacrine produces no clinically relevant improvement over 36 weeks at the doses tolerated by these patients.

Cholinergic 'blockade' as a model of the cognitive deficits in Alzheimer's disease.

The performance of 44 Alzheimer patients and 33 controls was examined on tests previously found to be differentially affected by scopolamine administration. Tests of secondary memory, performance intelligence, primary memory, semantic retrieval, procedural memory and verbal intelligence were included. It was found that Alzheimer patients performed more poorly than controls on tests of secondary memory, as measured by selective reminding, recall and recognition. Procedural memory, as measured by stem completion, homophone spelling and transformed text reading, did not differ between Alzheimer patients and controls. Semantic memory, verbal intelligence and primary memory were impaired in moderate and severe cases. However, patients with 'mild' dementia, as measured by the Mini-Mental State Examination, did not differ from controls on tests of semantic memory, verbal intelligence and primary memory. It was concluded that the pattern of anterograde memory deficits and preserved abilities in mild dementia mimicked that previously observed in scopolamine administration in young subjects.

Increased production of cysteinyl leukotrienes in hepatorenal syndrome.

The cysteinyl leukotrienes C4 and D4 are potent renal vasoconstrictors which may modulate glomerular function in vivo, and may therefore be important in the pathogenesis of hepatorenal syndrome. Urinary leukotriene E4, the major metabolite of leukotrienes C4 and D4, was elevated in patients with hepatorenal syndrome (17.8 ng/h) when compared with normal controls (5.1 ng/h) or subjects with renal failure alone (1.9 ng/h). Urinary leukotriene E4 was also elevated in subjects with decompensated liver disease (cirrhosis with ascites 28.6 ng/h, severe hepatocellular dysfunction 57.5 ng/h), but normal in compensated liver disease (6.7 ng/h). In the early stages of hepatorenal syndrome, leukotriene E4 excretion rate was up to 100-fold higher (560 ng/h) than in normals, and fell in parallel with creatinine clearance, indicative of the glomerular filtration rate-dependent renal excretion. Following correction for creatinine clearance, leukotriene E4, excretion was considerably higher in hepatorenal syndrome (54.1 pg/ml creatinine clearance) compared with normals (1.0 pg/ml creatinine clearance), chronic renal failure (3.2 pg/ml creatinine clearance), decompensated liver disease (ascites 7.7 pg/ml creatinine clearance, and severe hepatocellular dysfunction 11.0 pg/ml creatinine clearance), and compensated liver disease (1.9 pg/ml creatinine clearance). To interpret the significance of these findings, we determined renal clearance and endogenous metabolism of the cysteinyl leukotrienes by infusion of [3H]leukotriene C4 into a single subject with hepato-renal syndrome and two control subjects. Renal clearance of leukotriene E4, was reduced in hepatorenal syndrome (2.4 ml/min) compared with controls (greater than 17 ml/min) which together with the increased excretion rate of leukotriene E4 demonstrates that there is increased cysteinyl leukotriene production in hepatorenal syndrome. This may be one of the factors involved in its pathogenesis.

Leukotriene C4 elimination and metabolism in man.

Three doses of radiolabeled leukotriene C4 (0.2 to 15 muCi) were infused into three subjects to investigate its metabolism and routes of elimination during 4 days. Between 12% and 20% of the infused dose was recovered in the urine within 24 hours, of which a substantial and relatively constant proportion (4.1% to 6.3% total dose) appeared as leukotriene E4 (LTE4), mainly in the first 4 hours. Polar omega-oxidation products, N-acetyl LTE4, and tritiated water were also present. Fecal elimination accounted for a further 30% to 40% of the infused dose. In the absence of altered metabolism or biliary excretion, urinary LTE4 may be a useful measure of whole body production of the cysteinyl leukotrienes.

Pulmonary endothelium-derived relaxing factor is impaired in hypoxia.

1. The vasoconstrictor and vasodilator activity of cultured bovine pulmonary artery endothelial cells was measured to determine how exposure to different partial pressures of O2 [PO2 142,42 and 15 mmHg (18.9, 5.6 and 2 kPa)] affects the production of endothelial-derived relaxing and constrictor factors. 2. A de-endothelialized rat aortic ring [maintained at a PO2 of 142 mmHg (18.9 kPa)] was used to bioassay the effluent from a perfused column of bovine endothelial cells grown on microcarrier beads. The endothelial cells were stimulated by 10(-7) mol/l bradykinin given for 1 min at 12 min intervals. 3. At the start, middle and end of the experiment the bovine endothelial cells were exposed to a PO2 of 142 mmHg (18.9 kPa) and when stimulated by bradykinin the perfusate caused respectively a 70 +/- 4%, 63 +/- 6% and 63 +/- 6% (mean +/- SEM) relaxation of an aortic ring which had been pre-contracted by 10(-6) mol/l phenylephrine. At a PO2 of 42 mmHg (5.6 kPa) the relaxation induced by the cells was not significantly altered, but this tailed to zero after 26-38 min exposure of the cells to a PO2 of 15 mmHg (2 kPa). 4. These responses were unaltered by the presence of 10(-5) mol/l indomethacin, suggesting that prostacyclin is not a significant vasodilator in this system. 5. Reduced production of endothelium-derived relaxant factor rather than production of a constrictor factor, or a direct effect on the smooth muscle, may be involved in pulmonary hypoxic vasoconstriction.

Urinary leukotriene E4 after antigen challenge and in acute asthma and allergic rhinitis.

The leukotrienes LTC4, D4, and E4 are potent bronchoconstrictor agents and are thought to have an important role in asthma. Urinary LTE4, a stable urinary end-product of LTC4 and LTD4, was measured, by means of high-performance liquid chromatography and radioimmunoassay. LTE4 excretion followed a log-normal distribution in twenty-nine healthy controls, with a geometric mean of 23.8 (95% confidence interval 19.9-28.2) ng/mmol creatinine. Urine was collected from eight atopic subjects for 3 h after antigen inhalation and a control urine collection was made a week later at the same time of day. Urinary LTE4 was significantly higher after antigen challenge than in the control sample (153.7 [87.1-271.3] vs 23.5 [13.7-69.5] ng/mmol creatinine; p less than 0.01). Urinary LTE4 was also measured in twenty patients with severe acute asthma and nine patients with seasonal allergic rhinitis. Mean urinary LTE4 was higher in the asthmatic patients (78.3 [46.5-131.8] ng/mmol creatinine) than in normal subjects (p less than 0.01), although there was substantial overlap into the normal range. The urinary LTE4 values of the rhinitis patients were within the normal range whether or not they had symptoms. LTC4 and LTD4 were also found in bronchoalveolar lavage fluid from one of the three atopic subjects challenged with antigen before lavage, and in a single patient who underwent lavage after admission with severe acute asthma. These studies provide evidence that leukotrienes are released in vivo in man after antigen challenge and in acute asthma.

Leukotriene E4 release in cold urticaria.

Cold urticaria is a rare condition characterized by abnormal wealing following exposure to cold. It has been suggested that lipid-derived mediators may be involved in the pathogenesis of this condition. We have investigated whether the inflammatory reaction in cold urticaria is associated with the release of cysteinyl-leukotrienes. Leukotriene E4 (LTE4; a stable metabolic product of LTC4 and LTD4) and histamine were measured in the blood draining the site of a cold-challenge in five patients with clinical histories of cold urticaria. Three of the patients showed a typical clinical response to the challenge, and this was associated with an increase in the concentration of LTE4 and histamine. No increase in LTE4 or histamine levels were observed following cold challenge in the non-responding individuals.

Single-step procedure for the extraction and purification of leukotrienes B4, C4 and D4.

A rapid and simple method for the on-line concentration and high-performance liquid chromatographic (HPLC) purification of the leukotrienes in good yield from biological fluids is described. Readily available antisera are used in conjunction with this system to give a specific and sensitive assay for leukotrienes B4, C4 and D4 with sub-nanogram limits of detection. Tritium-labelled leukotrienes are used as internal standards, both to locate the leukotrienes post-HPLC and to accurately determine recoveries.

Oral nafazatrom in man: effect on inhaled antigen challenge.

The effect of oral nafazatrom (Bay g6575, 2 X 3 g) or placebo on inhaled antigen challenge was assessed in a double-blind study. In four subjects antigen challenge resulted in an immediate fall of 93.2 +/- 3.36% in airflow at 40% of vital capacity (Vp40) and a 45.85 +/- 4.95% reduction in forced partial expiratory volume at one second (FEV1). Neither nafazatrom nor placebo had any effect on baseline lung function or that after challenge. Leukotriene B4 was generated by ex vivo stimulus of blood with ionophore A23187, and quantified by high performance liquid chromatography (h.p.l.c.)-radioimmunoassay. No inhibition of LTB4 formation occurred ex vivo following oral nafazatrom, although addition of 10(-5) M nafazatrom to blood in vitro significantly inhibited LTB4 release. Peak plasma nafazatrom levels during the study ranged from 3.3 X 10(-7) M to 1.47 X 10(-6) M which are below the concentration (10(-5) M) at which significant 5-lipoxygenase inhibition occurs in vitro. Oral nafazatrom is ineffective as a 5-lipoxygenase inhibitor in man, probably because of poor bioavailability after administration.