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QUESTIONS UNDER STUDY/PRINCIPLES: We describe the proportion of severely depressed outpatients reaching complete remission at the different stages of a drug treatment algorithm. We compare several treatment options for SSRI (selective serotonin reuptake inhibitor) non-responders and test the feasibility of the algorithm in clinical conditions. METHODS: Patients with severe depressive disorders (ICD-10; MADRS > or = 25) admitted to an academic outpatient clinic were enrolled in this algorithm-guided sequential treatment protocol (starting with an SSRI and ending with a tricyclic, lithium, triodothyronine combination). The general principle of the algorithm was to boost the drug therapy in the event of non-response. RESULTS: 135 patients entered the study and 131 were eligible for analysis. From this group, 86 patients dropped out (65.6%), 40 reached complete remission (30.5%) and 5 patients did not reach remission at all (3.8%). In the 117 patients to whom a last observation carried forward approach was applied, the median improvement of the MADRS score was 48.0% (range -20.7%-100%), with 48.7% of patients considered responders, 23.1% partial responders and 28.2% non-responders. Median retention time was 8 weeks (range 2-34). CONCLUSIONS: This algorithm-guided antidepressant treatment was acceptable for clinicians and resulted in an elevated final response rate among study completers. However, the dropout rate was high, mainly due to treatment interruption or non-observance.

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OBJECTIVE: Although genetic factors have been implicated in the etiology of bipolar disorder, no specific gene has been conclusively identified. Given the link between abnormalities in serotonergic neurotransmission and bipolar disorder, a candidate gene association approach was applied to study the involvement of the monoamine oxidase A (MAOA) gene, which codes for a catabolic enzyme of serotonin, in the susceptibility to bipolar disorder. METHOD: In France and Switzerland, 272 patients with bipolar disorder and 122 healthy subjects were typed for three polymorphic markers of the MAOA gene: the MAOA-CA repeat, the MAOA restriction fragment length polymorphism (RFLP), and a repeat directly adjacent to the variable number of tandem repeats (VNTR) locus. RESULTS: A significant difference in the distribution of the alleles for the MAOA-CA repeat was observed between the female bipolar patients and comparison group. CONCLUSIONS: The results obtained in the French and Swiss population confirm findings from two studies conducted in the United Kingdom.

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Despite numerous suggestions of the involvement of GTP-binding proteins in the mechanisms of action of psychoactive drugs in bipolar affective disorder, few studies have been conducted during the drug treatment of patients. The aim of the present study was to investigate the effects of a mood stabilizer and an antipsychotic drug on Galphas proteins. Patients with bipolar affective disorder under lithium treatment with or without haloperidol were assessed with respect to their mononuclear leukocyte (MNL) Galphas subunit protein. Galphas-45 protein subunit levels were analyzed by the Western immunoblot method. The subjects consisted of a group of 20 patients, all diagnosed as euthymic bipolars, and a comparison group of 15 drug-free healthy subjects. Results showed that Galphas levels were significantly decreased in the bipolar patients (BP) compared to drug-free healthy subjects (Mann-Whitney U test, p < 0.002). The drug effect was evaluated by a factorial analysis of variance and showed significant differences between groups (Kruskal-Wallis H test, p < 0.02). Lithium-treated patients displayed the most decreased Galphas levels (normalized mean values 53.2 +/- 31 vs. 122 +/- 45% for BP and controls, respectively, p < 0.001), while no change was observed in Galphas levels of haloperidol-treated patients compared to controls (mean values: 124.9 +/- 37%; NS). The data indicate that lithium and haloperidol affect the mechanism of Galphas protein signal transduction differently, consistent with previous animal studies.

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The effects of active immunization against peripheral insulin beta subunits on different sleep variables and food consumption were studied in rats. Insulin subunits beta coupled to thyroglobulin was used as immunogen and rats immunized with thyroglobulin alone served as controls. Active immunization against insulin beta subunits affects sleep variables, particularly slow-wave sleep during the dark period, increasing significantly this stage of sleep and decreasing waking. Feeding behavior and body weight remained unchanged. These results are compatible with previous studies showing a positive correlation between decrease of insulin secretion and sleep disturbances. A possible relationship between peripheral alpha and or beta subunits of insulin, sleep, and feeding is suggested.

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The purpose of this study is to report a case of a very large arachnoid cyst in a patient having spent a very active life and who had never presented any neurological or psychiatric symptomatology beside a dementia in the last years of her life. The gross examination of the brain revealed the presence of a voluminous frontal bilateral cyst, located in the midline and displacing laterally the frontal lobes, so they displayed a foliated aspect. Microscopically, the examination of the cyst walls confirmed its arachnoid origin and the cerebral cortex contained lesions typical for senile dementia. This case exemplifies the histological nature and the pathogeny of arachnoid cysts, in particular of congenital origin. This also shows that the very early occurrence of such a malformation does not prevent the development of functional neuronal pathways, owing to the important plasticity of the central nervous system.

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Monoclonal antibodies were produced following immunization of rats with delta sleep-including peptide (DSIP). The spleen cells of the rats were fused with the myeloma cell line SP2/0. The supernatants of hybridomas were screened on a solid-phase immunoassay using dot-immunobinding of DSIP and some DSIP fragments. The supernatants of six stable producer clones were found to react with DSIP. From this procedure it was also deduced that all these monoclonal antibodies recognized epitope(s) of the penta carboxy-terminal region of DSIP (DSIP5-9). Application of these monoclonal antibodies to rat median eminence sections gave a strong immunolabelling of a large population of fibres and terminal-like structures, mainly localized through the lateral areas. Elution-restaining experiments using a monoclonal antibody to DSIP and a polyclonal antiserum to luteinizing hormone-releasing hormone (LHRH) showed that the patterns of immunoreactivity respectively visualized overlap almost completely. Although numerous LHRH-immunoreactive neuronal elements were also easily demonstrated in the median eminence of the mouse, the hamster and the gerbil species, incubation of sections with monoclonal antibodies to DSIP failed to give any immunoreaction. Taken together these data argue for the independence of the DSIP/LHRH immunolabelling systems. Furthermore, it was demonstrated that DSIP5-9-related epitopes detected in the rat median eminence have no counterpart in the three other rodent species investigated. These species differences may reflect the fact that the carboxy-terminal sequence of the nonapeptide DSIP originally discovered in the rabbit is not conserved in all rodent species.

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Alzheimer's disease (AD) is characterized neuropathologically by high densities of neurofibrillary tangles (NFT) and neuritic plaques (NP) in the cerebral cortex, in particular in neocortical association areas and in the hippocampal formation. We report here the case of an AD patient who developed signs of motor dysfunction early in the clinical evolution. A quantitative neuropathologic analysis revealed much higher densities of NFT and NP in the primary motor cortex than is usually observed in AD. This case, together with other reports, points to the existence of neurologically defined subgroups of AD with unusual clinical deficits that are correlated with the regional and laminar distribution of NP and NFT, and further supports the hypothesis that the symptomatology presented by AD patients results from the loss of specific neuronal populations leading to a syndrome of global cortical disconnection.

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Several studies have demonstrated that the accurate visualization and quantification of pathological lesions in neurodegenerative disorders depend on the reliability of staining methods. In an attempt to gain a better assessment of the density and distribution of the neuropathological markers of Alzheimer's disease, we compared the staining efficiency of a modified thioflavine S protocol for neurofibrillary tangles (NFT) and senile plaques (SP) to different argentic impregnation techniques (Bielchowsky, Gallyas, Globus, Campbell-Switzer-Martin) and to immunohistochemical stainings obtained with two different antibodies against the amyloid beta protein A4 and the microtubule-associated tau protein. The modified thioflavine S technique (MTST) detects up to 60% more SP and up to 50% more NFT than the Bielschowsky and Globus methods, respectively. The results obtained with the specific antibodies are comparable to those obtained with the MTST, but these immunotechniques are more expensive and time consuming for routine neuropathological evaluation, and the appropriate antibodies are not always commercially available. Furthermore, the morphological appearance of NFT and SP with MTST is greatly improved when compared to the classical thioflavine S and the increased signal-to-noise ratio between specifically stained structures and background permits an accurate semi-automatic quantification.

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The present status of research clearly demonstrates the occurrence of lesions characteristic of Alzheimer's disease in patients suffering from a Down's syndrome or trisomy 21. The senile plaques appear very early in trisomy 21 (from the age of 20) and are constant after 40 or 45 years. In these two illnesses, the beta-amyloid protein or A4 protein (4.2 kD) leads to deposits in preferential regions of the central nervous system within two compartments: 1) intracellular, contributing to the formation of neurofibrillary tangles and 2) extracellular, making up the amyloid center of senile plaques as well as around the wall of some blood vessels, then corresponding to the amyloid congophilic angiopathies. Unexpectedly, larger proteins including the A4 sequence have been shown to be normally present in several tissues of normal as well as sick individuals and represent possible precursors of the A4 protein. Alzheimer's disease may happen either sporadically or following a familial incidence associated with an autosomic dominant mode of transmission. Moreover, the risk of incidence of trisomy 21 seems to be enhanced for collaterals of Alzheimer's disease patients. Since 1987, the use of molecular biology tools has revealed particularly fruitful. A linkage analysis has been undertaken that showed an association of the putative gene for the familial form of Alzheimer's disease (FAD) with the gene coding for amyloid precursor proteins (APP).(ABSTRACT TRUNCATED AT 250 WORDS)

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Using the indirect immunofluorescence method, the distribution of the delta sleep-inducing peptide was studied in the cat brain and hypophysis. Delta sleep-inducing peptide-like-immunoreactive cell bodies mostly visualized in colchicine-pretreated animals were mainly found scattered throughout the diagonal band of Broca, the ventral septum and the anterior hypothalamic areas. A few immunoreactive cell somata were also seen in the ventrolateral hypothalamic area and more occasionally in the triangular septal nucleus. The heaviest concentrations of delta sleep-inducing peptide-like-immunoreactive varicose fibres and terminal-like structures were observed in the septo-preoptic region, in the median eminence and pituitary stalk. Some other brain regions supplied with few delta sleep-inducing peptide-immunoreactive fibres included the fimbria-fornix, the dorsal part of the subfornical organ, the medial habenular nucleus and more caudally, the periaqueductal gray. Elution-restaining experiments revealed that delta sleep-inducing peptide-like immunoreactivity frequently occurred in luteinizing hormone-releasing hormone-immunoreactive neurons and vice versa. At the pituitary level, delta sleep-inducing peptide-like immunoreactivity was detected in most, if not all, melanocorticotropes of the pars intermedia and further in a large subpopulation of corticotropes mainly located in the zona tuberalis of the pars distalis. Taken together these anatomical findings support the view that delta sleep-inducing peptide (or a closely related molecular form) could play a modulatory role at various levels of the hypothalamo-pituitary system.

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Seventeen cases of Huntington's chorea have been studied on a clinical and anatomopathological basis. Fourteen genealogical trees have been established. Clinically, involuntary movements of choreic type and an impairment of higher brain functions are constant symptoms. Gait disorders, dysarthria and a tendinous hyperreflexia are usual (present in 95, 95 and 80% of cases). Anorexia, muscular hypotony and dysphagia are also frequent (present in 75, 60 and 50% of cases). The neuropathological examination shows macroscopically a neostriatal atrophy in 90% of cases and a cerebral cortical atrophy in 75%. Microscopically, a neuronal loss--mainly in small cells (Golgi II)--is evident in the neostriatum of all the cases. The pallidum is also affected, but to a lesser degree. A cortical cell loss is present in 90% of the cases, mainly in layers III, IV, V and sometimes also in layer VI of frontal and parietal lobes. In 75% of the cases, a cortical gliosis is noticed, mostly at the level of the frontal pole.

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Substance P-like immunoreactivity was visualized by immunohistochemical methods in 20 postmortem brains: 6 senile, 4 presenile Alzheimer dementia (AD), 3 AD with interhemispheric asymmetric cortical atrophy, and 7 control cases. For all pathological cases, the SP-like immunoreactivity was significantly reduced in the neocortical areas and in the hippocampus. This contrasted with an enhanced SP-like immunoreactivity in the pallidum and the substantia nigra in AD brains and a more pronounced SP-like immunoreactivity in the more atrophic side in the asymmetrically atrophied brains.

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The distribution of delta sleep inducing peptide (DSIP) in the rabbit brain has been studied with immunohistochemical techniques. DSIP-like immunoreactivity was predominantly detected in the basal forebrain, hypothalamus and hypophysis. Even in colchicine-pretreated animals, immunolabeled cell bodies were relatively few. They were mostly scattered through the ventrolateral septum, the diagonal band of Broca and preoptic areas. Clusters of positive cell bodies were also found in the arcuate nucleus and adjacent lateral hypothalamic areas. Large populations of varicose fibers and terminal-like structures were observed in the juxtaventricular zone of the ventrolateral septum, in the preoptic areas and lamina terminalis especially around the preoptic recess of the third ventricle and more caudally, in the ventromedial nucleus of the hypothalamus. Dense networks of immunolabeled fibers were visualized in the median eminence and pituitary stalk where many fibers could be seen in close apposition to the capillaries. Many DSIP-immunoreactive fibers were observed in the subfornical organ. Other extra-hypothalamic regions displaying a low-to-moderate density of immunoreactive fibers were the indusium griseum, the hippocampus, the fimbria of the fornix, the subcommissural organ, the medial habenula and, occasionally, the medial periaqueductal gray. Most cells of the pars intermedia and a few cells of the pars distalis of the anterior pituitary were DSIP-immunoreactive. Taken together these results in the rabbit brain emphasize the predominant localization of DSIP-like immunoreactivity in areas related to the hypothalamic neurosecretory systems.

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The anatomical distributions of luteinizing hormone-releasing hormone and delta sleep-inducing peptide immunoreactivity in the rabbit brain were studied by indirect immunofluorescence technique. The comparison of adjacent serial sections, one being immunolabeled with an antiserum to luteinizing hormone-releasing hormone, the other with an antiserum to delta sleep-inducing peptide, showed that the respective distribution patterns of immunoreactivity exhibited a remarkable overlap through the basal forebrain and hypothalamic regions. A sequential double-immunolabelling (elution-restaining method) clearly indicated that all the luteinizing hormone-releasing hormone-immunoreactive cell bodies displayed delta sleep-inducing peptide immunoreactivity. These cell bodies were sparse and mainly located throughout the septal-preoptico-suprachiasmatic region and the ventrolateral hypothalamus. The colocalization of luteinizing hormone-releasing hormone and delta sleep-inducing peptide immunoreactivity was also observed in many fibres supplying all these brain regions and terminal areas such as the organum vasculosum of the lamina terminalis, the subfornical organ, the median eminence and the pituitary stalk. These neuroanatomical findings are suggestive of interaction between delta sleep-inducing peptide and luteinizing hormone-releasing hormone in various brain areas including some circumventricular organs.

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Antinuclear antibodies (ANA) are found in the majority of patients with systemic lupus erythematosus (SLE). We report here the only documented case, out of a series of 38 patients, in which SLE was diagnosed in spite of the fact that we failed to demonstrate any type of autoantibodies. A 25-year-old black woman presented with 6 of the 11 criteria of the American Rheumatism Association for classification of SLE, between August 1984 and April 1985, i.e. malar rash, photosensitivity, arthritis, pleurisy and pericarditis, renal insufficiency and nephrotic syndrome, anemia and leukopenia. Renal biopsy revealed mesangial glomerulonephritis, tubulonephritis and many tubuloreticular inclusions in the capillary endothelium highly suggestive of SLE. Four ANA determinations were performed during the 8 months of observation which were all negative, as were all other antibodies (anti-nDNA, -Sm, -RPN, -Ro, -La). The outcome was very favourable under prednisone and cyclophosphamide. In the rare cases of ANA negative SLE (5-10%) photosensitive dermatitis is the prominent feature and renal or central nervous system involvement is less frequent. Those patients usually have other types of autoantibodies (especially anticytoplasmic) which was not the case in our patient. This indicates that the absence of autoantibodies does not rule out SLE.

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We used four monoclonal antibodies designated MLR-1, -2, -3, and -4, specifically directed against determinants uniquely present on activated T lymphocytes to analyze peripheral blood lymphocytes (PBL) of patients with multiple sclerosis (MS). By indirect immunofluorescence techniques, we found that many PBL expressed one or more of these activation antigens. Thus, high percentages of MLR-2 positive cells were found in all 20 MS patients (66 +/- 12% in 13 patients with the remitting form and 57 +/- 14% in 7 patients with the progressive form). MLR-3 positive cells were found in three patients with the remitting form and five patients with progressive MS, MLR-4 in seven patients with remitting MS and in five with the progressive type. MLR-1 positive cells were prominent in only two cases (one remitting and one progressive). Discrepancies between expression of MLR antigens and molecules coded by the HLA-DR region (Ia antigens) were observed.

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The coexistence in two sisters, born to related parents, of a corticoresistant nephrotic syndrome, lymphopenia, an immune deficit, short stature, and photophobia is described. The immune deficit is mainly cellular; studies of lymphocyte markers demonstrate a pronounced deficiency of T lymphocytes and Fc-mu receptor-bearing cells. It is suggested that a thorough examination of number and function of T cells should be performed in patients with a familial corticoresistant nephrotic syndrome and recurrent infectious episodes before considering immunosuppressive treatment.

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