PTPN11 mutation manifesting as LEOPARD syndrome associated with hypertrophic plexi and neuropathic pain.

BACKGROUND: LEOPARD syndrome (LS) belongs to the family of neuro-cardio-facio-cutaneous syndromes, which include Neurofibromatosis-1 (NF1), Noonan syndrome, Costello Syndrome, cardio-facio-cutaneous syndrome, Noonan-like syndrome with loose anagen hair and Legius syndrome. These conditions are caused by mutations in genes encoding proteins involved in the RAS-MAPK cellular pathway. Clinical heterogeneity and phenotype overlaps across those different syndromes is already recognized. CASE PRESENTATION: We hereby report a heterozygous de novo mutation in the PTPN11 gene (c.1403C > T) manifesting with a clinical picture of LS during childhood, and later development of neuropathic pain with hypertrophic plexi, which are typically observed in NF1 but have not been reported in LS. CONCLUSION: LS caused by PTPN11 mutations may be associated with hypertrophic roots and plexi. Consequently, clinicians should be aware of the possible development of neuropathic pain and consider specific diagnostic work-up and management.

Homonymous Ganglion Cell Layer Thinning After Isolated Occipital Lesion: Macular OCT Demonstrates Transsynaptic Retrograde Retinal Degeneration.

A 48-year-old man was examined 24 months after medial and surgical treatment of an isolated well-circumscribed right occipital lobe abscess. An asymptomatic residual left homonymous inferior scotoma was present. Fundus examination revealed temporal pallor of both optic discs, and optical coherence tomography (OCT) revealed mild temporal loss of retinal nerve fiber layer in both eyes. No relative afferent pupillary defect was present. Assessment of the retinal ganglion cell layer demonstrated homonymous thinning in a pattern corresponding to the homonymous visual field loss. There were no abnormalities of the lateral geniculate nuclei or optic tracts on review of the initial brain computed tomography and follow-up magnetic resonance imaging. We believe our patient showed evidence of transsynaptic retrograde degeneration after an isolated right occipital lobe lesion, and the homonymous neuronal loss was detected on OCT by assessing the retinal ganglion cell layer.

Visual signs and symptoms in patients with the visual variant of Alzheimer disease.

BACKGROUND: Prominent visual symptoms can present in the visual variant of Alzheimer's disease (VVAD). Ophthalmologists have a significant role to play in the early diagnosis of VVAD. METHODS: We retrospectively reviewed the files of ten consecutive patients diagnosed with VVAD. All patients had a full neuro-ophthalmologic examination, a formal neurological and neuro-psychological testing, and cerebral MRI to confirm diagnosis. In addition, functional neuroimaging was obtained in seven patients. RESULTS: The common primary symptom at presentation with all patients was difficulty with near vision (reading difficulty n = 8, "visual blur" in near vision n = 2), and difficulty writing (n = 3). Following assessment, impaired reading and writing skills were evident in 9/10 and 8/10 patients respectively. Median distance visual acuity was 20/25 and at near the median visual acuity was J6. Partial homonymous visual field defect was detected in 80 % (8/10) of the patients. Color vision was impaired in all patients when tested with Ishihara pseudoisochromatic plates, but simple color naming was normal in 8/9 tested patients. Simultanagnosia was present in 8/10 patients. Vision dysfunction corresponded with cerebral MRI findings where parieto-occipital cortical atrophy was observed in all patients. PET scan (5 patients) or SPECT (2 patients) revealed parieto-occipital dysfunction (hypometabolism or hypoperfusion) in all 7 tested patients CONCLUSIONS: Visual difficulties are prominent in VVAD. Dyslexia, incomplete homonymous hemianopia, preserved color identification with abnormal color vision on Ishihara, and simultanagnosia were all symptoms observed frequently in this patient series. Ophthalmologists should be aware of the possibility of neurodegenerative disorders such as VVAD in patients with unexplained visual complaints, in particular reading difficulties.

Two cilengitide regimens in combination with standard treatment for patients with newly diagnosed glioblastoma and unmethylated MGMT gene promoter: results of the open-label, controlled, randomized phase II CORE study.

BACKGROUND: Survival outcomes for patients with glioblastoma remain poor, particularly for patients with unmethylated O(6)-methylguanine-DNA methyltransferase (MGMT) gene promoter. This phase II, randomized, open-label, multicenter trial investigated the efficacy and safety of 2 dose regimens of the selective integrin inhibitor cilengitide combined with standard chemoradiotherapy in patients with newly diagnosed glioblastoma and an unmethylated MGMT promoter. METHODS: Overall, 265 patients were randomized (1:1:1) to standard cilengitide (2000 mg 2×/wk; n = 88), intensive cilengitide (2000 mg 5×/wk during wk 1-6, thereafter 2×/wk; n = 88), or a control arm (chemoradiotherapy alone; n = 89). Cilengitide was administered intravenously in combination with daily temozolomide (TMZ) and concomitant radiotherapy (RT; wk 1-6), followed by TMZ maintenance therapy (TMZ/RT→TMZ). The primary endpoint was overall survival; secondary endpoints included progression-free survival, pharmacokinetics, and safety and tolerability. RESULTS: Median overall survival was 16.3 months in the standard cilengitide arm (hazard ratio [HR], 0.686; 95% CI: 0.484, 0.972; P = .032) and 14.5 months in the intensive cilengitide arm (HR, 0.858; 95% CI: 0.612, 1.204; P = .3771) versus 13.4 months in the control arm. Median progression-free survival assessed per independent review committee was 5.6 months (HR, 0.822; 95% CI: 0.595, 1.134) and 5.9 months (HR, 0.794; 95% CI: 0.575, 1.096) in the standard and intensive cilengitide arms, respectively, versus 4.1 months in the control arm. Cilengitide was well tolerated. CONCLUSIONS: Standard and intensive cilengitide dose regimens were well tolerated in combination with TMZ/RT→TMZ. Inconsistent overall survival and progression-free survival outcomes and a limited sample size did not allow firm conclusions regarding clinical efficacy in this exploratory phase II study.

How environmental sounds become meaningful

The term "sound object" describes an auditory experience that is associated with an acoustic event produced by a sound source. In natural settings, a sound produced by a living being or an object provides information about the identity and the location of the sound source. Sound's identity is orocessed alono the ventral "What" pathway which consists of regions within the superior and middle temporal cortices as well as the inferior frontal gyrus. This work concerns the creation of individual auditory object representations in narrow semantic categories and their plasticity using electrical imaging. Discrimination of sounds from broad category has been shown to occur along a temporal hierarchy and in different brain regions along the ventral "What" pathway. However, sounds belonging to the same semantic category, such as faces or voices, were shown to be discriminated in specific brain areas and are thought to represent a special class of stimuli. I have investigated how cortical representations of a narrow category, here birdsongs, is modulated by training novices to recognized songs of individual bird species. Dynamic analysis of distributed source estimations revealed differential sound object representations within the auditory ventral "What" pathway as a function of the level of expertise newly acquired. Correct recognition of trained items induces a sharpening within a left-lateralized semantic network starting around 200ms, whereas untrained items' processing occurs later in lower-level and memory-related regions. With another category of sounds belonging to the same category, here heartbeats, I investigated the cortical representations of correct and incorrect recognition of sounds. Source estimations revealed differential representations partially overlapping with regions involved in the semantic network that is activated when participants became experts in the task. Incorrect recognition also induces a higher activation when compared to correct recognition in regions processing lower-level features. The discrimination of heartbeat sounds is a difficult task and requires a continuous listening. I investigated whether the repetition effects are modulated by participants' behavioral performance. Dynamic source estimations revealed repetition suppression in areas located outside of the semantic network. Therefore, individual environmental sounds become meaningful with training. Their representations mainly involve a left-lateralized network of brain regions that are tuned with expertise, as well as other brain areas, not related to semantic processing, and occurring in early stages of semantic processing. -- Le terme objet sonore" décrit une expérience auditive associée à un événement acoustique produit par une source sonore. Dans l'environnement, un son produit par un être vivant ou un objet fournit des informations concernant l'identité et la localisation de la source sonore. Les informations concernant l'identité d'un son sont traitée le long de la voie ventrale di "Quoi". Cette voie est composée de regions situées dans le cortex temporal et frontal. L'objet de ce travail est d'étudier quels sont les neuro-mecanismes impliqués dans la représentation de nouveaux objets sonores appartenant à une meme catégorie sémantique ainsi que les phénomènes de plasticité à l'aide de l'imagerie électrique. Il a été montré que la discrimination de sons appartenant à différentes catégories sémantiques survient dans différentes aires situées le long la voie «Quoi» et suit une hiérarchie temporelle II a également été montré que la discrimination de sons appartenant à la même catégorie sémantique tels que les visages ou les voix, survient dans des aires spécifiques et représenteraient des stimuli particuliers. J'ai étudié comment les représentations corticales de sons appartenant à une même catégorie sémantique, dans ce cas des chants d'oiseaux, sont modifiées suite à un entraînement Pour ce faire, des sujets novices ont été entraînés à reconnaître des chants d'oiseaux spécifiques L'analyse des estimations des sources neuronales au cours du temps a montré que les representations des objets sonores activent de manière différente des régions situées le long de la vo,e ventrale en fonction du niveau d'expertise acquis grâce à l'entraînement. La reconnaissance des chants pour lesquels les sujets ont été entraînés implique un réseau sémantique principalement situé dans l'hémisphère gauche activé autour de 200ms. Au contraire, la reconnaissance des chants pour lesquels les sujets n'ont pas été entraînés survient plus tardivement dans des régions de plus bas niveau. J'ai ensuite étudié les mécanismes impliqués dans la reconnaissance et non reconnaissance de sons appartenant à une autre catégorie, .es battements de coeur. L'analyse des sources neuronales a montre que certaines régions du réseau sémantique lié à l'expertise acquise sont recrutées de maniere différente en fonction de la reconnaissance ou non reconnaissance du son La non reconnaissance des sons recrute des régions de plus bas niveau. La discrimination des bruits cardiaques est une tâche difficile et nécessite une écoute continue du son. J'ai étudié l'influence des réponses comportementales sur les effets de répétitions. L'analyse des sources neuronales a montré que la reconnaissance ou non reconnaissance des sons induisent des effets de repétition différents dans des régions situées en dehors des aires du réseau sémantique. Ainsi, les sons acquièrent un sens grâce à l'entraînement. Leur représentation corticale implique principalement un réseau d'aires cérébrales situé dans l'hémisphère gauche, dont l'activité est optimisée avec l'acquisition d'un certain niveau d'expertise, ainsi que d'autres régions qui ne sont pas liée au traitement de l'information sémantique. L'activité de ce réseau sémantique survient plus rapidemement que la prédiction par le modèle de la hiérarchie temporelle.

Transient ocular motor nerve palsies associated with presumed cranial nerve schwannomas.

BACKGROUND: Cranial nerve schwannomas are radiologically characterized by nodular cranial nerve enhancement on magnetic resonance imaging (MRI). Schwannomas typically present with gradually progressive symptoms, but isolated reports have suggested that schwannomas may cause fluctuating symptoms as well. METHODS: This is a report of ten cases of presumed cranial nerve schwannoma that presented with transient or recurring ocular motor nerve deficits. RESULTS: Schwannomas of the third, fourth, and fifth nerves resulted in fluctuating deficits of all 3 ocular motor nerves. Persistent nodular cranial nerve enhancement was present on sequential MRI studies. Several episodes of transient oculomotor (III) deficts were associated with headaches, mimicking ophthalmoplegic migraine. CONCLUSIONS: Cranial nerve schwannomas may result in relapsing and remitting cranial nerve symptoms.

New opportunities in vasopressin and oxytocin research: a perspective from the amygdala.

In the present review, we discuss how the evolution of oxytocin and vasopressin from a single ancestor peptide after gene duplication has stimulated the development of the vertebrate social brain. Separate production sites became possible with a hypothalamic development, which, interestingly, is triggered by the same transcription factors that underlie the development of various subcortical regions where vasopressin and oxytocin receptors are adjacently expressed and which are connected by inhibitory circuits. The opposite modulation of their output by vasopressin and oxytocin could thus create a dynamic equilibrium for rapid responsiveness to external stimuli. At the level of the individual, nurturing early in life can long-lastingly program oxytocin signaling, maintaining a capability of learning and sensitivity to external stimuli that contributes to development of social behavior in adulthood. Oxytocin and vasopressin are thus important for the development of a vertebrate brain that supports bonding between individuals and building of an interactive community.

Epidémiologie et systémique

L'épidémiologie et la systémique présentent des analogies aussi bien dans leur champ d'application que dans leurs méthodes, bien qu'elles s'attachent chacune à un corps de doctrine différent. Certaines de ces analogies sont illustrées par des exemples d'épidémiologie en médecine du travail et en psychiatrie.

Brain metastases in gastro-oesophageal adenocarcinoma: insights into the role of the human epidermal growth factor receptor 2 (HER2).

BACKGROUND: Gastro-oesophageal adenocarcinomas rarely metastasize to the central nervous system (CNS). The role of the human epidermal growth factor receptor 2 (HER2) in patients with these cancers and CNS involvement is presently unknown. PATIENTS AND METHODS: A multicentre registry was established to collect data from patients with gastro-oesophageal adenocarcinomas and CNS involvement both retrospectively and prospectively. Inclusion in the study required a predefined clinical data set, a central neuro-radiological or histopathological confirmation of metastatic CNS involvement and central assessment of HER2 by immunohistochemistry (IHC) and in situ hybridisation (ISH). In addition, expression of E-cadherin and DNA mismatch repair (MMR) proteins were assessed by IHC. RESULTS: One hundred patients fulfilled the inclusion criteria. The population's median age was 59 years (interquartile range: 54-68), of which 85 (85%) were male. Twenty-five patients were of Asian and 75 of Caucasian origin. HER2 status was positive in 36% (95% CI: 26.6-46.2) of cases. Median time from initial diagnosis to the development of brain metastases (BMets) or leptomeningeal carcinomatosis (LC) was 9.9 months (95% CI: 8.5-15.0). Median overall survival from diagnosis was 16.9 months (95% CI: 14.0-20.7) and was not related to the HER2 status. E-cadherin loss was observed in 9% of cases and loss of expression in at least one DNA MMR proteins in 6%. CONCLUSIONS: The proportion of a positive HER2 status in patients with gastro-oesophageal adenocarcinoma and CNS involvement was higher than expected. The impact of anti-HER2 therapies should be studied prospectively.

Programmed death ligand 1 expression and tumor-infiltrating lymphocytes in glioblastoma.

BACKGROUND: Immune checkpoint inhibitors targeting programmed cell death 1 (PD1) or its ligand (PD-L1) showed activity in several cancer types. METHODS: We performed immunohistochemistry for CD3, CD8, CD20, HLA-DR, phosphatase and tensin homolog (PTEN), PD-1, and PD-L1 and pyrosequencing for assessment of the O6-methylguanine-methyltransferase (MGMT) promoter methylation status in 135 glioblastoma specimens (117 initial resection, 18 first local recurrence). PD-L1 gene expression was analyzed in 446 cases from The Cancer Genome Atlas. RESULTS: Diffuse/fibrillary PD-L1 expression of variable extent, with or without interspersed epithelioid tumor cells with membranous PD-L1 expression, was observed in 103 of 117 (88.0%) newly diagnosed and 13 of 18 (72.2%) recurrent glioblastoma specimens. Sparse-to-moderate density of tumor-infiltrating lymphocytes (TILs) was found in 85 of 117 (72.6%) specimens (CD3+ 78/117, 66.7%; CD8+ 52/117, 44.4%; CD20+ 27/117, 23.1%; PD1+ 34/117, 29.1%). PD1+ TIL density correlated positively with CD3+ (P < .001), CD8+ (P < .001), CD20+ TIL density (P < .001), and PTEN expression (P = .035). Enrichment of specimens with low PD-L1 gene expression levels was observed in the proneural and G-CIMP glioblastoma subtypes and in specimens with high PD-L1 gene expression in the mesenchymal subtype (P = 5.966e-10). No significant differences in PD-L1 expression or TIL density between initial and recurrent glioblastoma specimens or correlation of PD-L1 expression or TIL density with patient age or outcome were evident. CONCLUSION: TILs and PD-L1 expression are detectable in the majority of glioblastoma samples but are not related to outcome. Because the target is present, a clinical study with specific immune checkpoint inhibitors seems to be warranted in glioblastoma.

Patterns of care in recurrent glioblastoma in Switzerland: a multicentre national approach based on diagnostic nodes.

Despite moderate improvements in outcome of glioblastoma after first-line treatment with chemoradiation recent clinical trials failed to improve the prognosis of recurrent glioblastoma. In the absence of a standard of care we aimed to investigate institutional treatment strategies to identify similarities and differences in the pattern of care for recurrent glioblastoma. We investigated re-treatment criteria and therapeutic pathways for recurrent glioblastoma of eight neuro-oncology centres in Switzerland having an established multidisciplinary tumour-board conference. Decision algorithms, differences and consensus were analysed using the objective consensus methodology. A total of 16 different treatment recommendations were identified based on combinations of eight different decision criteria. The set of criteria implemented as well as the set of treatments offered was different in each centre. For specific situations, up to 6 different treatment recommendations were provided by the eight centres. The only wide-range consensus identified was to offer best supportive care to unfit patients. A majority recommendation was identified for non-operable large early recurrence with unmethylated MGMT promoter status in the fit patients: here bevacizumab was offered. In fit patients with late recurrent non-operable MGMT promoter methylated glioblastoma temozolomide was recommended by most. No other majority recommendations were present. In the absence of strong evidence we identified few consensus recommendations in the treatment of recurrent glioblastoma. This contrasts the limited availability of single drugs and treatment modalities. Clinical situations of greatest heterogeneity may be suitable to be addressed in clinical trials and second opinion referrals are likely to yield diverging recommendations.

Les Neurosciences au Tribunal: de la responsabilité à la dangerosité

In recent years, an explosion of interest in neuroscience has led to the development of "Neuro-law," a new multidisciplinary field of knowledge whose aim is to examine the impact and role of neuroscientific findings in legal proceedings. Neuroscientific evidence is increasingly being used in US and European courts in criminal trials, as part of psychiatric testimony, nourishing the debate about the legal implications of brain research in psychiatric-legal settings. During these proceedings, the role of forensic psychiatrists is crucial. In most criminal justice systems, their mission consists in accomplishing two basic tasks: assessing the degree of responsibility of the offender and evaluating their future dangerousness. In the first part of our research, we aim to examine the impact of Neuroscientific evidence in the assessment of criminal responsibility, a key concept of law. An initial jurisprudential research leads to conclude that there are significant difficulties and limitations in using neuroscience for the assessment of criminal responsibility. In the current socio-legal context, responsibility assessments are progressively being weakened, whereas dangerousness assessments gain increasing importance in the field of forensic psychiatry. In the second part of our research we concentrate on the impact of using neuroscience for the assessment of dangerousness. We argue that in the current policy era of zero tolerance, judges, confronted with the pressure to ensure public security, may tend to interpret neuroscientific knowledge and data as an objective and reliable way of evaluating one's dangerousness and risk of reoffending, rather than their responsibility. This tendency could be encouraged by a utilitarian approach to punishment, advanced by some recent neuroscientific research which puts into question the existence of free will and responsibility and argues for a rejection of the retributive theory of punishment. Although this shift away from punishment aimed at retribution in favor of a consequentialist approach to criminal law is advanced by some authors as a more progressive and humane approach, we believe that it could lead to the instrumentalisation of neuroscience in the interest of public safety, which can run against the proper exercise of justice and civil liberties of the offenders. By advancing a criminal law regime animated by the consequentialist aim of avoiding social harms through rehabilitation, neuroscience promotes a return to a therapeutical approach to crime which can have serious impact on the kind and the length of sentences imposed on the offenders; if neuroscientific data are interpreted as evidence of dangerousness, rather than responsibility, it is highly likely that judges impose heavier sentences, or/and security measures (in civil law systems), which can be indeterminate in length. Errors and epistemic traps of past criminological movements trying to explain the manifestation of a violent and deviant behavior on a biological and deterministic basis stress the need for caution concerning the use of modern neuroscientific methods in criminal proceedings.

Novel insights into gliotransmitters.

It is becoming increasingly clear that astrocytes play an active role in neural communications by releasing neuro-active gliotransmitters into extra-cellular spaces, where they act on neighbouring neurons in order to modulate synaptic transmission and plasticity, and affect behaviour. However, in terms of cell biology, our knowledge of the mechanisms governing the secretion of gliotransmitters is so much less detailed than our knowledge of those governing neurotransmitters that it has even been questioned whether astrocytes are capable of secreting molecules. This review critically evaluates the currently available findings concerning gliotransmitters with the aim of stimulating discussion in the field.

Environmental factors in multiple sclerosis [Environmental factors in multiple sclerosis]

Although multiple sclerosis (MS) is recognized as a disorder involving the immune system, the interplay of environmental factors and individual genetic susceptibility seems to influence MS onset and clinical expression, as well as therapeutic responsiveness. Multiple human epidemiological and animal model studies have evaluated the effect of different environmental factors, such as viral infections, vitamin intake, sun exposure, or still dietary and life habits on MS prevalence. Previous Epstein-Barr virus infection, especially if this infection occurs in late childhood, and lack of vitamin D (VitD) currently appear to be the most robust environmental factors for the risk of MS, at least from an epidemiological standpoint. Ultraviolet radiation (UVR) activates VitD production but there are also some elements supporting the fact that insufficient UVR exposure during childhood may represent a VitD-independent risk factor of MS development, as well as negative effect on the clinical and radiological course of MS. Recently, there has been a growing interest in the gut-brain axis, a bidirectional neuro-hormonal communication system between the intestinal microbiota and the central nervous system (CNS). Indeed, components of the intestinal microbiota may be pro-inflammatory, promote the migration of immune cells into the CNS, and thus be a key parameter for the development of autoimmune disorders such as MS. Interestingly most environmental factors seem to play a role during childhood. Thus, if childhood is the most fragile period to develop MS later in life, preventive measures should be applied early in life. For example, adopting a diet enriched in VitD, playing outdoor and avoiding passive smoking would be extremely simple measures of primary prevention for public health strategies. However, these hypotheses need to be confirmed by prospective evaluations, which are obviously difficult to conduct. In addition, it remains to be determined whether and how VitD supplementation in adult life would be useful in alleviating the course of MS, once this disease has already started. A better knowledge of the influence of various environmental stimuli on MS risk and course would certainly allow the development of add-on therapies or measures in parallel to the immunotherapies currently used in MS.