Conti, Andrea

Gensini, Gian Franco

English

Florence Research

First, sleep in early life has been suggested toplay a crucial role in brain development [3]. Beingregarded as an ‘‘unconscious’’ state to outsidestimuli (non-REM sleep) and an ‘‘active’’ state ofmemory consolidation (REM sleep), sleep helpsour brain work better by eliminating useless infor-mation, updating stored information and reinforc-ing efficient brain connectivity, to develop amore and more ‘‘personally perfect’’ internal rep-resentation of the world and a more and more effi-cient cognitive system. Sleep problems in autisticpeople, especially the greater fragmentation ofsleep, may lead to less efficient brain connectivityin the developing brain, which could furnish a neu-ral substrate for forming such a specificity of infor-mation processing (weak central coherence).Second, abnormal melatonin physiology has beensupposed to explain sleep problems in autistic peo-ple. Melatonin receptors are detected in a widespectrum of tissues and cell types of human brainand peripheral structures. Its rhythmic secretionhas been suggested to be a major messenger thatsupports biological rhythm synchronization [4] andmodifies the sleep-vigilance states. Interestingly,the secretion of melatonin in autistic subjects hasalso been reported to be elevated during daytime[5]. Such an abnormal neurotransmitter physiologi-cal regulating could probably make a ‘‘functionaldisconnection effect’’ during the day, just like thenormal ‘‘fading of consciousness’’ effect duringthe night as reported byMassimini et al. [6] who sup-pose that the fading of consciousness during certainstages of sleep might be related to a breakdown incortical effective connectivity. So we suggest thatthe capacity of the brain to integrate informationmight be reduced in autistic people given that theregulation of the sleep-vigilance neurotransmitternetworks was disturbed.Thus, sleep problems and abnormal melatoninphysiology found in autistic people may play animportant role for their specificity in brain connec-tivity and in information processing.References[1] Planche P, Lemonnier E, Moalic K, Labous C, Lazartigues A.Modalities of information processing in autistic children. AnnMe´dico-psychol revue psychiatr 2002;160(8):559–64.[2] Bertone A, Mottron L, Jelenic P, Faubert J. Enhanced anddiminished visuo-spatial information processing in autismdepends on stimulus complexity. Brain 2005;128: 2430–41.[3] Frank MG, Issa NP, Stryker MP. Sleep enhances plasticity inthe developing visual cortex. Neuron 2001;30:275–87.[4] Anisimov SV, Popovic N. Genetic aspects of melatoninbiology. Rev Neurosci 2004;15:209–30.[5] Ritvo ER, Ritvo R, Yuwiler A, Brothers A. Elevated daytimemelatonin concentrations in autism: a pilot study. Eur ChildAdolesc Psychiatr 1993;2(2):75–8.[6] Massimini M, Ferrarelli F, Huber R, Esser SK, Singh H, TononiG. Breakdown of cortical effective connectivity duringsleep. Science 2005;309:2228–32.Fei Chen*Eric LemonnierAlain LazartiguesService de Pe´dopsychiatrie, CHU de Brest,Hoˆpital de Bohars, BP17, 29820 Bohars, France*Tel.: +33 668214673.E-mail addresses: pierre.fei.chen@gmail.com(F. Chen),eric.lemonnier@chu-brest.fr (E. Lemonnier),alain.lazartigues@chu-brest.fr (A. Lazartigues).Pascale PlancheDe´partement de Psychologie,Faculte´ des Lettres et Sciences Sociales,Universite´ de Bretagne Occidentale,29200 Brest, FranceE-mail address: pascale.planche@univ-brest.fr.doi:10.1016/j.mehy.2006.01.004Hemodynamic profiles of heart failure patientsand ‘‘elementary qualities’’ ofpre-hippocratic medicine: A hypothesis fora linguistic and epistemological relationshipClinical assessment is capable of identifying hemo-dynamic profiles associated with long term out-comes of subjects with heart failure. Simpleclassification of heart failure patients accordingto measurements of congestion and perfusion atthe time of hospitalization has proved to be useful1246 Correspondenceand accurate in predicting clinical status and inselecting and titrating pharmacological therapy[1]. The classifying system, detectable throughbasic physical examination, is based upon the clin-ical features of hemodynamic profiles, namelywet/cold (congestion and hypoperfusion), wet/warm (congestion and normal clinical perfusion),dry/cold (no clinical congestion and hypoperfusion)and dry/warm (neither clinical congestion norhypoperfusion). In effect, in recent publishedresearch, congestion has been assessed by scien-tists through the presence of jugular venous disten-tion, rales, orthopnea, peripheral edema and otherelementary physical signs, while (deteriorated)perfusion has been evaluated by detecting, amongother findings, pulsus alternans, cold extremitiesand symptomatic hypotension. In patients admit-ted with heart failure, survival analysis hasconvincingly shown that wet/warm patients andwet/cold patients have a higher risk of death plusurgent transplantation, as compared with dry/warm and dry/cold individuals. In an era of limitedresources, such as the current one, simple, noninvasive and inexpensive predictive tools areimportant for prognostic stratification of problem-atic patients such as heart failure ones.The same terms and underlying characteristicswere used, however, in other distant eras. Cold,warm, dry and wet were precisely the so-called‘‘elementary qualities’’, whose balanced presencein human bodies was considered by ancient philos-ophers and physicians to be essential for an optimalhealth status. According to the philosopher Emped-ocles (V century B.C.), these elementary qualitieswere in effect properties of bodies, with theirdetectable attributes of heat and humidity. ToEmpedocles is attributable the first identificationof a relationship between elementary qualitiesand health status. His idea was determined by hisconviction of the continuous action of naturalforces on primordial elements (water, air, earth,fire) [2]. A direct application of this theory to thehealth context was proposed by Alcmeones, themost representative naturalist philosopher andphysician of the pre-hippocratic period, who con-sidered human health status to be the result of abalanced presence of these qualities. In his view,the cause of diseases was to be re-conducted tothe relative prevalence of one quality over another(e.g., wet over dry) or to the scarcity of one ofthem (e.g., the deficiency of dry). The therapy ofdiseases was consequently based on attempts tore-establish the equilibrium of disarranged quali-ties, both by means of diet and of appropriate(for the time) drugs. Even if with Hippocrates(V–IV century B.C.) the theory of the fourelements lost part of its importance, it was laterre-evaluated by distinguished personages, includ-ing the philosopher Aristotle (IV century B.C.) andthe physician Galen (II century A.D.).Of course, in present times, the theory of ele-mentary qualities with their medical fall out is nolonger considered scientifically valid. It is interest-ing to note, however, that modern linguistic termi-nology and epistemological options show someintriguing echoes of it. With regard to linguisticterms, it may be observed that the qualities ofAlcmeones are precisely the same ones that iden-tify the clinical characteristics of the hemody-namic profiles of heart failure patients presentedin recent research [1]. With regard to the episte-mological aspect, just as in ancient Greek medicineimportance was attributed to prognosis, so todaythe current importance of the identification of‘‘qualities’’ lies in its clinical application to theprognosis of heart failure patients. It is pertinentto remember that in classical times the creditand reputation of physicians was essentially deter-mined by their prognostic competence, given theextremely poor effectiveness of therapeutic reme-dies; the exactness of their prognosis was the onlyway in which the patient and his/her family couldassess technical ability and decide whether to fol-low the prescriptions [3].The correct and reliable prediction of the clini-cal outcome of patients still constitutes a majorchallenge for modern technological medicine. Inthe continuous search for economic and easy toimplement approaches, based on physical examina-tion, the identification of the clinical aspects ofhemodynamic profiles (wet/cold, wet/warm, dry/cold and dry/warm) for heart failure individuals re-mains a valid prognostic tool, reminding us of theheritage of the past.AcknowledgementThe authors thank Professor Luisa Camaiora, B.A.,M.Phil., for her correction of the English.References[1] Nohria A, Tsang SW, Fang JC, et al. Clinical assessmentidentifies hemodynamic profiles that predict outcomes inpatients admitted with heart failure. J Am Coll Cardiol2003;41:1797–804.[2] Porter R. Blood and guts. A short history of medicine. GreatBritain: Allen Lane, Penguin Books; 2002.[3] Lippi D, Conti AA, Conti A. Storia della Medicina per il Corsodi Laurea triennale per Tecnici Sanitari di RadiologiaMedica. Bologna: Editore CLUEB; 2002.Correspondence 1247Gian Franco GensiniAndrea A. Conti*Department of Critical Care Medicine and Surgery,University of Florence, Viale Morgagni 85,I-50134 Florence, ItalyDon Carlo Gnocchi Foundation IRCCS,Florence, Italy*Tel.: +39 055 417928; fax: +39 055 4379384.E-mail address: aa.conti@dac.unifi.it(A.A. Conti).doi:10.1016/j.mehy.2005.12.038Combined dexamethasonesuppression/corticotropin-releasing hormonestimulation test and antidepressants:Different antidepressants may produce differenteffectsThere is a growing interest in the use of the com-bined dexamethasone suppression/corticotropin-releasing hormone (DEX-CRH) test for psychiatricresearch around the world [1–3]. The DEX-CRHtest has been used to study depression, suicidalbehavior, alcoholism, and other psychiatric condi-tions. In some DEX-CRH studies, patients are main-tained on antidepressants, and, in some studies,patients are medication free. How much do antide-pressants influence hypothalamic-pituitary-adrenal(HPA) regulation and the DEX-CRH test results? TheDEX-CRH test appears to be the most sensitive toolto detect depression-related changes in the HPAaxis [1]. Changes in HPA axis reactivity in this testwere correlated with changes in depressive symp-tomatology. Normalization of the DEX-CRH testwas shown to anticipate or parallel response toantidepressant treatment [1,4–6]. It has been sug-gested that antidepressant treatment does not ap-pear to affect test outcome in the absence ofclinical response [4]. Kunzel et al. [4] did not findan association of presence or absence of antide-pressant treatment, the type of antidepressanttreatment or of the number of previous ineffectiveantidepressant treatment attempts before hospi-talization and the results of the DEX-CRH test.However, it has been shown that mirtazapineeffectively reduces the overshoot of cortisol andadrenocorticotropic hormone (ACTH) during theDEX-CRH test both in treatment responders andnon-responders within 1 week [7]. The authors sug-gest that mirtazapine rapidly attenuates HPA axishyperactivity in depressed patients via direct phar-macoendocrinological effects and this ameliorationof HPA system dysregulation is not necessarily re-lated to clinical improvement. In another study,both 6- and 12-week fluvoxamine treatments wereassociated with a significant and robust reductionof ACTH and cortisol response to the DEX-CRH testin patients with borderline personality disorder[8]. These results were independent of psychiatriccomorbidity including comorbidity with majordepression. It has also been reported that imipra-mine, clomipramine and desipramine have substan-tial effects on the HPA axis [9].The existing body of evidence suggests that anti-depressants may affect HPA function and the DEX-CRH test results. Antidepressants may have effectsthat are independent of their effects on biogenicamine metabolism or receptors and which producenormalization of initial HPA dysregulation. However,it is not clear how much antidepressants affect theHPA axis and the results of the DEX-CRH test in treat-ment non-responders. It is interesting to hypothesizethat different antidepressants produce different ef-fects on the HPA function and the DEX-CRH test re-sults. This intriguing question merits further study.References[1] Heuser I, Yassouridis A, Holsboer F. The combined dexa-methasone CRH test: a refined laboratory test for psychiat-ric disorders. J Psychiatr Res 1994;28:341–56.[2] Watson S, Gallagher P, Ritchie JC, Ferrier IN, Young AH.Hypothalamic-pituitary-adrenal axis function in patientswith bipolar disorder. Br J Psychiatry 2004;184:496–502.1248 Correspondence

Hemodynamic profiles of heart failure patients and &quot;elementary qualities&quot; of pre-hippocratic medicine: a hypothesis for a linguistic and epistemological relationship.

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Hemodynamic profiles of heart failure patients and "elementary qualities" of pre-hippocratic medicine: a hypothesis for a linguistic and epistemological relationship.

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Hemodynamic profiles of heart failure patients and &quot;elementary qualities&quot; of pre-hippocratic medicine: a hypothesis for a linguistic and epistemological relationship.

Abstract

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Florence Research

Hemodynamic profiles of heart failure patients and "elementary qualities" of pre-hippocratic medicine: a hypothesis for a linguistic and epistemological relationship.