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From sensation to cognition.

Sensory information undergoes extensive associative elaboration and attentional modulation as it becomes incorporated into the texture of cognition. This process occurs along a core synaptic hierarchy which includes the primary sensory, upstream unimodal, downstream unimodal, heteromodal, paralimbic and limbic zones of the cerebral cortex. Connections from one zone to another are reciprocal and allow higher synaptic levels to exert a feedback (top-down) influence upon earlier levels of processing. Each cortical area provides a nexus for the convergence of afferents and divergence of efferents. The resultant synaptic organization supports parallel as well as serial processing, and allows each sensory event to initiate multiple cognitive and behavioural outcomes. Upstream sectors of unimodal association areas encode basic features of sensation such as colour, motion, form and pitch. More complex contents of sensory experience such as objects, faces, word-forms, spatial locations and sound sequences become encoded within downstream sectors of unimodal areas by groups of coarsely tuned neurons. The highest synaptic levels of sensory-fugal processing are occupied by heteromodal, paralimbic and limbic cortices, collectively known as transmodal areas. The unique role of these areas is to bind multiple unimodal and other transmodal areas into distributed but integrated multimodal representations. Transmodal areas in the midtemporal cortex, Wernicke's area, the hippocampal-entorhinal complex and the posterior parietal cortex provide critical gateways for transforming perception into recognition, word-forms into meaning, scenes and events into experiences, and spatial locations into targets for exploration. All cognitive processes arise from analogous associative transformations of similar sets of sensory inputs. The differences in the resultant cognitive operation are determined by the anatomical and physiological properties of the transmodal node that acts as the critical gateway for the dominant transformation. Interconnected sets of transmodal nodes provide anatomical and computational epicentres for large-scale neurocognitive networks. In keeping with the principles of selectively distributed processing, each epicentre of a large-scale network displays a relative specialization for a specific behavioural component of its principal neurospychological domain. The destruction of transmodal epicentres causes global impairments such as multimodal anomia, neglect and amnesia, whereas their selective disconnection from relevant unimodal areas elicits modality-specific impairments such as prosopagnosia, pure word blindness and category-specific anomias. The human brain contains at least five anatomically distinct networks. The network for spatial awareness is based on transmodal epicentres in the posterior parietal cortex and the frontal eye fields; the language network on epicentres in Wernicke's and Broca's areas; the explicit memory/emotion network on epicentres in the hippocampal-entorhinal complex and the amygdala; the face-object recognition network on epicentres in the midtemporal and temporopolar cortices; and the working memory-executive function network on epicentres in the lateral prefrontal cortex and perhaps the posterior parietal cortex. Individual sensory modalities give rise to streams of processing directed to transmodal nodes belonging to each of these networks. The fidelity of sensory channels is actively protected through approximately four synaptic levels of sensory-fugal processing. The modality-specific cortices at these four synaptic levels encode the most veridical representations of experience. Attentional, motivational and emotional modulations, including those related to working memory, novelty-seeking and mental imagery, become increasingly more pronounced within downstream components of unimodal areas, where they help to create a highly edited subjective version of the world. (ABSTRACT TRUNCATED)

Attention↗

Optimal management of nasopharyngeal carcinoma.

PURPOSE OF REVIEW: Given the high rate of mortality still associated with advanced stages of nasopharyngeal carcinoma, this review focuses on some specific aspects of this potentially curable disease that could translate into improved therapeutic approaches. RECENT FINDINGS: Epstein-Barr viral-induced carcinogenesis is almost constantly reported in the undifferentiated type of nasopharyngeal carcinoma. Nasopharyngeal carcinoma retains clonal characteristics and p53 functionality up to late stages that may account for its high level of chemo- and radiotherapy sensitivity, with several cases of long-term survivors reported among patients with bone metastasis. Recent imaging and biologic techniques will help to identify patients at risk of distant failures (detection of plasma Epstein-Barr virus DNA) or those harboring posttherapeutic residual diseases (positron emission tomographic scan). Cisplatin-based induction chemotherapy has shown disease-free survival benefit, whereas concomitant chemoradiotherapy is associated with an improved local-regional control. Late radiation-induced toxicities (especially xerostomia) will hopefully be reduced using intensity-modulated radiation therapy. New therapeutic agents such as taxanes, or targeted therapies (epidermal growth factor receptor inhibitors) are of major interest in the challenge of circumventing resistance to alkylating agents. SUMMARY: Better knowledge of nasopharyngeal carcinoma pathogenesis and biology, management of patients in highly specialized oncologic units, and careful selection of cytotoxic agents along with multimodality integrated therapeutic programs will likely yield to improved survival, particularly for patients with locally advanced nasopharyngeal carcinoma.

Disease Management↗

Spatial coincidence modulates interaction between visual and somatosensory evoked potentials.

The time course of interaction between concurrently applied visual and somatosensory stimulation with respect to evoked potentials (EPs) was studied. Visual stimuli, either in the left or right hemifield, and electric stimuli to the left wrist were delivered either alone or simultaneously. Visual and somatosensory EPs were summed and compared to bimodal EPs (BiEP, response to actual combination of both modalities). Temporal coincidence of stimuli lead to sub-additive or over-additive amplitudes in BiEPs in several time windows between 75 and 275 ms. Additional effects of spatial coincidence (left wrist with left hemifield) were found between 75 and 300 ms and beyond 450 ms. These interaction effects hint at a temporo-spatial pattern of multiple brain areas participating in the process of multimodal integration.

Adult↗

Metabolic imaging with FDG: a primer.

The rapid advances in imaging technologies are a challenge for both radiologists and clinicians who must integrate these technologies for optimal patient care and outcomes at minimal cost. Multiple indications for functional imaging using fluorode-oxyglucose (FDG) are now well accepted in the fields of neurology, cardiology, and oncology, including differentiation of benign from malignant lesions, staging of malignant lesions, detection of malignant recurrence, and monitoring of therapy. The fusion of anatomic and molecular images (computed tomography [CT] and FDG) obtained with integrated positron emission tomography (PET)-CT systems, sequentially in time but without moving the patient from the imaging table, allows optimal co-registration of anatomic and molecular images, leading to accurate attenuation correction and precise anatomic localization of lesions with increased metabolism. This powerful technology provides a valuable new tool for diagnostic and therapeutic applications. The diagnostic accuracy is improved in approximately 50% of patients because of improvement of lesion detection on both CT and FDG PET images, better differentiation between physiologic and pathological foci of FDG uptake, and better localization of malignant foci of FDG uptake. This new technology affects the management of 10%-20% of cases by guiding further therapy. Promising clinical applications include guiding biopsy to the metabolically active sites of tumors, guiding surgery, and planning intensity-modulated radiation therapy. In addition, new PET radiopharmaceuticals are emerging for indications for which FDG has limitations. Some of the new PET tracers are labeled with (18)F, which has a practical half-life for commercial distribution. In the past few years, the clinical indications for FDG have broadened dramatically, and the rapid technical developments of integrated multimodality imaging systems and new PET tracers further extend the horizon.

Fluorodeoxyglucose F18↗

Digital pathology and spatial omics in steatohepatitis: Clinical applications and discovery potentials.

Steatohepatitis with diverse etiologies is the most common histological manifestation in patients with liver disease. However, there are currently no specific histopathological features pathognomonic for metabolic dysfunction-associated steatotic liver disease, alcohol-associated liver disease, or metabolic dysfunction-associated steatotic liver disease with increased alcohol intake. Digitizing traditional pathology slides has created an emerging field of digital pathology, allowing for easier access, storage, sharing, and analysis of whole-slide images. Artificial intelligence (AI) algorithms have been developed for whole-slide images to enhance the accuracy and speed of the histological interpretation of steatohepatitis and are currently employed in biomarker development. Spatial biology is a novel field that enables investigators to map gene and protein expression within a specific region of interest on liver histological sections, examine disease heterogeneity within tissues, and understand the relationship between molecular changes and distinct tissue morphology. Here, we review the utility of digital pathology (using linear and nonlinear microscopy) augmented with AI analysis to improve the accuracy of histological interpretation. We will also discuss the spatial omics landscape with special emphasis on the strengths and limitations of established spatial transcriptomics and proteomics technologies and their application in steatohepatitis. We then highlight the power of multimodal integration of digital pathology augmented by machine learning (ML)algorithms with spatial biology. The review concludes with a discussion of the current gaps in knowledge, the limitations and premises of these tools and technologies, and the areas of future research.

Humans↗

Physiological and morphological development of the rat cerebellar Purkinje cell.

Cerebellar Purkinje cells integrate multimodal afferent inputs and, as the only projection neurones of the cerebellar cortex, are key to the coordination of a variety of motor- and learning-related behaviours. In the neonatal rat the cerebellum is undeveloped, but over the first few postnatal weeks both the structure of the cerebellum and cerebellar-dependent behaviours mature rapidly. Maturation of Purkinje cell physiology is expected to contribute significantly to the development of cerebellar output. However, the ontogeny of the electrophysiological properties of the Purkinje cell and its relationship to maturation of cell morphology is incompletely understood. To address this problem we performed a detailed in vitro electrophysiological analysis of the spontaneous and intracellularly evoked intrinsic properties of Purkinje cells obtained from postnatal rats (P0 to P90) using whole-cell patch clamp recordings. Cells were filled with neurobiotin to enable subsequent morphological comparisons. Three stages of physiological and structural development were identified. During the early postnatal period (P0 to approximately P9) Purkinje cells were characterized by an immature pattern of Na(+)-spike discharge, and possessed only short multipolar dendrites. This was followed by a period of rapid maturation (from approximately P12 to approximately P18), consisting of changes in Na(+)-spike discharge, emergence of repetitive bursts of Na(+) spikes terminated by Ca(2+) spikes (Ca(2+)-Na(+) bursts), generation of the trimodal pattern, and a significant expansion of the dendritic tree. During the final stage (> P18 to P90) there were minor refinements of cell output and a plateau in dendritic area. Our results reveal a rapid transition of the Purkinje cell from morphological and physiological immaturity to adult characteristics over a short developmental window, with a close correspondence between changes in cell output and dendritic growth. The development of Purkinje cell intrinsic electrophysiological properties further matches the time course of other measures of cerebellar structural and functional maturation.

Action Potentials↗

Retrospective geometric correlation of MR, CT, and PET images.

Magnetic resonance imaging, computed tomographic, and positron emission tomographic studies of the brain provide complementary information, and many patients undergo more than one of these studies during the course of their diagnostic workup and treatment. A new technique for quantitative geometric correlation of such studies makes it possible to create integrated multimodality images by mapping features from one image onto an image obtained with another modality. The coordinate transformation between any pair of images is found by a semiautomatic algorithm for matching models of the patient's external surface as depicted in the two data sets. The resultant hybrid images, which combine complementary features of different studies, are often more useful for diagnosis and treatment planning than are the original single-modality images. The algorithm can also be used for spatial registration of baseline studies with follow-up images created with the same modality, which allows tracking of a lesion to detect subtle interval changes in size and shape. This technique can be applied to images acquired in routine clinical practice, since it is completely retrospective and does not necessitate special positioning or landmarking of the patient.

Adolescent↗

Network activity evoked by neocortical stimulation in area 36 of the guinea pig perirhinal cortex.

The perirhinal cortex is a key structure involved in memory consolidation and retrieval. In spite of the extensive anatomical studies that describe the intrinsic and extrinsic associative connections of the perirhinal cortex, the activity generated within such a network has been poorly investigated. We describe here the pattern of synaptic interactions that subtend the responses evoked in area 36 of the perirhinal cortex by neocortical and local stimulation. The experiments were carried out in the in vitro isolated guinea pig brain. The synaptic perirhinal circuit was reconstructed by integrating results obtained during intracellular recordings from layer II-III neurons with simultaneous current source density analysis of laminar profiles performed with 16-channel silicon probes. Both neocortical and local stimulation of area 36 determined a brief monosynaptic excitatory potential in layer II-III neurons, followed by a biphasic synaptic inhibitory potential possibly mediated by a feed-forward inhibitory circuit at sites close to the stimulation electrode and a late excitatory postsynaptic potential (EPSP) that propagated at distance within area 36 along the rhinal sulcus. During a paired-pulse stimulation test, the inhibitory postsynaptic potential (IPSP) and the late EPSP were abolished in the second conditioned response, suggesting that they are generated by poli-synaptic circuits. Current source density analysis of the field responses demonstrated that 1) the monosynaptic activity was generated in layers II-III and 2) the sink associated to the disynaptic responses was localized within the superficial layer of area 36. We conclude that the neocortical input induces a brief monosynaptic excitation in area 36 of the perirhinal cortex, that is curtailed by a prominent inhibition and generates a recurrent excitatory associative response that travels at distance within area 36 itself. The results suggest that the perirhinal cortex network has the potentials to integrate multimodal incoming neocortical information on its way to the hippocampus.

Animals↗

Relative size of the hyperstriatum ventrale is the best predictor of feeding innovation rate in birds.

Within the avian telencephalon, the dorsal ventricular ridge (DVR) contains higher order and multimodal integration areas. Using multiple regressions on 17 avian taxa, we show that an operational estimate of behavioral flexibility, the frequency of feeding innovation reports in ornithology journals, is most closely predicted by relative size of one of these DVR areas, the hyperstriatum ventrale. Neither phylogeny, juvenile development mode, nor species sampled account for the relationship. Similar results are found when the hyperstriatum ventrale is lumped with a second DVR structure, the neostriatum. In simple correlations, size of the wulst and the striatopallidal complex is associated with feeding innovation rate, but the two structures are eliminated from the multiple regressions. Our results parallel those on primates showing a correlation between innovation rate and neocortex size and support the idea that the mammalian neocortex and the neostriatum-hyperstriatum ventrale complex in birds have similar integrative roles.

Animals↗

[Recurrent herpes zoster with neuralgia].

We present the case of a 40-year-old female patient suffering from recurrent herpes zoster and postherpetic neuralgia. Herpes zoster has recurred several times per year for more than 15 years. At admission, rash localised on the right sacral region and accompanied by neuralgia had lasted for 3 months. Standard out-patient treatment remained unsuccessful. A multimodal integrative therapy regimen including fasting, hydrotherapy, leech application and treatment with autologous blood led to rapid healing of herpetic lesions and persistent pain relief. The case is discussed.

Adult↗

Radiation therapy in the elderly patient.

In the management of cancer in the older patient, the treatment program designed should be based on careful analysis of the patient's problem and a decision made as to whether the patient can be cured by the radiation therapy technique for what is primarily a limited local regional disease process or palliated by virtue of the fact that the patient has more widespread disseminated disease. In both instances, careful attention must be given to proper, continuous and careful support of all the problems the older patient has. The patient's status may dictate a major change in the radiation therapy program by virtue of fractionation, protraction, total dose being delivered or even the volume being treated. The response to treatment in terms of normal tissue effects require careful medical management in order to minimize those effects. Interruptions of treatment should be allowed only if appropriate deliberate management of side effects are not effective. The basic principle in the management of the older patient with cancer is to allow for cure of those patients in which that is a reasonable possibility with the minimum in terms of complication as a consequence of the treatment program. Palliative radiation therapy programs are directed toward improvement in the quality of life by diminishing symptoms and hastening rehabilitation. When two definitive treatment programs, surgery or radiation therapy, have equal probability for long-term survival, the radiation therapy curatively administered would allow for the preservation of anatomy and function. The maximum potential for management in the older patient with cancer is achieved best in the circumstances of an integrated multimodal team for management including those specialists that are appropriate to the disease process being treated. These would include the surgeon, the radiation oncologist, the medical oncologist, the pathologist, the diagnostic radiologist, as well as other specialists such as anesthesiology, rehabilitation medicine, etc., along with paramedical support members of the team. It is within this environment that the maximum potentials of treatment can be achieved.

Aged↗

A hierarchy of associations in hippocampo-cortical systems: cognitive maps and navigation strategies.

In this letter we describe a hippocampo-cortical model of spatial processing and navigation based on a cascade of increasingly complex associative processes that are also relevant for other hippocampal functions such as episodic memory. Associative learning of different types and the related pattern encoding-recognition take place at three successive levels: (1) an object location level, which computes the landmarks from merged multimodal sensory inputs in the parahippocampal cortices; (2) a subject location level, which computes place fields by combination of local views and movement-related information in the entorhinal cortex; and (3) a spatiotemporal level, which computes place transitions from contiguous place fields in the CA3-CA1 region, which form building blocks for learning temporospatial sequences. At the cell population level, superficial entorhinal place cells encode spatial, context-independent maps as landscapes of activity; populations of transition cells in the CA3-CA1 region encode context-dependent maps as sequences of transitions, which form graphs in prefrontal-parietal cortices. The model was tested on a robot moving in a real environment; these tests produced results that could help to interpret biological data. Two different goal-oriented navigation strategies were displayed depending on the type of map used by the system. Thanks to its multilevel, multimodal integration and behavioral implementation, the model suggests functional interpretations for largely unaccounted structural differences between hippocampo-cortical systems. Further, spatiotemporal information, a common denominator shared by several brain structures, could serve as a cognitive processing frame and a functional link, for example, during spatial navigation and episodic memory, as suggested by the applications of the model to other domains, temporal sequence learning and imitation in particular.

Action Potentials↗

Pharmacotherapy for behavior disorders. Typical treatment practices.

The parents and teachers of 100 children receiving medications (primarily methylphenidate) for behavior disorders (primarily hyperactivity) were questioned about widely recommended treatment practices. The results showed that (a) in the majority of cases, pediatricians were responsible for supervising drug therapy; (b) most parents were satisfied with their current physician; and (c) approximately one half of the children had three or more office visits per year. However, teachers were rarely asked to use standardized procedures to evaluate drug response, and direct contact between teacher and physician was all but nonexistent. There was a considerable degree of disagreement between parents and teachers concerning drug efficacy, dosage, and the need for medication; and parents appeared to exert a considerable degree of control over treatment-related decisions. In general, drug-free periods were not scheduled on a regular basis, and evidence for an integrated multimodal treatment approach was lacking. The findings suggest that variables other than a clinically determined response to medication are often the salient elements of the treatment-related decision-making process.

Adolescent↗

Some lessons learned from imatinib mesylate clinical development in gastrointestinal stromal tumors.

Imatinib mesylate is a molecular-targeted agent, shown to be effective in chronic myeloid leukemia and gastrointestinal stromal tumors (GIST). The latter may currently serve as a model on which speculating how the future of molecular-targeted therapy in solid tumors will be. So far, some lessons have been learnt. 1) Molecular-targeted therapy can be effective in the advanced disease setting, resulting in major tumor responses. 2) Patterns of tumor responses may be peculiar, radiologically and pathologically. 3) Anti-tumor activity may be highly predictable by assessing tumor molecular biology. 4) The methodology of clinical development of molecular-targeted agents may differ from standard chemotherapy in some respects, because, say, the preclinical rationale may be stronger, thus increasing the Bayesian prior probability of efficacy, or the optimal dose cannot be determined separately from the assessment of activity and efficacy. 5) Molecular-targeted agents will hardly remain "orphan drugs", if effective. 6) While an obvious impact on survival in the advanced disease setting has been clearly demonstrated, the biologic and clinical impact of molecular-targeted therapy still needs to be elucidated. Its eradicating capabilities, as well as the implications of secondary resistance, are to be understood. 7) Integrated, multimodality approaches, including surgery, may still be of value in the molecular-targeted therapy era.

Benzamides↗

Bayesian integration of visual and auditory signals for spatial localization.

Human observers localize events in the world by using sensory signals from multiple modalities. We evaluated two theories of spatial localization that predict how visual and auditory information are weighted when these signals specify different locations in space. According to one theory (visual capture), the signal that is typically most reliable dominates in a winner-take-all competition, whereas the other theory (maximum-likelihood estimation) proposes that perceptual judgments are based on a weighted average of the sensory signals in proportion to each signal's relative reliability. Our results indicate that both theories are partially correct, in that relative signal reliability significantly altered judgments of spatial location, but these judgments were also characterized by an overall bias to rely on visual over auditory information. These results have important implications for the development of cue integration and for neural plasticity in the adult brain that enables humans to optimally integrate multimodal information.

Bayes Theorem↗

High-resolution spatio-temporal functional neuroimaging of brain activity.

The past decades have shown extraordinary progress in our ability to noninvasively image the functions of the human brain. Of particular interest is the recent trend in combining information from electrophysiological and magnetic resonance imaging, which we termed eMRI, to achieve high-resolution functional neuroimaging in both space and time domains. In this article, we review the recent progress in high-resolution functional neuroimaging, in particular the multimodal integration of electroencephalography (EEG) and magnetic resonance imaging (MRI). The state-of-the-art EEG inverse solutions based on different brain electric source models and various approaches to integrate the information from MRI are reviewed. The remaining challenges, future trends, and potential applications of the high-resolution functional neuroimaging research are discussed.

Action Potentials↗

The Challenge of Developing New Therapies for Childhood Cancers.

The current standard treatments for childhood cancers are highly successful. The five-year survival rates for all children diagnosed with cancer in the late 1980s approaches 70%, and the outlook continues to improve. For some types of localized embryonal tumors, such as retinoblastoma and Wilms' tumor, the cure rates approach or exceed 90%. Our success in treating childhood cancers can be attributed to the development and use of an integrated, multimodality treatment approach which includes surgery, radiaton, and combination chemotherapy. This approach has become standard treatment for most childhood solid tumors. However, for every two children who survive, one child still succumbs to cancer, and for some childhood cancers, such as neuroblastoma and certain types of brain tumors, the prognosis remains poor. Therefore, despite our successes, there remains a need to develop new chemotherapeutic agents as well as new treatment approaches for childhood cancers. In a previous volume of The Oncologist (1996;1:169-172), Dr. Charles Pratt discussed the need for developing new drugs to treat childhood cancers and the mechanisms by which the clinical trials can be efficiently conducted. However, the clinical development of new drugs and new treatment approaches becomes more difficult as our standard treatments improve. Clearly, as more patients are cured, fewer patients are available for treatment on conventional phase I and phase II trials, which are typically performed in patients who have relapsed after standard front-line and salvage therapy. The condition of patients at the time of entry onto investigational drug studies is also affected by the nature of their prior therapy. As a result of the increasing intensity of standard treatment regimens and the use of myeloablative therapy followed by bone marrow transplantation as salvage therapy, patients entering investigational drug trials are more intolerant of further treatment and they are more likely to have tumors that are refractory to any form of therapy. In essence, the children with refractory cancers who are entered on phase I and phase II trials are becoming less and less representative of children with newly diagnosed cancers. The tolerance of children and adults to anticancer drugs was reviewed by Marsoni et al. (Cancer Treat Rep 1985;69:1263-1269). Seventeen agents that entered into clinical testing prior to 1980 were studied on similar schedules in children and adults, and the pediatric maximum tolerated dose (MTD) exceeded the adult MTD for 16 of the 17 agents. For half the drugs the pediatric MTD was 30% higher than the adult MTD, suggesting that children had a significantly greater tolerance to the toxicity of cancer chemotherapy than adults. In the 1990s we have performed a number of phase I trials in children who were more heavily pretreated than those children treated on phase I trials in the 1970s, and the pediatric MTD has been equivalent to or below the adult MTD in several of our trials. Similarly, childhood cancers have been considered to be more chemosensitive than adult forms of cancer, but several recently approved agents that have significant antitumor activity in adult cancers appear to be inactive in conventional phase II trials performed in children with recurrent cancers. Careful meta-analysis of the results of phase I and II trials performed in children and adults in the 1990s will be needed to determine if the changes in the intensity of front-line and salvage treatment regimens for childhood cancers are having a significant impact on the results of conventional phase I and II trials. The clinical development of investigational drugs and the design of phase I and II may need to be adjusted to account for the apparent greater intolerance of the heavily pretreated children entering onto these trials and the greater refractoriness of their tumors. Phase I trials may need to be performed in both heavily pretreated and less heavily pretreated children, as is currently done in adults. Limited intrapatient dose escalations can also be incorporated into phase II trials, because the patient population entering phase II trials tends to be less heavily pretreated than patients entered onto phase I trials. For new agents that appear to be inactive in conventional phase II trials, additional testing can be performed in newly diagnosed patients by administering a limited number of doses of the new agent and assessing response prior to initiation of standard therapy. This phase II window has been incorporated into the design of several front-line treatment protocols. The design of future pediatric phase I and II trials must account for the changing characteristics of the patient population that will be treated on those trials. As our knowledge about the underlying molecular defects in cancer cells expands, new biologically based treatment approaches (e.g., tumor vaccines, differentiating agents, immunotherapy, growth factor inhibitors, gene therapy), which promise to provide more rational and selective therapy for childhood cancers, are being discovered. The clinical development of these exciting new approaches will also be challenging for clinical investigators. For cancers that are successfully treated with standard multimodality treatment regimens, the impact of adding one of these new treatment approaches to the standard regimen may be difficult to detect and quantify, because of the already high survival rates; and substituting a new unproven treatment approach for a highly successful standard treatment is difficult to justify. Evaluating these new treatment approaches in heavily pretreated patients with recurrent disease may also underestimate their antitumor activity. For example, tumor vaccines depend on the patient's immue response, which may be substantially suppressed by prior dose-intensive chemotherapy and radiation. It may be more feasible to initially test these new treatment approaches in those cancers in which current standard therapy is less successful. Once they have been demonstrated to have antitumor activity in poor prognosis tumors, they can be applied to the treatment of cancers that respond well to current standard multimodality treatments. With these changes in the patient population entering investigational drug studies and the development of new non-cytotoxic treatment approaches, the design and end-points of conventional phase I and II trials must be adapted to ensure that new therapies are efficiently developed in the pediatric population.

Journal Article↗

[Auditory perception and language: functional imaging of speech sensitive auditory cortex].

Since the description of cortical deafness, it has been known that the superior temporal cortex is bilaterally involved in the initial stages of language auditory perception but the precise anatomical limits and the function of this area remain debated. Here we reviewed more than 40 recent papers of positron emission tomography and functional magnetic resonance imaging related to language auditory perception, and we performed a meta-analysis of the localization of the peaks of activation in the Talairach's space. We found 8 studies reporting word versus non-word listening contrasts with 54 activation peaks in the temporal lobes. These peaks clustered in a bilateral and well-limited area of the temporal superior cortex, which is here operationally defined as the speech sensitive auditory cortex. This area is more than 4cm long, located in the superior temporal gyrus and the superior temporal sulcus, both anterior and posterior to Heschl's gyrus. It do not include the primary auditory cortex nor the ascending part of the planum temporale. The speech sensitive auditory cortex is not activated by pure tones, environmental sounds, or attention directed toward elementary components of a sound such as intensity, pitch, or duration, and thus has some specificity for speech signals. The specificity is not perfect, since we found a number of non-speech auditory stimuli activating the speech sensitive auditory cortex. Yet the latter studies always involve auditory perception mechanisms which are also relevant to speech perception either at the level of primitive auditory scene analysis processes, or at the level of specific schema-based recognition processes. The dorsal part of the speech sensitive auditory cortex may be involved in primitive scene analysis processes, whereas distributed activation of this area may contribute to the emergence of a broad class of "voice" schemas and of more specific "speech schemas/phonetic modules" related to different languages. In addition, this area is activated by language-related lip movement, suggesting that a multimodal integration of the auditory and the visual information relevant in speech perception occurs at this level. Finally, there is a task-related top-down modulation of the pattern of activation of the speech sensitive auditory cortex which may reflect the fact that the different parts of this structure are connected to different down-stream cortical regions involved in the neural processing of different types of tasks.

Auditory Cortex↗