Volhard Lecture. Brain, blood pressure and stroke

BRAIN AND BLOOD PRESSURE IN EXPERIMENTAL ANIMALS: Our experiments in models of experimental hypertension in the rabbit in the early 1970s demonstrated that increased activity of bulbospinal pressor neurons containing noradrenaline or serotonin mediated the elevated arterial blood pressure. Other workers had demonstrated decreased activity of noradrenergic neurons in the medulla. Accordingly, I proposed the hypothesis that the hypertension in these models arose from 'disinhibition', due to unrestrained activity of descending pressor pathways, released from the inhibitory influences present in normal animals. Over the next 15-20 years, experiments from our group and from other laboratories demonstrated that there were two distinct bulbospinal pressor pathways descending from the rostral ventral medulla, one containing adrenaline, neuropeptide Y and glutamate, and the other containing serotonin, substance P and glutamate. It has also been established that the key depressor area is in the caudal ventrolateral medulla and that the main inhibitory input, restraining the activity of the bulbospinal pressor pathways, is a short gamma-aminobutyric acid (GABA) projection ascending from the caudal ventrolateral medulla to the rostral ventral medulla. More recent experiments in the spontaneously hypertensive rat (SHR) using the immediate-early gene c-fos as a marker of neuronal activity, have demonstrated that impaired activity of this short inhibitory GABA pathway in the SHR disinhibits the bulbospinal pressor pathway, thus contributing to the hypertension in this model. BLOOD PRESSURE AND STROKE IN HUMANS: The risks of primary stroke and of secondary or recurrent stroke are both directly related to the level of blood pressure and clinical trials have clearly demonstrated that lowering blood pressure markedly reduces the incidence of primary stroke. The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) was launched to test the hypothesis that lowering the blood pressure in subjects who have already had a stroke or a transient ischaemic attack will also reduce the risk of stroke. A major unresolved issue for practising clinicians is how to manage the raised blood pressure that is so common in the acute phase of stroke. Accordingly, the PROGRESS investigators are planning another major multinational trial to assess the benefits and risks of lowering blood pressure in the first 3 days after the onset of a stroke.

Hypertension optimal treatment (HOT) study: a brilliant concept, but a qualified success

BACKGROUND TO THE STUDY

The Hypertension Optimal Treatment (HOT) study was designed to answer two questions: whether low-dose aspirin (75 mg/day) is effective in the primary prevention of myocardial infarction, without an increase in cerebral haemorrhage in hypertensive patients whose blood pressure is well controlled, and whether there are additional benefits with a progressive reduction of diastolic blood pressure from 90 mmHg to below 80 mmHg.

SUCCESSES

In a landmark outcome, low-dose aspirin was indeed shown to be effective in the primary prevention of myocardial infarction. Moreover, the study has shed light on many important issues for blood pressure lowering in the treatment of hypertension, providing an excellent demonstration that with aggressive combination therapy, the elevated blood pressure in hypertensive subjects can be lowered and maintained in the normotensive range in over 90% of cases. DISAPPOINTMENT: The biggest disappointment was that the intention to treat analysis failed to demonstrate a significant difference between the three randomized target blood pressure groups for the majority of cardiovascular events.

Surveillance of sexually transmitted infections in Scotland

Applications of the surveillance of sexually transmitted infections (STIs) include setting priorities for and planning preventive and treatment services, evaluating interventions, and shaping research hypotheses. In Scotland routine data on STIs, (other t

Bötzinger neurons project towards bulbospinal neurons in the rostral ventrolateral medulla of the rat

Sympathetic nerve activity often fluctuates with the respiratory cycle, but the central neurons that impose this respiratory modulation have not been conclusively identified. In the present study, we used intracellular recording and dye-filling to identify expiratory neurons in the Bötzinger complex. Our aim was to see if Bötzinger neurons project towards putative cardiovascular neurons in the rostral ventrolateral medulla. In the first series of experiments, histochemistry and immunohistochemistry were used to reveal the labelled Bötzinger neurons and neurons immunoreactive for tyrosine hydroxylase. Two out of four Bötzinger neurons had axon varicosities that were closely apposed to tyrosine hydroxylase-immunoreactive neurons with cell bodies located within 0.6 mm caudal to the facial nucleus (three and five close appositions, respectively). In a second series of studies, rats were injected with cholera toxin B into the intermediolateral cell column of the spinal cord 4-7 days before the electrophysiological recording. Eight of the fourteen labelled Bötzinger neurons had a direct projection towards cholera toxin B-labelled neurons in the rostral ventrolateral medulla. Close appositions were found on both somata and proximal dendrites (5 +/- 2 close appositions/neuron, n = 8). The present study supports the idea that a direct projection from Bötzinger neurons to presympathetic neurons in the rostral medulla plays a role in the respiratory modulation of sympathetic nerve activity.

Respiratory activity of the rat posterior cricoarytenoid muscle

An anatomic and electrophysiological study of the rat posterior cricoarytenoid (PCA) muscle is described. The intramuscular nerve distribution of the PCA branch of the recurrent laryngeal nerve was demonstrated by a modified Sihler's stain. The nerve to the PCA was found to terminate in superior and inferior branches with a distribution that appeared to be confined to the PCA muscle. Electromyography (EMG) recordings of PCA muscle activity in anesthetized rats were obtained under stereotaxic control together with measurement of phrenic nerve discharge. A total of 151 recordings were made in 7 PCA muscles from 4 rats. Phasic inspiratory activity with a waveform similar to that of phrenic nerve discharge was found in 134 recordings, while a biphasic pattern with both inspiratory and post-inspiratory peaks was recorded from random sites within the PCA muscle on 17 occasions. The PCA EMG activity commenced 24.6 +/- 2.2 milliseconds (p < .0001) before phrenic nerve discharge. The results are in accord with findings of earlier studies that show that PCA muscle activity commences prior to inspiratory airflow and diaphragmatic muscle activity. The data suggest that PCA and diaphragm motoneurons share common or similar medullary pre-motoneurons. The earlier onset of PCA muscle activity may indicate a role for medullary pre-inspiratory neurons in initiating PCA activity.

Operating theatres. Funders keepers

Recruiting and retaining operating theatre staff is a constant problem for many trusts. One trust has introduced a pay supplement of 1,500 Pounds for all operating theatre staff, and is now planning to implement a single pay spine for all categories of operating theatre staff. The long-standing staffing difficulties suggest it is time to reconsider skill mix in operating theatres.

Design, construction and evaluation of systems to predict risk in obstetrics

We present a systematic, practical approach to developing risk prediction systems, suitable for use with large databases of medical information. An important part of this approach is a novel feature selection algorithm which uses the area under the receiver operating characteristic (ROC) curve to measure the expected discriminative power of different sets of predictor variables. We describe this algorithm and use it to select variables to predict risk of a specific adverse pregnancy outcome: failure to progress in labour. Neural network, logistic regression and hierarchical Bayesian risk prediction models are constructed, all of which achieve close to the limit of performance attainable on this prediction task. We show that better prediction performance requires more discriminative clinical information rather than improved modelling techniques. It is also shown that better diagnostic criteria in clinical records would greatly assist the development of systems to predict risk in pregnancy.

Role of spinal GABA receptors in depressor responses to chemical stimulation of the A5 area in normal and hypertensive rats

Chemical stimulation of neurons in the pontine A5 area by microinjection of L-glutamate lowers arterial blood pressure. The mechanism of this 'A5 depressor response' is not well-established. Here, we examine the involvement of spinal cord gamma-aminobutyric acid (GABA) receptors in this depressor response in normotensive Wistar-Kyoto rats (WKY) and spontaneously hypertensive rats (SHR). Experiments were conducted in male WKY and age-matched SHR anaesthetised with sodium pentobarbitone and chloral hydrate. An intrathecal catheter was implanted with the tip located between T9 and L2. Three days later, rats were re-anaesthetised and 10 nl of 40 mM L-glutamate was injected into the A5 area before, during and after, blockade of spinal cord GABA-A receptors by intrathecal injection of bicuculline methiodide (1 mM in 10 microliters phosphate-buffered saline). Injection of L-glutamate (10, 20, 40, 80 mM in 10 nl) produced depressor responses that were similar in WKY (n = 6) and SHR (n = 6). Intrathecal injection of bicuculline elicited a pressor response that was greater in SHR (n = 7, 28.5 +/- 7.6% increase in mean arterial pressure) than WKY (n = 11, 11.6 +/- 3.6%, p < 0.05). After bicuculline, the depressor response to injection of L-glutamate into the A5 area was eliminated in both WKY (n = 7) and SHR (n = 6). Intrathecal injection of vehicle had no effect on either resting arterial blood pressure or the depressor response to A5 stimulation. Basal blood pressure and control responses to A5 stimulation were fully restored by around 90 min after bicuculline injection in each animal. In separate groups of rats, intrathecal injection of muscimol elicited depressor responses that were greater in SHR (n = 6, -32.0 +/- 6.2%) than WKY (n = 6, -17.3 +/- 1.5%, p < 0.05). Our results suggest that the A5 depressor response is due to a projection from the A5 area to the spinal cord. This projection acts directly, or through a spinal interneuron and uses GABA as a neurotransmitter. Furthermore, our results indicate a hyper-responsiveness to GABA-A receptor stimulation in SHR since intrathecal bicuculline elicited much greater increases and intrathecal muscimol elicited much greater decreases, in blood pressure in SHR than in WKY. Finally, it seems likely that the A5-spinal depressor pathway is less effective in SHR than WKY under physiological conditions since chemical stimulation of the A5 area with L-glutamate produced a comparable depressor response in both strains.

Central control mechanisms in hypertension

There is substantial evidence for an activation of the sympathetic nervous system in man as well as in genetic models of hypertension, such as the spontaneously hypertensive rat (SHR), but we are only beginning to understand the central mechanisms that generate changes in sympathetic activity and elevate blood pressure (BP). Significant recent advances have been made in defining the neural pathways involved in BP regulation and in identifying the neurotransmitters these neurones utilise. In this overview, we describe the neural pathways within the medulla oblongata and spinal cord that participate in BP control and examine the role of amino acid neurotransmitters within these pathways. We demonstrate how alterations in these pathways explain the sympathetic activation observed in the SHR and contribute to hypertension in this model. Lastly, we examine the application of modern molecular biological approaches to further our understanding of the neural regulation of the circulation. In these studies, we used the administration of antisense oligonucleotides to interrupt gene expression.

Blood pressure lowering for the prevention of cognitive decline in patients with cerebrovascular disease. PROGRESS Management Committee. Perindopril Protection Against Recurrent Stroke Study

Cerebrovascular disease and high blood pressure both appear to increase the risk of vascular dementia. PROGRESS aims to investigate whether blood pressure lowering with an angiotensin coverting enzyme inhibitor-based regimen will reduce the risk of cognitive impairment in patients with a history of stroke or transient ischaemic attack. A total of at least 6000 patients will be randomised to receive perindopril (+/- indapamide) or matching placebo(s), with treatment and follow-up scheduled to continue for at least 4 years. Substudies will investigate the effects of treatment on cognitive decline in subgroups defined by apo-E genotype and on white matter lesions assessed by magnetic resonance imaging. Final results from the study should be available in 2001.

Phosphate-activated glutaminase immunoreactivity in brainstem respiratory neurons

The aim of this study was to determine if immunoreactivity for phosphate activated glutaminase (PAG), an enzyme involved in the biosynthesis of glutamate and a putative marker for neurons that use glutamate as a neurotransmitter, is present within respiratory neurons in the ventrolateral medulla oblongata. Intracellular recordings were obtained from neurons in the ventrolateral medulla of adult anaesthetised Sprague-Dawley rats. Neurons with a respiratory-related modulation of their membrane potential were filled with Neurobiotin (Vector, CA). After histochemical processing, sections of brainstem were examined by fluorescence and light microscopy. Some PAG immunoreactivity was found in all of the four types of respiratory neurons examined. PAG immunoreactivity was graded as strong or weak. (1) Of six inspiratory neurons in the rostral ventral respiratory group five were strongly PAG immunoreactive and one was weakly PAG immunoreactive. (2) Of six expiratory neurons in the caudal ventral respiratory group five were strongly PAG immunoreactive while one was weak. (3) Seven motoneurons in the nucleus ambiguous were all strongly PAG immunoreactive. (4) Five neurons in the Bötzinger area were examined. Four were weakly PAG immunoreactive while one contained strong PAG immunoreactivity. These data demonstrate a heterogeneity of PAG immunoreactivity amongst brainstem respiratory neurons.

Role of AMPA/kainate receptors in transmission of the sympathetic baroreflex in rat CVLM

We examined the role of alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)/kainate receptors within the caudal ventrolateral medulla (CVLM) in mediating the sympathetic baroreceptor reflex in anesthetized and paralyzed rats. Bilateral microinjection into CVLM of either DL-2-amino-5-phosphonovaleric acid [APV; a selective N-methyl-D-aspartic acid (NMDA) receptor antagonist, 20 mM, 100 nl] or 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX; a selective AMPA/kainate receptor antagonist, 2 mM, 100 nl) alone failed to eliminate the aortic nerve stimulation-evoked hypotension and inhibition of splanchnic sympathetic nerve activity (SNA) or the cardiac-related rhythmicity of SNA. All components of the sympathetic-baroreceptor reflex were abolished when kynurenate (100 mM, 30 nl) or mixtures of APV and CNQX (10 and 1 mM, respectively, 100 or 30 nl) were injected into CVLM. Injection of APV or CNQX into CVLM reduced aortic nerve-evoked inhibitory responses of bulbospinal sympathoexcitatory neurons in rostral ventrolateral medulla (RVLM). The extent of this reduction was variable. Usually, significant inhibition was preserved. In seven RVLM neurons, intravenous injection of MK-801 (NMDA receptor antagonist, 2 mg/kg) failed to eliminate aortic nerve-evoked inhibitory responses. However, inhibitory responses were abolished when CNQX was injected into CVLM after intravenous MK-801. We conclude that both NMDA and AMPA/kainate receptors in CVLM transmit baroreceptor information.

Role of excitatory amino acid receptors in cardiorespiratory coupling in ventrolateral medulla

The role of (+/-)-alpha-amino-3-hydroxy-5-methyl-isoxazole-4-propionic acid (AMPA)-kainate and N-methyl-D-aspartate (NMDA) receptors in the rostral ventrolateral medulla (RVLM) and caudal ventrolateral medulla (CVLM) on the central respiratory drive (CRD)-related activity of splanchnic sympathetic nerve activity (SNA) was examined in rats. SNA increased during inspiration (I peak) and postinspiration (PI peak). Bilateral microinjections of 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX; AMPA-kainate antagonist) or DL-2-amino-5-phosphonovaleric acid (APV; NMDA antagonist) into RVLM abolished the PI, but not the I, peak. Blockade of all excitatory amino acid receptors in RVLM with kynurenate, or mixtures of APV and CNQX, also failed to eliminate the I peak. Somatosympathetic responses were abolished by CNQX injection into RVLM, but were unaffected by APV. CNQX, but not APV, injection into CVLM increased the PI peak of SNA. Our findings suggest the following. 1) Both NMDA and AMPA-kainate receptors in RVLM are involved in the coupling between the sympathetic nervous system and CRD, which generates the PI peak seen in SNA. 2) The I peak of SNA is independent of excitatory amino acid transmission within RVLM. 3) There are different relative amounts of NMDA and AMPA-kainate receptors at synapses where respiratory and somatic inputs converge onto RVLM neurons. 4) Glutamatergic inputs to CVLM neurons modulate the coupling between SNA and CRD in RVLM.

Treatment guidelines in hypertension: current limitations and future solutions

AREAS OF AGREEMENT

Among the many guidelines and recommendations put forward by national and international authorities in recent years, there has been close agreement that the physician should assess each patient carefully over many months, should address the total profile of cardiovascular risk not just the raised blood pressure, and should treat patients right up to the age of 85 years with either classical essential hypertension or isolated systolic hypertension. The major guidelines described five groups of first-line antihypertensive drugs: diuretics, beta-blockers, angiotensin converting enzyme (ACE) inhibitors, calcium antagonists and alpha-blockers.

AREAS OF UNCERTAINTY

In other areas, the various guidelines were either united in uncertainty, or divided on the best course of action. The availability of many new methods and approaches for the measurement of blood pressure has introduced greater uncertainty into the interpretation of the blood pressure level in the individual patient, with question marks still surrounding the interpretation of white-coat hypertension, of ambulatory blood pressure monitoring and of home blood pressure readings in relation to clinic blood pressure. There is lack of uniformity in recommendations for the threshold values at which raised blood pressure should be lowered and in the recommendations for the target blood pressure the physician should set in the individual patient.

CHOICE OF DRUG TO INITIATE TREATMENT

Since the publication of the major guidelines in 1993 and 1994, the greatest uncertainty has surrounded the choice of drugs to initiate treatment. This reflects the fact that so far no major trials have been completed confirming that the newer agents such as ACE inhibitors, calcium antagonists or alpha-blockers reduce cardiovascular morbidity and mortality in hypertensive patients. While awaiting the results of the many prospective randomized trials that are in progress with these newer agents, a number of case-control studies have raised concerns that non-potassium-sparing diuretics may increase the incidence of sudden cardiac death and that calcium antagonists might increase the occurrence of coronary heart disease in hypertensive subjects.

CURRENT ACTION

These issues highlight the importance of initiating prospective, randomized, controlled trials early in the development of all new drugs. While awaiting the results of trials currently in progress, the physician should continue to use all five groups of antihypertensive drugs, tailoring the choice of drug to suit the individual patient, and should use low doses of antihypertensive drugs either alone, or in appropriate combinations.

Delayed diagnosis of juvenile primary hyperparathyroidism

Primary hyperparathyroidism (PHP) is most common in adults in the fifth and sixth decades of life, but is seen infrequently in adolescence and is extremely rare in children under the age of 14 years. We report the case of a young female whom we suspect had PHP from the age of 6 years. This condition remained undiagnosed for the next 11 years in spite of repeated hospital admissions. The hypercalcaemia which was initially labelled as 'idiopathic' was eventually found to be secondary to a parathyroid adenoma, which was treated successfully by surgery. The case illustrates two important advances: (1) in parathyroid hormone measurement with a new sensitive immuno-radiometric assay, and (2) in the development of radionuclide scanning for localization of parathyroid adenoma(s). No case of hypercalcaemia should be labelled as 'idiopathic' or left unexplained without a detailed exploration of the neck to exclude PHP arising from a parathyroid adenoma.

[Role of diuretics in the treatment of hypertension: from large controlled trials to international guidelines]

Diuretics were used in most of the major trials that demonstrated that lowering the blood pressure reduced cardiovascular morbidity and mortality. Nevertheless in the second half of the eighties, there were misgivings about the widespread use of thiazide diuretics, driven in part by the relative failure of the large trials to reduce myocardial infarction-to the extent predicted by large scale epidemiological studies. There was much attention on metabolic side effects of thiazide diuretics including dyslipidaemia, glucose intolerance, hypokalaemia, hyperuricaemia, and then microalbuminuria particularly in diabetic subjects. These issues were current when JNC (IV) (1988) and the WHO-ISH guidelines (1989) were being written. Three major clinical trials SHEP, STOP and MRC published in the early nineties established that thiazide diuretics alone, or in combination with beta blockers, did reduce cardiovascular morbidity and mortality in elderly subjects with hypertension. All guidelines published since 1993 include diuretics among the first line drugs. Possibly the most important factor in the restoration of diuretics has been the use of progressively lower doses that minimise the metabolic side effects. Diuretics are effective as monotherapy in the treatment of mild essential hypertension and of isolated systolic hypertension in elderly subjects. They are very useful in combination with beta blockers or with ACE inhibitors. They should be avoided in patients with gout and should not be used as first line drugs in patients with diabetes. They should only be used with caution in young obese subjects with dyslipidaemia and increased risk of coronary artery disease, facing many decades of treatment for hypertension. However there is no doubt that diuretics are effective, cheap and have a central role in the control of hypertension in all communities around the world.

How have patients reacted to the implications of the DCCT?

OBJECTIVES

To assess the reactions of people with insulin-treated diabetes (ITD) to the results of the Diabetes Control and Complications Trial (DCCT).

RESEARCH DESIGN AND METHODS

A leaflet documenting the purpose and results of the DCCT was circulated to all 771 patients ages 15-60 years with ITD attending our clinic. Patients were invited to complete and return a questionnaire on their responses.

RESULTS

Of 550 respondents, 330 felt encouraged to improve glycemic control. Female respondents (P = 0.003) and younger age-groups (15-25 years, P = 0.001) were most likely to want to improve control. Patients with long duration of diabetes (> 20 years, P = 0.00001), hypoglycemia unawareness (P = 0.0001), or previous severe hypoglycemia (P = 0.001) were less likely to want to improve their control. Fear of hypoglycemia concerned all age-groups, whereas female respondents were most likely to be worried about the potential for weight gain (P = 0.00006).

CONCLUSIONS

Knowledge of the results of the DCCT encourages significant numbers of patients to want to improve glycemic control. Fear of hypoglycemia and, in women, weight gain may prove significant impediments to the clinical implementation of the results of the DCCT.

AMPA/kainate receptors mediate sympathetic chemoreceptor reflex in the rostral ventrolateral medulla

Previous studies have reported that information from carotid chemoreceptors activates sympathetic premotor neurons in the rostral ventrolateral medulla (RVLM) exclusively via N-methyl-D-aspartic acid (NMDA) receptors. In this study, we examined the possible involvement of alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)/kainate receptors in the RVLM on sympathetic chemoreceptor reflex in pentobarbitone anaesthetised, vagotomised and artificially ventilated rats. Carotid chemoreceptor stimulation with brief N2 inhalation increased splanchnic sympathetic nerve activity and arterial pressure in animals that had received an intravenous injection of the non-competitive NMDA receptor blocker, MK-801 (2 mg/kg). RVLM sympathetic premotor neurons could also be activated by brief hypoxia in the presence of MK-801. However, microinjection of 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX, a selective AMPA/kainate receptor antagonist, 2 mM, 100 nl) into the RVLM after intravenous MK-801 abolished the hypoxia evoked sympathoexcitatory response. These results demonstrate that AMPA/kainate receptors in the RVLM are involved in the chemoreceptor reflex pathway.

The treatment of hypertension

1. A 'retrospective' of the development of the drug treatment of hypertension is presented from the early days of ganglion blockers to the present time together with a review of the evidence of benefit from treatment. 2. Current issues and debates are summarised including shortfalls in the control of hypertension in populations, difficulties surrounding the measurement of blood pressure, disagreement on the levels of blood pressure to treat, the goal blood pressures to aim at, issues surrounding lifestyle measures such as the low salt diet and low intensity exercise, and treatment with diuretics and with calcium antagonists. 3. A 'perspective' is presented on some avenues for progress in the years ahead. These will include the identification of genetic markers to determine the hypertensive individuals with the greatest risk of death and of cardiovascular complications.

Blood pressure lowering in patients with cerebrovascular disease: results of the PROGRESS (Perindopril Protection Against Recurrent Stroke Study) pilot phase

1. Among patients with cerebrovascular disease, there is a direct and continuous association between blood pressure and the risk of stroke, but previous trials of blood pressure lowering in this patient group have been inconclusive. 2. PROGRESS (Perindopril Protection Against Recurrent Stroke Study) is a multicentre, randomized, placebo-controlled trial that aims to determine reliably the effect of angiotensin converting enzyme (ACE) inhibitor-based blood pressure lowering on stroke risk in patients with a history of cerebrovascular disease. If a 4 week run-in period on active perindopril is well tolerated, participants are randomized to either perindopril (4 mg) +/- indapamide (2.5 mg) or matching placebo(s). The primary study outcome is stroke and follow-up is for a minimum of 4 years. 3. For the pilot study nearly 5000 medical records were screened and 60 patients with recent cerebrovascular events were approached directly in hospital or at a clinic visit. Sixty-seven patients entered the run-in phase (52 from retrospective screening and 15 by prospective approach) and 60 patients proceeded to randomization. Treatment with perindopril was well tolerated; only three patients were withdrawn due to side effects and four were withdrawn for other reasons. The mean age of randomized patients was 68 years; 70% were male and 55% were 'non-hypertensive'. The mean entry blood pressure was 142/83 mmHg and following pre-randomization treatment this was reduced by 7/4 mmHg. 4. Most patients were identified by retrospective review of medical records, but this was less efficient than prospective methods. Blood pressure lowering was well tolerated by both hypertensive and non-hypertensive patients with cerebrovascular disease. The small numbers of patients and the non-randomized nature of the data reported limit the conclusions that can be drawn, but the results confirm the feasibility of the main study.

Thyrotropin-releasing hormone immunoreactive boutons form close appositions with medullary expiratory neurons in the rat

The aim of the present study was to assess the size of the input from TRH immunoreactive varicosities to medullary respiratory neurons in the Bötzinger complex and caudal ventral respiratory group. Neurobiotin was intracellularly injected into seven neurons in the Bötzinger complex, between 0.4 and 0.9 mm caudal to the facial nucleus. Five of the seven Bötzinger neurons had extensive local axonal projections, with bouton-like varicosities clustered predominantly between their somata and the nucleus ambiguus. Seven neurons in the caudal ventral respiratory group, located between 1.6 and 2.4 mm caudal to the facial nucleus, were also labelled. All but one caudal respiratory neurons had no, or very few, medullary collaterals. TRH immunoreactive fibres were seen in many medullary nuclei, including the ventral reticular formation. Bötzinger neurons were closely apposed by an average of 29 +/- 8 TRH immunoreactive boutons/neuron (mean +/- S.D., n = 7). In contrast, caudal ventral respiratory group neurons were apposed by only 5 +/- 3 TRH immunoreactive boutons/neuron (n = 7). Bötzinger neurons form many intramedullary and bulbospinal inhibitory connections with premotoneurons and motoneurons that are important in the timing, amplitude and shape, of respiratory activity. Our findings suggest a role for endogenous TRH-containing neurons in modulating the activity of inhibitory Bötzinger neurons and neurons in the caudal ventral respiratory group. The significance of the apparent difference in size of this input remains to be determined.

Impact of guidelines for antihypertensive treatment on clinical practice

Many Guidelines and Consensus Statements were published in 1993 and 1994. The pressure to produce these guidelines comes from clinicians faced with rapid change, from a wish to provide an independent authoritative view rather than rely on commercial promotion of particular treatments, and from governments seeking assistance with the allocation of scarce resources. Evaluation of the impact that guidelines exert on clinical practice is notoriously difficult, but has been attempted using the self-report questionnaire, or the more reliable but expensive analysis of actual practice data, before and after publication of the guidelines. Rigorous evaluation has been attempted and reported in North America and in Europe, in relation to surgical and obstetrical procedures and psychiatric disorders as well as medical treatments. Specific evaluation of the impact of recommendations from the Joint National Committee in the USA, for the treatment of hypertension, has also been attempted, as well as surveys of doctors' perceptions of Consensus Statements. The evidence available suggests that the main value obtained from Guidelines and Consensus Statements lies in their capacity to codify good or "best practice", at times of rapid change in a particular field. They also serve as a source of support for local opinion leaders, and as they are usually produced by respected authors they have substantial influence with Government. Guidelines are not effective in producing rapid change in clinical practice. If a change in practice is sought a more comprehensive program of action is necessary, with guidelines as one useful element.

Altered c-fos in rostral medulla and spinal cord of spontaneously hypertensive rats

Neurons immunoreactive for Fos, the protein product of the immediate early gene c-fos, have been compared in the rostral ventral medulla and spinal cord of conscious normotensive Wistar-Kyoto rats (WKY) and spontaneously hypertensive rats (SHR) after baroreceptor unloading. Hypotension induced by a 60-minute intravenous infusion of sodium nitroprusside reduced baroreceptor activity; controls received intravenous saline. In WKY, 474 +/- 56 (n=6) Fos-positive neurons were identified in the rostral ventral medulla after nitroprusside infusion, a fivefold increase from controls; 50% of the tyrosine hydroxylase-containing neurons in the rostral ventral medulla were activated by this hypotension. Sympathetic preganglionic neurons, mainly sympathoadrenal neurons, were Fos positive after nitroprusside, but Fos-positive sympathetic preganglionic neurons were not observed in control WKY. In SHR, Fos immunoreactivity in the rostral ventral medulla was elevated in the control group compared with the WKY controls (236 +/- 31 and 93 +/- 15, respectively, n=6 for both). Nitroprusside hypotension did not further increase Fos immunoreactivity in the rostral ventral medulla, although the number of Fos-positive spinal sympathetic neurons increased. Our results have identified different neuronal activities between WKY and SHR in sites that are critical to sympathetic outflow. In WKY, nitroprusside effects are consistent with an activation of rostral ventral medulla neurons, including bulbospinal neurons, that are normally inhibited by baroreceptor activity. In SHR, basal nerve activity is increased, so even at rest, rostral ventral medulla neurons and sympathetic preganglionic neurons, mainly sympathoadrenal neurons, are Fos immunoreactive. These activated neurons are likely to contribute to the elevated blood pressure in this rat strain.

Antisense to thyrotropin releasing hormone receptor reduces arterial blood pressure in spontaneously hypertensive rats

We report in the present study the effect of intrathecal treatment with antisense oligonucleotides complementary to thyrotropin releasing hormone (TRH) receptor mRNA on the pressor response to intrathecal administration of TRH and on resting arterial blood pressure in Wistar-Kyoto (WKY) rats and spontaneously hypertensive rats (SHR). In 16-week-old male WKY rats, 18-base phosphodiester antisense or mismatch oligonucleotides to TRH receptor mRNA (100 micrograms per day) were injected intrathecally for 3 days. Twenty-four hours after the last injection, the magnitude of the pressor response to intrathecal TRH (10 micrograms) was significantly smaller in the antisense-treated group (n = 7) compared with mismatch-treated controls (n = 7) (change in mean arterial pressure, +20.3 +/- 3.0 versus +32.6 +/- 2.5 mm Hg, P < .01). No differences were observed in the pressor responses to injection of N-methyl-D-aspartic acid. Resting arterial blood pressure was unaffected by antisense treatment in WKY rats. In separate experiments, 16-week-old male SHR were treated with antisense (n = 7) or mismatch (n = 6) oligonucleotides for 3 days. Mean resting arterial blood pressure was significantly reduced by treatment with antisense oligonucleotides (from 157 +/- 4.8 to 119 +/- 8.8 mm Hg, P < .01), but no significant changes were observed in mismatch-treated animals. Our results suggest that the expression of TRH receptors in spinal sympathetic preganglionic neurons can be selectively reduced by intrathecal treatment with antisense oligonucleotides and that TRH projections to sympathetic preganglionic neurons play an important role in the elevation of arterial blood pressure in SHR.

Abnormal insulin treatment behaviour: a major cause of ketoacidosis in the young adult

Diabetic ketoacidosis occurs more frequently in the young adult population than in any other age group. In a 3-year retrospective casenote review of all patients admitted with ketoacidosis to this hospital, we have defined the clinical characteristics of ketoacidosis in this age group. Young adults (< 25 years) had worse preceding glycaemic control (median HbA1 14.6 vs 10.1%, p = 0.0001) and more frequent episodes of ketoacidosis in the previous 5 years (3 vs 0, p = 0.0001) than older adults (> 25 years); on admission they had lower blood urea concentrations (p = 0.0001) and had a lower incidence of systolic hypotension (6% vs 32%, p = 0.007). There were fewer complications of ketoacidosis in the young adults, and the duration of hospital stay was less than that in the older age group (4 vs 8 days, p = 0.0003). Young adults were less likely to have a proven underlying infective or other organic precipitant for ketoacidosis, but were investigated and treated in a similar way to older adults. Insulin error or manipulation was identified in 42% of young adults; abnormal insulin treatment behaviour is likely to be the major cause of ketoacidosis in this age group.

Synapses on axons of sympathetic preganglionic neurons in rat and rabbit thoracic spinal cord

Axosomatic and axodendritic synapses occur on sympathetic preganglionic neurons, but it is not yet known whether their axons receive synaptic input, which could be particularly effective at regulating sympathetic outflow. Here, we examined retrogradely labelled sympathetic preganglionic axons to see if they received synapses. Cholera toxin B subunit (CTB) or CTB conjugated to horseradish peroxidase (CTB-HRP) was used to label neurons projecting to the rat or rabbit superior cervical ganglion, the rat adrenal medulla, or the rabbit stellate ganglion. At the light microscopic level, small groups of CTB-immunoreactive axons travelled through the ventral horn near its lateral boundary, with occasional axons taking a more medial course. The axons passed through the ventrolateral funiculus to exit at the ventral roots. In parasagittal section, a few axons branched within the ventral horn, sending processes rostrally and caudally for short distances before they turned ventrally to exit the spinal cord. At the ultrastructural level, CTB-immunoreactive rat and rabbit sympathetic preganglionic axons were almost exclusively unmyelinated. In contrast, labelling with CTB-HRP revealed both myelinated and unmyelinated axons in the ventral horn, the ventrolateral white matter, and the ventral roots. CTB-HRP also allowed the detection of the initial segment of a sympathetic preganglionic axon. Synapses, with vesicles clustered presynaptically and membrane specializations postsynaptically, were found on some unmyelinated CTB-immunoreactive axons. Occasional axons received several synapses. Synapses were most common on CTB-containing axons just ventral to the intermediolateral cell column. One synapse was found on an axon within 2 microns of its origin from a proximal dendrite. Rare synapses were found several hundred micrometers ventral to the intermediolateral cell column. One branching axon had synapses just below the branch point on both the main axon and the axonal branch. These findings indicate an extensive synaptic input to the axons of at least some sympathetic preganglionic neurons. These axoaxonic synapses could have a profound effect on sympathetic activity.

Central inspiration increases barosensitivity of neurons in rat rostral ventrolateral medulla

Barosensitive neurons in the rostral ventrolateral medulla (RVLM) often have a respiratory-related modulation of their activity. However, the extent of the interaction between baroreceptor and respiratory inputs is controversial. The main aim of the present study was to determine the effect of central respiratory drive (CRD) on the barosensitivity of RVLM neurons. Extracellular recordings were obtained from 68 barosensitive neurons in the RVLM of anesthetized, paralyzed, and bilaterally vagotomized Sprague-Dawley rats. Examination of phrenic-triggered histograms revealed five activity patterns among barosensitive neurons: inspiratory depression (type I, n = 20), early inspiratory activation (type II, n = 14), postinspiratory activation (type III, n = 18), expiratory depression (type IV, n = 5) and no modulation (type V, n = 11). In most neurons (types I and III and 56% of type II) inhibition produced by aortic nerve stimulation was greater in inspiration than in expiration. Cardiac-related modulation, as an index of natural phasic baroreceptor activation, was also greater in inspiration than expiration in type III neurons. The results demonstrate that CRD modulates the baroreflex at the level of the RVLM.

Serotonin inputs to rabbit sympathetic preganglionic neurons projecting to the superior cervical ganglion or adrenal medulla

The input from serotonin-containing nerve fibres to rabbit sympathetic preganglionic neurons projecting to either the superior cervical ganglion or the adrenal medulla was investigated by combining retrograde tracing with the B subunit of cholera toxin and immunocytochemistry for serotonin. There were pronounced rostrocaudal variations in the density of serotonin fibres in the rabbit intermediolateral cell column from T1 to L4; maximum numbers of fibres were found in T3-6 and L3-4 and minimum numbers in T1 and T10-12. By light microscopy, retrogradely labelled sympathetic preganglionic neurons projecting to the superior cervical ganglion or the adrenal medulla received variable densities of close appositions from serotonin-immunoreactive fibres. Some neurons from each population received many close appositions, whereas others received moderate numbers or few appositions. Appositions occurred on the cell bodies, dendrites, and occasionally axons of sympathetic preganglionic neurons. Rare neurons in both groups of retrogradely labelled cells received no appositions from serotonin-containing nerve fibres. At the ultrastructural level, synapses were found between serotonin-positive boutons and sympathetic preganglionic neurons projecting either to the superior cervical ganglion or to the adrenal medulla. These results indicate that, through direct synaptic contacts, serotonin-immunoreactive, presumably bulbospinal, nerve fibres affect the activity of the vast majority of sympathetic preganglionic neurons that send axons either to the superior cervical ganglion or to the adrenal medulla. This serotonin input may be sympathoexcitatory and could mediate increases in sympathetic nerve activity and in the release of catecholamines from the adrenal medulla.

Aminoacetone metabolism by semicarbazide-sensitive amine oxidase in rat aorta

High speed (105,000 g/60 min) membrane fractions from rat aorta homogenates metabolized the aliphatic amine aminoacetone (AA) to methylglyoxal (MG) with a Km of 19 +/- 3 microM, and Vmax of 510 +/- 169 nmol MG/hr/mg protein. This deaminating activity appears to be due to a semicarbazide-sensitive amine oxidase (SSAO), which is associated with smooth muscle cells in blood vessels of the rat and other species. AA was a competitive inhibitor (Ki of 28 +/- 6 microM) of the metabolism of benzylamine, a synthetic amine often used as an assay substrate for SSAO. AA is produced endogenously from mitochondrial metabolism of threonine and glycine, and thus could be a physiological substrate for SSAO, whereas the production of MG by SSAO could have cytotoxic implications for cellular function.

A set of ninety-seven overlapping yeast artificial chromosome clones spanning the human Y chromosome euchromatin

Contiguous arrays of yeast artificial chromosomes (YACs) extending from proximal heterochromatic Yq into the pseudoautosomal portion of the Y chromosome and separated by a small interval at the centromere have been constructed. A total of 97 YACs have been aligned along the Y chromosome by STS content analysis using 222 sequence tagged sites (STSs) that detect 263 loci. Forty-five of the STSs used are novel. Their inclusion provides a significant improvement over previously available maps on the density of STS coverage along the Y chromosome, reducing the average spacing to 120 kb assuming a length of 30 Mb for the euchromatin. The average size of 61 YACs determined by pulsed-field gel electrophoresis analysis was at least 0.9 Mb. Minor differences noted between the ordering of STSs on this map compared with those previously reported may be attributed to inherent polymorphism between the Y chromosomes used to construct the YAC libraries.

Kynurenic acid, an endogenous glutamate antagonist, in SHR and WKY rats: possible role in central blood pressure regulation

1. Kynurenine aminotransferase catalyzes the conversion of kynurenine to kynurenic acid, an endogenous antagonist of excitatory amino acid receptors. The kynurenic acid content and kynurenine aminotransferase activity was measured in micro-dissected regions of spontaneously hypertensive rats (SHR) and their normotensive controls (Wistar-Kyoto rats: WKY). 2. Of the brain regions examined the highest kynurenine aminotransferase activity was found in the medulla followed by the olfactory bulb and the cerebellum, with the spinal cord showing the lowest activity. 3. All samples from SHR showed greatly reduced kynurenine aminotransferase activity compared to WKY. These reductions were most pronounced in the medulla and spinal cord, approximately 45-55%, and lowest in the cerebellum and olfactory bulbs, approximately 25-30%. 4. The kynurenic acid content of the rostral and caudal medulla as well as the spinal cord was also significantly lower in SHR. 5. These results suggest that there may be a deficiency in the kynurenic acid content and kynurenine aminotransferase activity in the SHR. 6. Given the accumulating evidence of the importance of medullary glutamatergic pathways in the control of blood pressure, as well as the higher sensitivity of cardiovascular neurons of SHR to applied glutamate, it seems possible that endogenous kynurenic acid in the brain may play a role in the control of blood pressure and the pathogenesis of experimental hypertension in the SHR.

Central neurons and neurotransmitters in the control of blood pressure

1. In this paper we review recent work from our laboratory on two major pathways important in the central control of blood pressure. 2. We report experiments on the sympatho-excitatory bulbospinal pathway from the rostral ventral medulla. Here we focus particularly on the role of excitatory amino acids. 3. We review studies on the short inhibitory or depressor pathway ascending from the caudal to the rostral ventral medulla, which is thought to use gamma-aminobutyric acid (GABA) as its neurotransmitter. We report on experiments with the immediate early gene, c-fos, demonstrating that its expression in the bulbospinal pressor neurons is increased by stimuli that activate these nerves, and that this expression can be blocked in vivo by treatment with an antisense oligonucleotide. We also show that basal and stimulated expression of the c-fos gene is important in the central control of blood pressure.

Intracellular recording from sympathetic preganglionic neurons in cat lumbar spinal cord

Sympathetic preganglionic neurons (SPN) are responsible for the control of many autonomic targets including the heart and blood vessels. Previous intracellular studies have examined the morphology of SPN in the thoracic spinal cord, but there are no intracellular studies of SPN in the lumbar spinal cord. In this study we identified lumbar SPN using intracellular recording and dye-filling so that we could study their entire soma-dendritic tree, as well as their axons. At the same time, axonal conduction velocity was measured, and any evidence of an input in phase with phrenic nerve discharge was noted. Intracellular recordings were made from SPN in the L3 (n = 125) and T3 (n = 17) segments of the cat spinal cord. Axonal conduction velocities ranged from 0.6-8.4 m/s. In 85 lumbar SPN, the recordings lasted long enough to assess respiratory-related modulation. A respiratory-related modulation of the membrane potential was seen in 7 of these 85 neurons. All 7 respiratory-related neurons had a conduction velocity of 2.0 m/s or less, while none of the SPN with conduction velocities of more than 2.0 m/s had a respiratory rhythmicity. Histological analysis of 50 biocytin-filled SPN, including 3 with a respiratory-related modulation of their membrane potential, revealed that they occurred mostly in the principal part of the intermediolateral cell column and tended to be elongated in the rostro-caudal direction. Dendrites ramified in the intermediolateral cell column, the dorsolateral white matter and the ventral and medial gray matter. Axons arose either from cell bodies or from primary dendrites and did not bifurcate or have varicose intraspinal collaterals. This is the first report of the morphology of intracellularly filled SPN in the lumbar spinal cord.

Lingual infarction in cranial arteritis

An unusual case is described of infarction of the tongue as a presentation of cranial arteritis. The lingual necrosis may have been precipitated in part by the use of ergotamine to relieve the headache of the temporal arteritis, mistaken initially for migraine. The patient recovered with high-dose steroid therapy.

One year comparative trial of metformin and glipizide in type 2 diabetes mellitus

Forty-eight diabetic subjects with diet-failed Type 2 mellitus, aged 40-69 years, were randomised to metformin (24 patients) or glipizide (24 patients) therapy, and followed prospectively for 12 months. Most subjects were obese. Metformin gave better fasting plasma glucose control compared to glipizide at 24 (p < 0.01), 36 (p < 0.05) and 52 weeks (p < 0.05) with a lower HbA1 concentration at 52 weeks (p < 0.05). Metformin treated patients lost weight whereas glipizide treated subjects gained weight. The weight change between the treatment groups reached significance at 4 weeks (p < 0.05) and was highly significant (p < 0.001) at 8, 12, 24, 36 and 52 weeks. There were no significant changes in either fasting plasma lipid or blood lactate levels in either the metformin or glipizide treated groups. Both drugs caused a similar reduction in albumin excretion rates. In conclusion, metformin gave better glycaemic control than glipizide, with weight loss rather than weight gain in obese Type 2 patients.

c-fos antisense in rostral ventral medulla reduces arterial blood pressure

The effect of blocking the expression of c-fos in the rostral ventral medulla (RVM) on the control of arterial blood pressure was determined. In six male Wistar-Kyoto rats (WKY), unilateral injection of an antisense oligonucleotide to c-fos mRNA suppressed the expression of Fos-like immunoreactivity in neurons in the RVM in response to inhibition of depressor neurons in the caudal ventrolateral medulla (CVLM). Under pentobarbital anesthesia the mean arterial pressure of rats injected with antisense oligonucleotide (n = 10) bilaterally into RVM was significantly reduced after 6 h compared with sense-treated controls (n = 9) (76.5 +/- 3.7 vs. 92.4 +/- 3.5 mmHg; P < 0.05). Furthermore, the pressor response to bilateral injection of muscimol into CVLM was significantly smaller in rats injected with antisense oligonucleotide 6 h earlier (n = 6) compared with sense-treated controls (n = 6) (changes in mean arterial pressure, +40.3 +/- 3.6 vs. +68.7 +/- 4.8 mmHg, P < 0.005). These studies demonstrate that expression of c-fos in the RVM can be blocked in vivo by treatment with an antisense oligonucleotide, and that basal and stimulated expression of the c-fos gene is important in the central control of arterial blood pressure.

Close appositions between tyrosine hydroxylase immunoreactive boutons and respiratory neurons in the rat ventrolateral medulla

The extent of the adrenergic input to respiratory neurons in the ventrolateral medulla oblongata of rats was assessed by using a combination of intracellular recording, dye filling, and immunohistochemistry. Twenty-two neurons that displayed a pronounced respiration-related modulation of their membrane potential, and could not be antidromically activated by electrical stimulation of the superior laryngeal, vagus, or facial nerves, were labelled by intracellular injection of biocytin. Three types of respiration-related neurons were labelled: small neurons located in the Bötzinger complex between 0.5 and 1.0 mm caudal to the facial nucleus; medium-sized neurons located in the ventral respiratory group 1.0 to 2.0 mm caudal to the facial nucleus; and large motoneurons located within the nucleus ambiguus 0.5 to 2.0 mm caudal to the facial nucleus. Small Bötzinger neurons [length = 22 +/- 5 microns, width = 13 +/- 3 microns, area = 222 +/- 79 microns2; (mean +/- SD, n = 5)] had membrane potentials of -15 to -27 mV during the recording period. Four of five of these cells had profuse axonal terminations between 50 microns caudal and 450 microns rostral to their somata, suggesting that they may form part of local networks responsible for generating respiratory activity. Medium-sized ventral respiratory group neurons (length = 26 +/- 5 microns, width = 18 +/- 4 microns, area = 377 +/- 141 microns2; n = 5) were found in the vicinity of the nucleus ambiguus dorsal to the lateral reticular nucleus. Three of five of these neurons had an axon that crossed the midline and travelled caudally. One axon had a collateral with varicosities close to its soma. The somata of motoneurons (length = 29 +/- 6 microns, width = 21 +/- 4 microns, area = 485 +/- 142 microns2; n = 12) were located within the nucleus ambiguus, and had axons that could be traced to exist points from the medulla. Tyrosine hydroxylase immunoreactive cells and their terminal fibres within the medulla were localised by immunocytochemistry. Small Bötzinger neurons received the largest number of close appositions from tyrosine hydroxylase immunoreactive boutons (13 +/- 2 appositions/neuron; n = 5). Medium-sized ventral respiratory group neurons received fewer appositions (8 +/- 4 appositions/neuron; n = 5). Most motoneurons (n = 10) received few appositions from tyrosine hydroxylase immunoreactive boutons, while two received none. The average number was 3 +/- 3 appositions/neuron (n = 12).(ABSTRACT TRUNCATED AT 400 WORDS)

Projections from inspiratory neurons of the ventral respiratory group to the subretrofacial nucleus of the cat

Arterial blood pressure and the activity of many sympathetic nerves are known to be affected by changes in central respiratory activity. The central neurons responsible for this respiratory modulation are unknown. In the present study we have labelled inspiratory neurons (n = 24) in the rostral ventral respiratory group and Bötzinger complex in the medulla oblongata of the cat using intracellular injection of biocytin. The filled neurons were examined to see if they had axonal projections to the subretrofacial nucleus, an important brainstem nucleus in the tonic and reflex control of blood pressure. The subretrofacial nucleus was identified histologically as a cluster of neurons in the rostral ventrolateral medulla, some of which are tyrosine hydroxylase immunoreactive. Varicose axons arising from labelled inspiratory neurons were mostly found dorsal to this cluster, within the area corresponding to the Bötzinger complex. A small number of axon varicosities were seen in the subretrofacial nucleus. The results suggest that a part of the respiratory modulation of sympathetic nerve activity may be due to a direct synaptic input from inspiratory neurons of the ventral respiratory group to neurons of the subretrofacial nucleus.