Receptor characteristics and recovery of function following kainic acid lesions and fetal transplants of the striatum. I. Cholinergic systems

Exploring socioeconomic inequities in access to palliative and end-of-life care in the UK: a narrative synthesis

BACKGROUND

Efforts inequities in access to palliative and end-of-life care require comprehensive understanding about the extent of and reasons for inequities. Most research on this topic examines differences in receipt of care. There is a need, particularly in the UK, for theoretically driven research that considers both receipt of care and the wider factors influencing the relationship between socioeconomic position and access to palliative and end-of-life care.

METHODS

This is a mixed studies narrative synthesis on socioeconomic position and access to palliative and end-of-life care in the UK. Study searches were conducted in databases AMED, Medline, Embase, CINAHL, SocIndex, and Academic Literature Search, as well as grey literature sources, in July 2020. The candidacy model of access, which describes access as a seven-stage negotiation between patients and providers, guided study searches and provided a theoretical lens through which data were synthesised.

RESULTS

Searches retrieved 5303 studies (after de-duplication), 29 of which were included. The synthesis generated four overarching themes, within which concepts of candidacy were evident: identifying needs; taking action; local conditions; and receiving care.

CONCLUSION

There is not a consistent or clear narrative regarding the relationship between socioeconomic position and receipt of palliative and end-of-life care in the UK. Attempts to address any inequities in access will require knowledge and action across many different areas. Key evidence gaps in the UK literature concern the relationship between socioeconomic position, organisational context, and assessing need for care.

Differentiation of pluripotent stem cells into striatal projection neurons: a pure MSN fate may not be sufficient

Huntington's disease (HD) is an autosomal dominant inherited disorder leading to the loss inter alia of DARPP-32 positive medium spiny projection neurons ("MSNs") in the striatum. There is no known cure for HD but the relative specificity of cell loss early in the disease has made cell replacement by neural transplantation an attractive therapeutic possibility. Transplantation of human fetal striatal precursor cells has shown "proof-of-principle" in clinical trials; however, the practical and ethical difficulties associated with sourcing fetal tissues have stimulated the need to identify alternative source(s) of donor cells that are more readily available and more suitable for standardization. We now have available the first generation of protocols to generate DARPP-32 positive MSN-like neurons from pluripotent stem cells and these have been successfully grafted into animal models of HD. However, whether these grafts can provide stable functional recovery to the level that can regularly be achieved with primary fetal striatal grafts remains to be demonstrated. Of particular concern, primary fetal striatal grafts are not homogenous; they contain not only the MSN subpopulation of striatal projection neurons but also include all the different cell types that make up the mature striatum, such as the multiple populations of striatal interneurons and striatal glia, and which certainly contribute to normal striatal function. By contrast, present protocols for pluripotent stem cell differentiation are almost entirely targeted at specifying just neurons of an MSN lineage. So far, evidence for the functionality and integration of stem-cell derived grafts is correspondingly limited. Indeed, consideration of the features of full striatal reconstruction that is achieved with primary fetal striatal grafts suggests that optimal success of the next generations of stem cell-derived replacement therapy in HD will require that graft protocols be developed to allow inclusion of multiple striatal cell types, such as interneurons and/or glia. Almost certainly, therefore, more sophisticated differentiation protocols will be necessary, over and above replacement of a specific population of MSNs. A rational solution to this technical challenge requires that we re-address the underlying question-what constitutes a functional striatal graft?

Striatal grafts alleviate bilateral striatal lesion deficits in operant delayed alternation in the rat

In order to assess the capacity of striatal grafts to alleviate cognitive deficits of the frontal type that arise following bilateral striatal lesions, control, lesion and grafted rats were tested in an operant test of delayed alternation. Bilateral striatal lesions induced a marked impairment in choice accuracy, and signal detection analysis indicated that the lesion animals were reliably impaired on both parametric and non-parametric indices of discriminative sensitivity but not of response bias. The impairment was apparent at all intertrial interval delays, including the very shortest, suggesting the deficit is one of frontal-type executive function rather than of short-term memory. The grafted animals exhibited a significant alleviation of the deficit, again apparent at all delays. Histological analyses indicated good graft survival, and injections of a dextran amine anterograde tracer bilaterally into the host prefrontal cortex indicated reformation of extensive projections into the grafted tissues. Since performance of the operant delayed alternation task is dependent upon the integrity of corticostriatal connections, which is disrupted bilaterally by the lesions and restored to the grafts in the transplanted animals, the results corroborate the hypothesis that striatal grafts can alleviate complex cognitive functions of the frontal type by a mechanism that involves functional integration of the grafted neurons into the neural circuits of the host brain.

Chemical anatomy of striatal interneurons in normal individuals and in patients with Huntington's disease

This paper reviews the major anatomical and chemical features of the various types of interneurons in the human striatum, as detected by immunostaining procedures applied to postmortem tissue from normal individuals and patients with Huntington's disease (HD). The human striatum harbors a highly pleomorphic population of aspiny interneurons that stain for either a calcium-binding protein (calretinin, parvalbumin or calbindin D-28k), choline acetyltransferase (ChAT) or NADPH-diaphorase, or various combinations thereof. Neurons that express calretinin (CR), including multitudinous medium and a smaller number of large neurons, are by far the most abundant interneurons in the human striatum. The medium CR+ neurons do not colocalize with any of the known chemical markers of striatal neurons, except perhaps GABA, and are selectively spared in HD. Most large CR+ interneurons display ChAT immunoreactivity and also express substance P receptors. The medium and large CR+ neurons are enriched with glutamate receptor subunit GluR2 and GluR4, respectively. This difference in AMPA GluR subunit expression may account for the relative resistance of medium CR+ neurons to glutamate-mediated excitotoxicity that may be involved in HD. The various striatal chemical markers display a highly heterogeneous distribution pattern in human. In addition to the classic striosomes/matrix compartmentalization, the striosomal compartment itself is composed of a core and a peripheral region, each subdivided by distinct subsets of striatal interneurons. A proper knowledge of all these features that appear unique to humans should greatly help our understanding of the organization of the human striatum in both health and disease states.

Towards a protocol for the preparation and delivery of striatal tissue for clinical trials of transplantation in Huntington's disease

There is a growing body of scientific evidence contributing to the development of clinical transplantation programs in patients with Huntington's disease. Phase I clinical trials have already commenced in France and North America and are starting in the near future in Sweden and the UK. Protocols for patient selection, surgical implantation, and pre- and postoperative follow-up are well defined. However, considerable variability exists with respect to the harvesting, preparation, and timing of implantation of the donor material. In this article we review the scientific evidence on which a rational protocol for donor tissue preparation and delivery may be based. Strategies aimed at minimizing the variability of tissue preparation should reduce the variability of functional outcome of striatal transplantation observed in animal models of Huntington's disease.

Rationale for intrastriatal grafting of striatal neuroblasts in patients with Huntington's disease

Huntington's disease is a genetic disease, autosomal and dominant, that induces motor disorders, an inexorable deterioration of higher brain functions and psychiatric disturbances. At present, there are no known therapeutics against Huntington's disease. The Network of European CNS Transplantation and Restoration (NECTAR) has begun a program aimed at defining the conditions under which intrastriatal transplantation of fetal striatal cells could be attempted as an experimental treatment for Huntington's disease. This review presents the reasons why our group is considering participating in these trials. The validity of this therapeutic approach is supported by three main series of data: (i) neuropathological, clinical and imaging data indicate that Huntington's disease is, above all, a localized affection of a specific neuronal population ("medium-spiny" neurons) in the striatum; (ii) a large body of experimental results, obtained in rats and non-human primates, demonstrates that transplanted fetal striatal cells are able to integrate the host brain and to substitute for previously lesioned host striatal neurons; (iii) expertise in clinical neural transplantation has now been acquired from the treatment of patients with Parkinson's disease. These different sets of data are presented and discussed in this review. There are a number of problems which do not yet appear to be entirely resolved, nor are they likely to be using the experimental models currently available. These problems are identified and explicitly presented as working hypotheses. (1) Anatomo-functional results obtained in rodents and non-human primates with excitotoxic striatal lesions can serve as a basis for the extrapolation of what can be obtained from patients with Huntington's disease. (2). Huntington's disease can be efficiently fought by substituting degenerated striatal neurons alone. (3) Huntington's disease is due to a genetic defect which either hits the neurons that carry it directly or hits them indirectly only after several decades. Transplanted neurons, because they do not carry the gene or because they are of fetal origin, will not be rapidly affected by the ongoing disease process. Given the current state of knowledge, intracerebral transplantation appears to be the most serious opportunity (if not the only one that has been experimentally validated) for clinical improvement to be obtained in patients with Huntington's disease. The purpose of this review is to open a scientific discussion on its experimental bases before actual clinical trials start.

Reversal of early phenobarbital-induced cholinergic and related behavioral deficits by neuronal grafting

The present experiment was performed to assess the possible restoration of normal maze behavior, as well as parallel muscarinic receptor binding capabilities, in mice pre- or neonatally exposed to phenobarbital. Mice were exposed to phenobarbital prenatally by feeding the mother phenobarbital (3 gkg milled food) on gestation days 9-18 (PreB mice), or neonatally, by daily injections of 50 mg/kg Na phenobarbital to the pups on days 2-21 (NeoB). At adulthood, PreB and NeoB mice were 61.3% and 65% deficient, respectively, in the hippocampus-related Morris maze behavior, as compared to control. Both groups had a 58% increase in their hippocampal muscarinic receptors maximal binding (Bmax) (p < 0.001); the dissociation constant (Kd) was not affected by the phenobarbital exposure. Treated animals and their respective controls received septal cholinergic embryonic graft into the hippocampus. The viability of the transplants was confirmed by AChE histochemistry. Nine weeks later the grafted mice showed significant improvement in the Morris maze (52% for both PreB and NeoB (p < 0.001)). Their Bmax was also reduced from early phenobarbital exposed animals' levels by 15% for PreB and by 25% for NeoB (p < 0.001). The results suggest that early phenobarbital-induced behavioral deficit and their related biochemical alterations can be partially corrected by the appropriate neural grafting, and thus provide further support to the apparent relationship between the early phenobarbital-induced septohippocampal cholinergic alterations and the hippocampus-related behavioral deficits.

Striatal grafts in infarct striatopallidum increase GABA release, reorganize GABAA receptor and improve water-maze learning in the rat

We grafted fetal striatal cells in ischemic rat models, and investigated graft survival/growth, GABA release, GABAA receptor reorganization and functional recovery. One hour intraluminal occlusion of the middle cerebral artery (MCA) induced ischemic infarct in the lateral part of the striatum and adjacent cortex. In ischemic rats, the acquisition of Morris' water-maze learning was significantly slower than that of control rats. In these animals GABA level in the globus pallidus, detected by microdialysis, was about the half of that of controls. However, after the grafts of fetal striatal cells in the striatopallidum, the acquisition was improved, thus no difference was observed in the time course of learning curves in control and grafted animals. GABA level recovered to almost normal level by the graft. It further increased by the treatment of a GABA uptake blocker (nipecotic acids) in the perfusion. In the grafts, GABAA receptor organization detected by autoradiography using [3H] labeled SR95531 was restored for more than 1 year after the graft. Data suggest that fetal striatal cell grafts in infarct striatum may partially reconstruct striatopallidal GABA projection and reorganize GABAA receptor. This might be a basis of improvement of function.

Accelerating behavioral recovery after cortical lesions. II. In vivo evidence for cholinergic involvement

We recently demonstrated that insular cortex (IC) fetal implants supplemented by nerve growth factor (NGF) can accelerate the recovery of behavioral deficits induced by IC brain lesions. In the present report we describe results on in vivo assays of acetylcholine (ACh) turnover in the IC of rats subjected to the same brain lesion and implant treatments used in that research and for which detailed behavioral data are available. The neurochemical assays were carried out immediately after completion of the behavioral measurements. The assays showed that implants or NGF with heterotopic tissue continued to be associated with elevated levels of ACh and with deficits in learning and memory at a time postlesion when both behavior and ACh turnover in vivo, after treatment with homotopic implants and NGF combined, were at nonlesioned control levels. The results support the concept that, in vivo, the cholinergic neurotransmitter system is intimately involved in recovery from IC lesion-induced deficits in behavior and show that a combination of homotopic implant and NGF may be used as a means of manipulating that system to accelerate the repair of such deficits. Mechanisms by which this combination produces its effects are considered and the possibility is suggested that other neurotrophic factors (NTF) may also be useful when other types of brain lesions are involved.

Intrastriatal grafts derived from fetal striatal primordia--IV. Host and donor neurons are not intermixed

Embryonic striatal grafts transplanted into excitotoxin-damaged host striatum develop a heterogeneous structure in which some regions resemble striatum but others do not. In the experiments reported here, we tested for the possibility that the regions resembling striatum were actually derived from host neurons that migrated into the grafts, rather than being derived from donor cells. We placed embryonic striatal grafts into host brains in which striatal cells had been multiply pulse-labeled with [3H]thymidine. Four groups of host rats were exposed to [3H]thymidine at embryonic days 12 and 13-15, 15-18, 16-19, or 20 to postnatal day 1, and were allowed to reach maturity. One week prior to grafting, lesions of the caudoputamen were made unilaterally in each host rat by injecting ibotenic acid. At grafting, dissociated cells from embryonic days 14-16 rat striatal primordia were injected bilaterally into the host caudoputamen. The locations of [3H]thymidine-labeled neurons were analysed by autoradiography eight to 16.5 months post-grafting. Despite the presence of many intensely labeled neurons in the host striatum of rats in all four groups, intensely labeled neurons were rarely found in the cores of grafts. A few weakly labeled small cells appeared in the graft cores, and occasional strongly or weakly labeled medium-sized cells appeared at the margins of the graft zones. Some perivascular cells associated with blood vessels in the grafts were also weakly labeled, but the gliotic tissue surrounding the graft zones was not labeled. These results suggest that very few host striatal neurons migrate into the cores of intrastriatal grafts, or that, if they do, such neurons return to the host striatum or do not survive. At most, surviving host striatal neurons have limited spatial interactions with donor cells at the margins of the grafts, both in the damaged and in the intact host striatal environment. These observations, combined with our previous finding that [3H]thymidine-labeled cells derived from embryonic day 15 striatal primordia do not appear in the host striatum, indicate that no extensive mutual migrations of striatal donor neurons and host neurons occur in the zones of grafting.

Choline acetyltransferase- and substance P-like immunoreactive elements in fetal striatal grafts in the rat: a correlated light and electron microscopic study

Fetal striatal neurons were transplanted into the ibotenic acid-lesioned rat striatum. Three months after transplantation, the graft tissue was processed for choline acetyltransferase- and substance P-like immunoreactivity and was subsequently examined at the light and electron microscopic levels. The study demonstrated that choline acetyltransferase- and substance P-like-immunoreactive neurons were homogenously present throughout fetal striatal grafts, although in decreased numbers compared with those in the normal rat striatum. The majority of the choline acetyltransferase-immunoreactive neurons had fusiform, oval, or polygonal somata with somatic diameters greater than 20 microns and contained deeply invaginated nuclei surrounded by copious cytoplasm. In addition, choline acetyltransferase-immunoreactive neurons with somatic diameters between 10 and 20 microns were also demonstrated. The grafts' substance P-like-immunoreactive neurons, which had somatic diameters between 10 and 25 microns and had oval or polygonal perikarya, could be classified into two types based on their ultrastructural characteristics. Type I neurons contained an unindented nucleus which was surrounded by a thin rim or moderate amount of cytoplasm, whereas Type II immunoreactive neurons contained an indented nucleus which was surrounded by copious cytoplasm. Choline acetyltransferase- and substance P-like-immunoreactive dendrites in the grafts' neuropil were contacted by multiple unlabeled axon terminals. In addition, choline acetyltransferase- and substance P-like-immunoreactive axon terminals forming symmetric contacts with unlabeled dendrites were present within the graft. The study demonstrated that many of the neuroanatomical features of choline acetyltransferase- and substance P-like-immunoreactive elements found in the normal rat striatum are present in mature fetal striatal grafts.

Calbindin-D28K-containing neurons in animal models of neurodegeneration: possible protection from excitotoxicity

Brain levels of the calcium binding protein Calbindin-D28K (CaBP28K) and CaBP28K mRNA were measured for various animal models of neurodegenerative diseases (MPTP-treated C57BL/6J mice and Sprague-Dawley rats receiving striatal/intraperitoneal kainic acid or quinolinic acid into the nucleus basalis magnocellularis). Brain areas were tested (radioimmunoassay, Western blot, slot blot, and Northern blot) for levels of CaBP28K and CaBP28K mRNA. The various models did not exhibit any changes in protein or mRNA levels from the controls, suggesting that CaBP28K-containing neurons were not lost after exposure to these neurotoxins. Immunocytochemical characterization of the substantia nigra of the MPTP-treated mice revealed that there was significant dopaminergic cell loss in this brain area after MPTP treatment. The majority of dopaminergic neurons that degenerated did not contain CaBP28K. The small percentage of surviving neurons were CaBP28K-positive. These results suggest that the presence of CaBP28K may protect neurons from calcium-mediated neurotoxicity.

Striatal, ventral mesencephalic and cortical transplants into the intact rat striatum: a neuroanatomical study

Intrastriatal transplantation of fetal striatal (STR), cortical (CTX), or ventral mesencephalic (VM) tissue into the normal striatum has been shown to produce behavioral deficits (38). Here, we have examined the cellular elements of the transplants and their connectivity with the host using histochemistry for cytochrome oxidase (CO) and acetylcholinesterase (AChE), immunocytochemistry for glial fibrillary acidic protein (GFAP), OX42, tyrosine hydroxylase (TH), dopamine beta-hydroxylase (DBH), serotonin (5-HT), and cholecystokinin (CCK). Autoradiography for dopamine D1 and D2, muscarinic cholinergic, and serotonin 5-HT1 and 5-HT2 receptors at 5-15 months after transplantation was also investigated. CO staining showed that all transplants were metabolically active. The STR and VM transplants contained AChE-positive neurons and fibers. The CTX transplants exhibited AChE terminals with an appearance similar to that of the host cortex. AChE staining within the STR transplants was patchy. 5-HT-, TH-, and DBH-immunoreactive (IR) fibers were found in the STR and CTX transplants. In two of six CTX transplants, many TH-IR neurons were present. The VM transplants contained many TH-IR, 5-HT-IR, and DBH-IR cell bodies and fibers. CCK-IR stain was found in the VM transplant and was coextensive with regions containing TH-IR cell bodies. Fibers stained by all markers crossed the transplant and host border. Receptor autoradiography revealed that muscarinic cholinergic and 5-HT2 receptors were present in the STR, CTX, and VM transplants. In addition, dopamine D1 and D2 receptors were present in the STR transplants. Intermittent heavy staining for GFAP and OX42 were observed along the border of most transplants and the hosts. It was noted that high densities and hypertrophy of GFAP- or OX42-stained astrocytes or microglia, respectively, were present in the transplants and adjacent host. OX42-stained macrophages were found in many transplants. The present results indicate that intrastriatal transplants into the intact normal brain express numerous histochemical, immunocytochemical, and receptor features characteristic of the appropriate adult tissues. The afferents from the host extend into the STR and CTX transplants, and neural fibers from the VM transplants grew into surrounding host tissue, suggesting possible anatomical connection. Ultrastructural evidence is needed to determine if these fibers form synaptic connections. The results from GFAP and OX42 immunocytochemical staining support the possibility suggested by behavioral studies that damage to the host brain is induced by neural transplantation.

Development of D1 and D2 dopamine receptors and associated second messenger systems in fetal striatal transplants

Stereotactic implantation of fetal brain regional anlage into adult host brain ("brain transplantation") appears to be an increasingly viable strategy for therapy of neurodegenerative diseases. We have studied implantation of fetal striatum into adult striatum, previously lesioned by neurotoxic amino acid injection, as a model for transplantation therapy of Huntington's disease. The beginning of behavioral recovery to apomorphine is not apparent until 6.5 months after implantation. By 4 months after implantation cerebral blood flow through the implants appears equal to that in the intact contralateral striatum. At this time, cerebral glucose utilization is reduced in the implants but increases following apomorphine treatment. The development of D1 and D2 dopamine (DA) receptors is markedly deficient in the striatal grafts at both 4 and 6.5 months after implantation. Very little D2 radioligand binding was observed in the grafts at either time point; D1 receptors appeared in a patchy fashion by 6.5 months at densities approaching normal striatum. In situ hybridization of D2 dopamine receptor mRNA demonstrated robust hybridization signal in normal striatum and accumbens but no signal in 6.5-month-old striatal grafts. Adenylate cyclase (AC) activity, examined with high-affinity [3H]forskolin binding, also appeared in patches similar to D1 receptors at 6.5 months. In contrast, protein kinase C activity, labeled with [3H]phorbol ester, was very apparent in the grafts at both time points. Higher and generally homogenous densities of muscarinic cholinergic receptors, assessed with [3H]QNB binding, develop in the grafts, but there appear to be few functioning cholinergic terminals, as measured by [3H]hemicholinium binding.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term survival of GABA-, enkephalin-, NADPH-diaphorase- and calbindin-d28k-containing neurons in fetal striatal grafts

Neurons in long-term striatal grafts were examined to determine if they retain the neurotransmitter characteristics of cells in younger grafts. In addition, calbindin-d28k, a ubiquitous marker of medium spiny neurons, was used to examine the overall frequency and ultrastructural characteristics of spiny neurons in the older grafts. Grafts from 17-day fetal striata were injected into the quinolinic acid-lesioned caudate nucleus in 5 adult rats. After 16 months, the neostriatum was processed for the localization of immunoreactive GABA, calbindin, enkephalin and NADPH-diaphorase (-d) activity. The proportions of GABA-, enkephalin- and NADPH-d-labeled neurons to total Nissl-stained neurons in the 16-month-old grafts (25 +/- 6, 13 +/- 4, and 3 +/- 3, respectively) were similar to findings in 2-month-old grafts. Calbindin-positive cells formed the highest proportion (36.3 +/- 3) of labeled neurons in the older grafts. Nuclear and spine morphology of immunoreactive calbindin cells varied more in the grafts than in host caudate. Results show that there is long-term survival and stability of GABA, enkephalin and NADPH-d cell populations in the grafts and that some grafted spiny neurons may exhibit altered phenotype from those of host striatum.

Behavioral effects of neural transplants into the intact striatum

The behavioral effects of fetal brain tissue and adrenal medulla transplants into the intact striatum of rats were investigated. Following a bilateral injection of 1.5, 3 or 6 microliters of fetal striatal tissue, a volume-related weight loss was found in all transplanted groups, including the SHAM group, during the first 7 days after the surgery. Rearing behavior was changed in a transplant volume-related manner. Histological analysis suggested that the locomotor effects of transplants into the intact striatum are related to the volume of the transplants. Following bilateral transplantation of fetal cortex (CTX), substantia nigra (SN), striatum (STR), or adrenal medulla (AM) into the striatum, the different behavioral deficits were observed among these transplant groups. The SN group showed a decrease in spontaneous locomotion, significantly increased rearing activity in response to administration of amphetamine, reduction of food intake and water intake and a reduction in body weight. The CTX and AM groups showed a marked increase in spontaneous rearing activities. Hyporesponsiveness to the administration of apomorphine (1 mg/kg) and amphetamine (1 mg/kg) was evident in the CTX, STR, AM groups and SHAM groups. In contrast, the haloperidol-induced catalepsy scores of the CTX, STR, SN and AM were significantly higher than those of a normal control group. In addition, the CTX group showed a deficit in the delayed reward alternation test. These results indicated that the behavioral deficits produced by transplants into normal striatum may be related to both mechanical destruction due to transplant expansion and specific neurochemical interactions of each tissue type between the host and the transplant. Therefore, potential negative consequences of neural transplantation therapy should be considered as well as the beneficial effects.