Familial dysautonomia (a brief review)

Transcriptome analysis in a humanized mouse model of familial dysautonomia reveals tissue-specific gene expression disruption in the peripheral nervous system

Familial dysautonomia (FD) is a rare recessive neurodevelopmental disease caused by a splice mutation in the Elongator acetyltransferase complex subunit 1 ( ELP1 ) gene. This mutation results in a tissue-specific reduction of ELP1 protein, with the lowest levels in the central and peripheral nervous systems (CNS and PNS, respectively). FD patients exhibit complex neurological phenotypes due to the loss of sensory and autonomic neurons. Disease symptoms include decreased pain and temperature perception, impaired or absent myotatic reflexes, proprioceptive ataxia, and progressive retinal degeneration. While the involvement of the PNS in FD pathogenesis has been clearly recognized, the underlying mechanisms responsible for the preferential neuronal loss remain unknown. In this study, we aimed to elucidate the molecular mechanisms underlying FD by conducting a comprehensive transcriptome analysis of neuronal tissues from the phenotypic mouse model TgFD9 ; Elp1 Δ 20/flox . This mouse recapitulates the same tissue-specific ELP1 mis-splicing observed in patients while modeling many of the disease manifestations. Comparison of FD and control transcriptomes from dorsal root ganglion (DRG), trigeminal ganglion (TG), medulla (MED), cortex, and spinal cord (SC) showed significantly more differentially expressed genes (DEGs) in the PNS than the CNS. We then identified genes that were tightly co-expressed and functionally dependent on the level of full-length ELP1 transcript. These genes, defined as ELP1 dose-responsive genes, were combined with the DEGs to generate tissue-specific dysregulated FD signature genes and networks. Within the PNS networks, we observed direct connections between Elp1 and genes involved in tRNA synthesis and genes related to amine metabolism and synaptic signaling. Importantly, transcriptomic dysregulation in PNS tissues exhibited enrichment for neuronal subtype markers associated with peptidergic nociceptors and myelinated sensory neurons, which are known to be affected in FD. In summary, this study has identified critical tissue-specific gene networks underlying the etiology of FD and provides new insights into the molecular basis of the disease.

Development of an oral treatment that rescues gait ataxia and retinal degeneration in a phenotypic mouse model of familial dysautonomia

Familial dysautonomia (FD) is a rare neurodegenerative disease caused by a splicing mutation in elongator acetyltransferase complex subunit 1 (ELP1). This mutation leads to the skipping of exon 20 and a tissue-specific reduction of ELP1, mainly in the central and peripheral nervous systems. FD is a complex neurological disorder accompanied by severe gait ataxia and retinal degeneration. There is currently no effective treatment to restore ELP1 production in individuals with FD, and the disease is ultimately fatal. After identifying kinetin as a small molecule able to correct the ELP1 splicing defect, we worked on its optimization to generate novel splicing modulator compounds (SMCs) that can be used in individuals with FD. Here, we optimize the potency, efficacy, and bio-distribution of second-generation kinetin derivatives to develop an oral treatment for FD that can efficiently pass the blood-brain barrier and correct the ELP1 splicing defect in the nervous system. We demonstrate that the novel compound PTC258 efficiently restores correct ELP1 splicing in mouse tissues, including brain, and most importantly, prevents the progressive neuronal degeneration that is characteristic of FD. Postnatal oral administration of PTC258 to the phenotypic mouse model TgFD9;Elp1Δ20/flox increases full-length ELP1 transcript in a dose-dependent manner and leads to a 2-fold increase in functional ELP1 in the brain. Remarkably, PTC258 treatment improves survival, gait ataxia, and retinal degeneration in the phenotypic FD mice. Our findings highlight the great therapeutic potential of this novel class of small molecules as an oral treatment for FD.

Developmental regulation of neuronal gene expression by Elongator complex protein 1 dosage

Familial dysautonomia (FD), a hereditary sensory and autonomic neuropathy, is caused by a mutation in the Elongator complex protein 1 (ELP1) gene that leads to a tissue-specific reduction of ELP1 protein. Our work to generate a phenotypic mouse model for FD headed to the discovery that homozygous deletion of the mouse Elp1 gene leads to embryonic lethality prior to mid-gestation. Given that FD is caused by a reduction, not loss, of ELP1, we generated two new mouse models by introducing different copy numbers of the human FD ELP1 transgene into the Elp1 knockout mouse (Elp1-/-) and observed that human ELP1 expression rescues embryonic development in a dose-dependent manner. We then conducted a comprehensive transcriptome analysis in mouse embryos to identify genes and pathways whose expression correlates with the amount of ELP1. We found that ELP1 is essential for the expression of genes responsible for nervous system development. Further, gene length analysis of the differentially expressed genes showed that the loss of Elp1 mainly impacts the expression of long genes and that by gradually restoring Elongator, their expression is progressively rescued. Finally, through evaluation of co-expression modules, we identified gene sets with unique expression patterns that depended on ELP1 expression.

Selective retinal ganglion cell loss and optic neuropathy in a humanized mouse model of familial dysautonomia

Familial dysautonomia (FD) is an autosomal recessive neurodegenerative disease caused by a splicing mutation in the gene encoding Elongator complex protein 1 (ELP1, also known as IKBKAP). This mutation results in tissue-specific skipping of exon 20 with a corresponding reduction of ELP1 protein, predominantly in the central and peripheral nervous system. Although FD patients have a complex neurological phenotype caused by continuous depletion of sensory and autonomic neurons, progressive visual decline leading to blindness is one of the most problematic aspects of the disease, as it severely affects their quality of life. To better understand the disease mechanism as well as to test the in vivo efficacy of targeted therapies for FD, we have recently generated a novel phenotypic mouse model, TgFD9; IkbkapΔ20/flox. This mouse exhibits most of the clinical features of the disease and accurately recapitulates the tissue-specific splicing defect observed in FD patients. Driven by the dire need to develop therapies targeting retinal degeneration in FD, herein, we comprehensively characterized the progression of the retinal phenotype in this mouse, and we demonstrated that it is possible to correct ELP1 splicing defect in the retina using the splicing modulator compound (SMC) BPN-15477.

ELP1 Splicing Correction Reverses Proprioceptive Sensory Loss in Familial Dysautonomia

Familial dysautonomia (FD) is a recessive neurodegenerative disease caused by a splice mutation in Elongator complex protein 1 (ELP1, also known as IKBKAP); this mutation leads to variable skipping of exon 20 and to a drastic reduction of ELP1 in the nervous system. Clinically, many of the debilitating aspects of the disease are related to a progressive loss of proprioception; this loss leads to severe gait ataxia, spinal deformities, and respiratory insufficiency due to neuromuscular incoordination. There is currently no effective treatment for FD, and the disease is ultimately fatal. The development of a drug that targets the underlying molecular defect provides hope that the drastic peripheral neurodegeneration characteristic of FD can be halted. We demonstrate herein that the FD mouse TgFD9;Ikbkap^Δ20/flox recapitulates the proprioceptive impairment observed in individuals with FD, and we provide the in vivo evidence that postnatal correction, promoted by the small molecule kinetin, of the mutant ELP1 splicing can rescue neurological phenotypes in FD. Daily administration of kinetin starting at birth improves sensory-motor coordination and prevents the onset of spinal abnormalities by stopping the loss of proprioceptive neurons. These phenotypic improvements correlate with increased amounts of full-length ELP1 mRNA and protein in multiple tissues, including in the peripheral nervous system (PNS). Our results show that postnatal correction of the underlying ELP1 splicing defect can rescue devastating disease phenotypes and is therefore a viable therapeutic approach for persons with FD.

Sensory and autonomic deficits in a new humanized mouse model of familial dysautonomia

Familial dysautonomia (FD) is an autosomal recessive neurodegenerative disease that affects the development and survival of sensory and autonomic neurons. FD is caused by an mRNA splicing mutation in intron 20 of the IKBKAP gene that results in a tissue-specific skipping of exon 20 and a corresponding reduction of the inhibitor of kappaB kinase complex-associated protein (IKAP), also known as Elongator complex protein 1. To date, several promising therapeutic candidates for FD have been identified that target the underlying mRNA splicing defect, and increase functional IKAP protein. Despite these remarkable advances in drug discovery for FD, we lacked a phenotypic mouse model in which we could manipulate IKBKAP mRNA splicing to evaluate potential efficacy. We have, therefore, engineered a new mouse model that, for the first time, will permit to evaluate the phenotypic effects of splicing modulators and provide a crucial platform for preclinical testing of new therapies. This new mouse model, TgFD9; Ikbkap(Δ20/flox) was created by introducing the complete human IKBKAP transgene with the major FD splice mutation (TgFD9) into a mouse that expresses extremely low levels of endogenous Ikbkap (Ikbkap(Δ20/flox)). The TgFD9; Ikbkap(Δ20/flox) mouse recapitulates many phenotypic features of the human disease, including reduced growth rate, reduced number of fungiform papillae, spinal abnormalities, and sensory and sympathetic impairments, and recreates the same tissue-specific mis-splicing defect seen in FD patients. This is the first mouse model that can be used to evaluate in vivo the therapeutic effect of increasing IKAP levels by correcting the underlying FD splicing defect.

A review of the oro-dento-facial characteristics of hereditary sensory and autonomic neuropathy type III (familial dysautonomia)

The oro-dento-facial features and dysfunction of children with hereditary sensory and autonomic neuropathy type III, known as familial dysautonomia or Riley-Day syndrome, was first described in the scientific literature in 1949. They include dental trauma; dental and soft tissue self-mutilation; normal dental age; normal sequence and timing of eruption and exfoliation of teeth; smaller tooth size; different and disproportional tooth components; normal alveolar bone height; small jaws, mild crowding, and malocclusions. These persons have craniofacial morphology that is different from accepted norms but they resemble norms of their ethnic origin. The subjects can have gray, pale, shiny faces with an asymmetric suffering expression; frontal bossing, with eventual hypertelorism and narrow lips; a low-caries rate; drooling, and hypersalivation. They can have changes in salivary composition and content, which influences plaque and calculus and increases the risk of gingival and periodontal diseases. They also have difficulty in controlling oral muscles; a progressive decrease in number of tongue fungiform papillae, accompanied by lack of taste buds; and specific dysgeusia, but a normal sense of smell.

Loss of mouse Ikbkap, a subunit of elongator, leads to transcriptional deficits and embryonic lethality that can be rescued by human IKBKAP

Familial dysautonomia (FD), a devastating hereditary sensory and autonomic neuropathy, results from an intronic mutation in the IKBKAP gene that disrupts normal mRNA splicing and leads to tissue-specific reduction of IKBKAP protein (IKAP) in the nervous system. To better understand the roles of IKAP in vivo, an Ikbkap knockout mouse model was created. Results from our study show that ablating Ikbkap leads to embryonic lethality, with no homozygous Ikbkap knockout (Ikbkap(-)(/)(-)) embryos surviving beyond 12.5 days postcoitum. Morphological analyses of the Ikbkap(-)(/)(-) conceptus at different stages revealed abnormalities in both the visceral yolk sac and the embryo, including stunted extraembryonic blood vessel formation, delayed entry into midgastrulation, disoriented dorsal primitive neural alignment, and failure to establish the embryonic vascular system. Further, we demonstrate downregulation of several genes that are important for neurulation and vascular development in the Ikbkap(-)(/)(-) embryos and show that this correlates with a defect in transcriptional elongation-coupled histone acetylation. Finally, we show that the embryonic lethality resulting from Ikbkap ablation can be rescued by a human IKBKAP transgene. For the first time, we demonstrate that IKAP is crucial for both vascular and neural development during embryogenesis and that protein function is conserved between mouse and human.

Current approaches to development of the autonomic nervous system: clues to clinical problems

A number of different approaches to autonomic development utilizing a variety of experimental models and analytical techniques have been outlined. A scheme, which attempts to delineate a series of events involving separate but sometimes overlapping mechanisms, is proposed for the complex process of formation and maintenance of functional autonomic neuroeffector junctions. The relevance of these basic mechanisms of a variety of clinical abnormalities of autonomic function is discussed.

Pregnancy induces degenerative and regenerative changes in the autonomic innervation of the female reproductive tract

The uterus is supplied with an extensive system of adrenergic nerves. The neurobiological properties of this innervation have been investigated in a series of studies primarily using the guinea-pig as model. The guinea-pig uterus is supplied from three different sources: the paracervical plexus, containing short adrenergic neurons; the inferior mesenteric ganglion; and a cranial source, probably the aorticorenal plexus, via nerves in the uterine suspensory ligaments. The nerve density is higher in the tubal end of the uterine horn and in the cervix than in the main part of the uterine horn. The turnover rate of transmitter is lower in the uterus than in a control organ, such as the heart. Noradrenaline levels in the uterus, but not the heart, are influenced by alterations in the endocrine milieu, e.g. during the oestrous cycle and after treatment with sex steroids. In the uterine tissue surrounding the conceptus during pregnancy, there is an early and drastic decay in various functional parameters related to the adrenergic nerve plexus and primarily reflecting a local, pregnancy-induced axonal degeneration. In the main part of the empty horn, in unilateral pregnancy, there is an extensive decay in various adrenergic functional parameters; these, however, reflect changes in a nerve plexus that has an essentially intact structure. No sign of functional impairment is seen in the adrenergic nerves of the uterine cervix. The increased turnover rate and reduced transmitter content in this region during late pregnancy may reflect increased frequency of firing of the adrenergic nerves. The tubal end of the uterine horn shows no signs of altered sympathetic function. This is the only part of the uterine horn that appears unaffected by pregnancy. The deficient recovery post partum of the changes in the uterine horn that previously contained the fetuses suggests permanent damage to the adrenergic nerve plexus after a pregnancy. The post partum recovery of changes seen in the previously empty horn, however, is more pronounced but still incomplete by comparison with the innervation before pregnancy. Studies on the adult human uterus indicate that similar events to those described for the guinea-pig model occur in human pregnancy.

A humanized IKBKAP transgenic mouse models a tissue-specific human splicing defect

Familial dysautonomia (FD) is a severe hereditary sensory and autonomic neuropathy, and all patients with FD have a splice mutation in the IKBKAP gene. The FD splice mutation results in variable, tissue-specific skipping of exon 20 in IKBKAP mRNA, which leads to reduced IKAP protein levels. The development of therapies for FD will require suitable mouse models for preclinical studies. In this study, we report the generation and characterization of a mouse model carrying the complete human IKBKAP locus with the FD IVS20+6T-->C splice mutation. We show that the mutant IKBKAP transgene is misspliced in this model in a tissue-specific manner that replicates the pattern seen in FD patient tissues. Creation of this humanized mouse is the first step toward development of a complex phenotypic model of FD. These transgenic mice are an ideal model system for testing the effectiveness of therapeutic agents that target the missplicing defect. Last, these mice will permit direct studies of tissue-specific splicing and the identification of regulatory factors that play a role in complex gene expression.

Therapeutic potential and mechanism of kinetin as a treatment for the human splicing disease familial dysautonomia

Mutations that affect the splicing of pre-mRNA are a major cause of human disease. Familial dysautonomia (FD) is a recessive neurodegenerative disease caused by a T to C transition at base pair 6 of IKBKAP intron 20. This mutation results in variable tissue-specific skipping of exon 20. Previously, we reported that the plant cytokinin kinetin dramatically increases exon 20 inclusion in RNA isolated from cultured FD cells. The goal of the current study was to investigate the nature of the FD splicing defect and the mechanism by which kinetin improves exon inclusion, as such knowledge will facilitate the development of future therapeutics aimed at regulating mRNA splicing. In this study, we demonstrate that treatment of FD lymphoblast cell lines with kinetin increases IKBKAP mRNA and IKAP protein to normal levels. Using a series of minigene constructs, we show that deletion of a region at the end of IKBKAP exon 20 disrupts the ability of kinetin to improve exon inclusion, pinpointing a kinetin responsive sequence element. We next performed a screen of endogenously expressed genes with multiple isoforms resulting from exon skipping events and show that kinetin's ability to improve exon inclusion is not limited to IKBKAP. Lastly, we highlight the potential of kinetin for the treatment of other human splicing disorders by showing correction of a splicing defect in neurofibromatosis.

Of splice and men: what does the distribution of IKAP mRNA in the rat tell us about the pathogenesis of familial dysautonomia?

Familial dysautonomia (FD) is the best-known and most common member of a group of congenital sensory/autonomic neuropathies characterized by widespread sensory and variable autonomic dysfunction. As opposed to the sensory/motor neuropathies, little is known about the causes of neuronal dysfunction and loss in the sensory/autonomic neuropathies. FD involves progressive neuronal degeneration, has a broad impact on the operation of many of the body's systems, and leads to a markedly reduced quality of life and premature death. In 2001, we identified two mutations in the IKBKAP gene that result in FD. IKBKAP encodes IKAP, a member of the putative human holo-Elongator complex, which may facilitate transcription by RNA polymerase II. Whether or not the Elongator plays this role is moot. The FD mutation found on >99.5% of FD chromosomes does not cause complete loss of function. Instead, it results in a tissue-specific decrease in splicing efficiency of the IKBKAP transcript; cells from patients retain some capacity to produce normal mRNA and protein. To better understand the relationship between the genotype of FD patients and their phenotype, we have used in situ hybridization histochemistry to map the IKAP mRNA in sections of whole rat embryos. The mRNA is widely distributed. Highest levels are in the nervous system, but substantial amounts are also present in peripheral organs.

Tissue-specific reduction in splicing efficiency of IKBKAP due to the major mutation associated with familial dysautonomia

We recently identified a mutation in the I-kappa B kinase associated protein (IKBKAP) gene as the major cause of familial dysautonomia (FD), a recessive sensory and autonomic neuropathy. This alteration, located at base pair 6 of the intron 20 donor splice site, is present on >99.5% of FD chromosomes and results in tissue-specific skipping of exon 20. A second FD mutation, a missense change in exon 19 (R696P), was seen in only four patients heterozygous for the major mutation. Here, we have further characterized the consequences of the major mutation by examining the ratio of wild-type to mutant (WT:MU) IKBKAP transcript in EBV-transformed lymphoblast lines, primary fibroblasts, freshly collected blood samples, and postmortem tissues from patients with FD. We consistently found that WT IKBKAP transcripts were present, albeit to varying extents, in all cell lines, blood, and postmortem FD tissues. Further, a corresponding decrease in the level of WT protein is seen in FD cell lines and tissues. The WT:MU ratio in cultured lymphoblasts varied with growth phase but not with serum concentration or inclusion of antibiotics. Using both densitometry and real-time quantitative polymerase chain reaction, we found that relative WT:MU IKBKAP RNA levels were highest in cultured patient lymphoblasts and lowest in postmortem central and peripheral nervous tissues. These observations suggest that the relative inefficiency of WT IKBKAP mRNA production from the mutant alleles in the nervous system underlies the selective degeneration of sensory and autonomic neurons in FD.Therefore, exploration of methods to increase the WT:MU IKBKAP transcript ratio in the nervous system offers a promising approach for developing an effective therapy for patients with FD.

Familial dysautonomia: deep sedation and management in endoscopic procedures

OBJECTIVES

Familial dysautonomia is a rare genetic disorder that affects the development of the central nervous system, causing GI dysfunction. Because of an improved prognosis, elective surgical procedures are more common and present a unique problem to the anesthesiologist. All patients reported in the literature underwent these interventions under general anesthesia in the operating theater. We report our preliminary experience with deep sedation in the endoscopy room in patients with this rare syndrome.

METHODS

Four girls (7-16 yr old) underwent percutaneous endoscopic gastrostomy insertion and/or endoscopic retrograde cholangiopancreaticography. Preprocedure management consisted of adequate hydration and anxiolysis. Intraprocedure management consisted of stabilization of an erratic autonomic nervous system. Midazolam (0.1-0.2 mg/ kg) was administered i.v. before the procedure. Deep sedation was accomplished with propofol i.v. (0.5-1 mg/kg) and maintained with a propofol drip (50-100 microg/kg/min). Recovery was managed in the gastroenterology unit of our facility.

RESULTS

Body temperature, ventilation, heart rate, blood pressure, oxygen saturation, and end-tidal CO2 were stable during the endoscopies. The patients regained consciousness at the end of the endoscopy and were able to drink or to eat as normal. Pain that could precipitate a crisis was present in two patients and was successfully treated with a simple analgesic. No other complications occurred.

CONCLUSION

This rare genetic disorder presents unique management problems to the anesthesiologist, resulting in morbidity and mortality when general anesthesia is used. Our patients received appropriate management before endoscopy, and we performed the procedure under deep sedation. No complications occurred. We are thus confident that deep sedation in the endoscopy suite is safe in this rare syndrome.

Immunocytochemical and electron-microscopic features of tooth pulp innervation in hereditary sensory and autonomic neuropathy

Characteristics of the pulpal innervation in teeth obtained from a 4-year-old Asian boy with hereditary sensory and autonomic neuropathy, type II (HSAN) were investigated. Four minimally carious primary teeth were split longitudinally and prepared for either fluorescent immunocytochemistry or electron microscopy. The occurrence and distribution of specific neuropeptides were determined by the use of antisera to calcitonin gene-related peptide (CGRP), substance P (SP), neuropeptide Y (NPY), and vasoactive intestinal polypeptide (VIP). The overall innervation of the pulps was visualized using antiserum to protein gene product 9.5; an antiserum to dopamine beta-hydroxylase was used to identify postganglionic sympathetic fibres. Pulpal innervation in HSAN was notably different from that of normal teeth: in comparison with the controls, HSAN teeth had an overall marked reduction in pulpal innervation with an absence of large nerve bundles and the subodontoblastic plexus. CGRP- and SP-immunoreactivity was absent in HSAN specimens and VIP-immunoreactivity was reduced. However, NPY-immunoreactivity appeared to be increased within certain regions of the pulp/dentine complex. In addition, there was evidence of NPY-immunoreactive fibres extending into dentine, a feature not seen in the controls. Electron microscopy revealed an absence of myelinated nerve fibres and a paucity of unmyelinated fibres. CGRP and SP have a well-established role in nociceptive processing and their absence in the HSAN teeth would seem to correspond with the clinical presentation of marked peripheral sensory deficit, characteristic of this condition. An up-regulation of NPY-immunoreactivity has previously been reported in animal teeth following nerve injury and a similar mechanism may have stimulated increased NPY expression in HSAN teeth, but the functional significance of its presence within dentinal nerves is not known.

Early-onset multisystem degeneration with central motor, autonomic and optic nerve disturbances: unusual Riley-Day syndrome or new clinical entity?

We report a 21-year-old woman presenting with a slowly progressive tetraparesis, optic nerve atrophy on both sides, and autonomic disturbances since early childhood. The patient has been carefully followed up for 5 years with clinical and ancillary investigations. The results and the time course strongly suggest an underlying degenerative syndrome affecting parts of three major systems: autonomic, motor and visual. Some symptoms resemble familial dysautonomia (FD, Riley-Day syndrome), however, hallmarks of FD, such as absence of fungiform papillae of the tongue, abnormal reaction on intradermal histamine injection, absent tendon reflexes, are missing, and central motor disturbances have not been described in FD. We consider this syndrome a slowly progressive multisystemic degeneration with two unusual hitherto unreported features: the combination of affected systems (autonomic and motor systems, optic nerves), and the early onset.

Prenatal diagnosis of familial dysautonomia by analysis of linked CA-repeat polymorphisms on chromosome 9q31-q33

Familial Dysautonomia (FD) is an autosomal recessive sensory neuropathy that affects about 1 in 3,700 individuals of Ashkenazi Jewish ancestry. The underlying biochemical and genetic defects are unknown, thereby precluding prenatal diagnosis in at-risk families. Recently, the FD gene (DYS) was mapped with strong linkage disequilibrium to polymorphic markers in the chromosome 9 region q31-q33. In this report, the use of these markers for the prenatal diagnosis of FD by linkage analysis in families with a previously affected child was evaluated. Genomic DNA from appropriate family members was analyzed to construct haplotypes using informative CA repeat polymorphisms closely linked to and flanking the FD locus. The calculation of risk for the prenatal diagnoses was performed by linkage analysis. All seven FD families were informative for the closely linked polymorphic markers and fetal diagnoses were made in eight pregnancies. Six fetal diagnoses were predicted with > 98% accuracy, while two with recombinations were predicted with at least 88% and 92% accuracy. Use of these closely linked markers permitted the reliable prenatal diagnosis of FD in families with a previously affected child.

Autonomic failure, depression and anxiety in Parkinson's disease

BACKGROUND

The study tested the hypothesis that subjects with Parkinson's disease (PD) have more autonomic complaints and more attenuation of autonomic reflexes than controls, and that both clusters of variables are related to the presence of anxiety and depression.

METHOD

Thirty-two subjects and 32 healthy controls matched by age and sex were prospectively compared on psychiatric, cognitive and autonomic tests.

RESULTS

'Autonomic' symptoms: were more frequent in PD patients than in healthy controls; were not related to age or changes in autonomic reflexes; were significantly associated with depression and anxiety (medication was not relevant to the association); and did not correlate with motor symptoms.

CONCLUSIONS

The diagnosis of anxiety and depression in some PD subjects is likely to be a behavioural phenocopy caused by autonomic failure. This explains why antidepressant medication is often unhelpful in PD subjects diagnosed as depressed.

Fundoplication and gastrostomy in familial dysautonomia

Fundoplication with gastrostomy has become a frequent treatment for patients with familial dysautonomia, so we evaluated the use of both procedures in 65 patients. Although patients differed widely in presenting signs and age, from 5 weeks to 40 years, gastroesophageal reflux was documented in 95% of patients by cineradiography or pH monitoring. Panendoscopy was a useful adjunct. Preoperative symptoms of gastroesophageal reflux included vomiting, respiratory infections, and exaggerated autonomic dysfunction. Severe oropharyngeal incoordination frequently coexisted and resulted in misdirected swallows with aspiration, dependence on gavage feedings, or poor weight gain and dehydration. Follow-up after surgical correction ranged from 3 months to 11 years; 55 patients (85%) were available for a 1-year postoperative assessment. We had no instances of surgical death. The long-term mortality rate was 14%, primarily related to severe preexisting respiratory disease. Beyond the first postoperative year, 30 patients had pneumonia attributed to continued aspiration, exacerbation of preexisting lung disease, or recurrence of gastroesophageal reflux. Of 11 patients who vomited postoperatively, six had recurrence of reflux. Recurrence of gastroesophageal reflux was documented in eight patients (12%), and we revised the fundoplication in three patients. The number of patients with cyclic crises was reduced from 18 to 7; retching replaced overt vomiting in all but two of these seven patients, neither of whom had recurrence of reflux. Because oropharyngeal incoordination was prominent, concomitant use of gastrostomy and an antireflux procedure was especially effective in the treatment of younger patients with familial dysautonomia, before the development of severe respiratory disease. Despite the development of severe morning nausea in 15 patients, the combination procedure resulted in significantly improved nutritional status, decreased vomiting, and decreased respiratory problems. Appropriate use of gastrostomy feedings also contributed to success of the operation. The generally good outcome of fundoplication with gastrostomy confirms the benefit of this procedure in familial dysautonomia.

Trophic regulation of nodose ganglion cell development: evidence for an expanded role of nerve growth factor during embryogenesis in the rat

Peripheral sensory neurons are derived from two distinct embryonic tissues, the neural crest and epibranchial placodes. Studies in the chick suggest that embryonic lineage and trophic dependence are interrelated, such that many crest-derived cells depend on NGF for survival during development, whereas placodal derivates, including nodose ganglion neurons, do not (30). It remains controversial, however, whether or not a similar dichotomy exists in mammalian species, in which trophic requirements during early development of placodal ganglia have not been defined. To approach this issue, the present study examined the effects of nerve growth factor (NGF) on neuronal survival in embryonic rat nodose ganglion cultures. Treatment of E13.5-14.5 nodose explants with 20 ng/ml NGF resulted in a four-fold increase in neuronal survival that was blocked by anti-NGF antiserum. Increased neuronal survival and neurite outgrowth were also observed in neuron-enriched dissociated cell cultures; these effects were seen within 12 h of plating, indicating that NGF-responsive neurons or neuroblasts were already present in the ganglion at the time of explantation. This was further supported by immunocytochemical staining of nodose cell bodies in situ with the monoclonal antibody 192-IgG against the NGF receptor (12). These findings indicate that NGF may be important in regulating nodose development during early gangliogenesis in mammals and suggest that NGF plays a more widespread role in peripheral nervous system ontogeny than previously recognized.

Behavioral evidence in rats for a peptidergic-noradrenergic interaction in cutaneous sensory and vascular function

Cutaneous sensory and vascular function was examined following application of capsaicin to the sciatic nerve and systemic injection of guanethidine. Together the two drugs produced a reduction in sensitivity to heat-pain, inflammatory pain (formalin test), tactile stimulation and skin temperature of the foot that exceeded the effects of either drug alone. The inflammation produced by an injection of formalin to the plantar surface of the hind paw was reduced equally by capsaicin or capsaicin + guanethidine. Cold sensitivity and inflammation produced by yeast injection were unaffected by all treatments. The data imply a peripheral interaction between peptidergic and noradrenergic systems with significant functional implications that may be important in the pathology of familial dysautonomia.

Reduced substance P-like immunoreactivity in hereditary sensory neuropathy of pointer dogs

Two unrelated Pointer dogs, each from a breeding of normal parents which produced three affected pups in a litter of nine, began to bite their paws at 3 and 5 months of age. Insensitivity to painful stimuli was marked in the distal parts of the limbs and receded proximally. The affected dogs were euthanatized at 5 and 20 months because of acral mutilation and infection. Changes affecting the primary sensory neurons included: small spinal ganglia with reduced numbers of cell bodies, degeneration of unmyelinated and myelinated fibers in dorsal roots and peripheral nerves, and reduced fiber density in the dorsolateral fasciculus (dlf). Since nociceptive loss was the salient deficit in a neuropathy affecting primary sensory neurons, immunohistochemical studies focused on substance P, the undecapeptide imputed to mediate nociception at the first synapse in the spinal cord and brain. The localization and density of substance P-like (SPL) immunoreactivity was studied in three control dogs and the two Pointers by the indirect antibody peroxidase-antiperoxidase method. The spinal intumescences of the control dogs contained dense SPL-immunoreactivity in fibers of the dlf and the superficial laminae of the dorsal horn (i.e., laminae I, II, and the dorsal part of III). Immunoreactive fascicles on the lateral aspect of the dorsal horn and in the reticular process sent contributions medially to a plexiform fiber arrangement in lamina V. Medially, SPL-immunoreactive fibers were more loosely arranged in the internal third of laminae VI and VII and in lamina X.(ABSTRACT TRUNCATED AT 250 WORDS)

Biochemical and anatomical effects of antibodies against nerve growth factor on developing rat sensory ganglia

The importance of nerve growth factor (NGF) for the development of sensory ganglia was investigated by injecting rat fetuses (16.50 days of gestation) with a single dose of anti-NGF antiserum. Four months later the treated animals showed a very large decrease in substance P- and somatostatin-like immunoreactivities in dorsal root ganglia and skin with a lesser decrease in trigeminal ganglia. Fluoride-resistant acid phosphatase, substance P-, and somatostatin-like immunoreactivities were greatly decreased in the dorsal horn of the spinal cord. No change in neurotensin- and [Met]enkephalin-like immunoreactivities was observed. The anti-NGF antiserum treatment produced a greater than 90% decrease in the number of unmyelinated dorsal root fibers and a 35% decrease in the total number of myelinated fibers. The loss in myelinated fibers was restricted to small-diameter fibers with no change in large-diameter fibers. No change in taste bud morphology was noted, thereby refuting the proposal that anti-NGF antiserum treatment may represent an animal model for familial dysautonomia. The present results indicate that NGF is a necessary requirement for the normal development of a significant population of prenatal rat dorsal root ganglion cells.

Reduced substance P in hereditary sensory neuropathy in the mf rat

Mutilated foot (mf) is a mutant rat with an autosomal recessive sensory neuropathy. Affected animals become ataxic and their feet become mutilated. Morphological and quantitative studies have shown a reduced number of sensory ganglion cells and of cells of secondary sensory neurons. No degeneration was seen in the peripheral nervous system. Substance P (SP) is an undecapeptide which is thought to be involved in transmission of nociceptive information. Since mf rats show, in addition to ataxia, a decreased response to painful stimuli, SP immunoreactivity was examined. The density of SP staining was decreased at all levels of the spinal cord, mainly at cervical and lumbar levels and only in areas related to sensory pathways. In other areas of the spinal cord and in the substantia gelatinosa of the trigeminal tract, no reduction of SP staining was observed. The results further support the relationship between SP and transmission of pain stimuli. There are also many similarities between the appearance in mf rats and those in animals in which sensory afferents from dorsal root ganglia had been impaired with various methods, particularly in those treated from birth with capsaicin.

Newer concepts of the autonomic system's role derived from reductionist and behavioral studies of various animal species

The evolution of newer concepts, many from old precursors, are elaborated. Among the bases for new thought has been the realization that all body tissues receive autonomic innervation and that this system affects all functions. It is involved in the minutia or reactions studied by their reductionists and in activity of the total organism studied by behaviorists. Newer knowledge suggests that the system's functions can be subdivided into 2 major categories: (1) a role in basic metabolic or vegetative functions. There are 3 realms of such involvement: in energy storage and release; in control of endocrine and neuroendocrine secretions; and in control of exocrine secretion and thus intake, conservation or loss and transformation of energy. The hypothalamus is most highly involved in these autonomic system functions; (2) a role in behavior. The hypothalamus is also highly involved, especially in alerting and defense reactions, concepts relating to Cannon's ideas of emergency function and Selye's concepts of stress. It can be said that the normal, phasic functions of the autonomic system and its involvement in organ and body reactivity are controlled in parallel with the regulation of somatic performances. The several newer interpretative ideas originating from studies of reflexes, reflex patterns and sequences, and of general behavior are the integrative role, the supportive role, the modulatory and finally the anticipatory or determinative role in behavior. The similarity of the role of the autonomic nervous system function in all species, from birds to man, has caught the attention of investigators. This rather than the specializations of the system that are appropriate to the peculiar characteristics of individual species has been emphasized; but species specializations do exist and these should be worthy of future investigation. New concepts of the system's role are evolving from old ideas and new discoveries. Newer concepts of transmitter genesis and tissue receptors are developing that add more detail to our major channels of thought concerning the autonomic system's function. There is a new realization of the system's involvement in pain. Its' directives affect and integrate organ and tissue activity; it determines behavior and expresses the sympathy and judgements of man.

Effects of antibodies to nerve growth factor on intrauterine development of derivatives of cranial neural crest and placode in the guinea pig

Fetal guinea pigs transplacentally exposed to maternal nerve growth factor antibodies in the latter part of gestation show marked depletion of sensory neurons in the trigeminal ganglion. Sensory neurons of the nodose ganglion and spiral ganglion which are derived from placodes, and parasympathetic motor neurons of the ciliary, otic, and sphenopalatine ganglia which are derived, like the bulk of the trigeminal ganglion, from cranial neural crest, are unaffected by the antibodies. Previous studies showed that sensory and some sympathetic derivatives of spinal neural crest are effected but that more peripherally located structures of similar origin are not. The local microenvironment in the fetus appears to alter the NGF requirements of structures derived from the same primordia. The model described provides a useful means of studying the effect of trophic factor inhibition in the natural fetal setting and is free of many potential artifacts of tissue culture. Comparison of the animal results with the pathology of familial dysautonomia indicates that nerve growth factor dysfunction alone does not, in our current state of knowledge, adequately account for the etiology of the disease.

The anaesthetic management of a patient with familial dysautonomia

Familial dysautonomia is a rare inherited disease of the nervous system, involving mainly peripheral sensory and sympathetic nerves. The autonomic instability is of greatest importance for the anaesthetist although the sensory defect is the most dramatic symptom of the disease. A case report of a 15-year-old girl undergoing two operations for severe scoliosis is presented with a discussion of the anaesthetic problems encountered in this disease.

Gastroesophageal fundoplication and gastrostomy in familial dysautonomia

Gastric and esophageal dysfunction are components of familial dysautonomia. The limited success of various medical management programs, has led to two types of surgical intervention. Experience with nine patients who had gastrostomy alone and 12 patients who had gastroesophageal fundoplication is reviewed. Both surgical procedures decreased frequency of vomiting and pneumonias and had positive effects on weight gain. Although "dysautonomic crises" are not eliminated, sufficient modification in character occurs so that associated risks are lessened. It is suggested that if medical management cannot control recurrent pneumonia, postprandial vomiting, esophageal bleeding, and/or inadequate weight gain, then the patient should be evaluated for fundoplication and/or gastrostomy.

Behavioral effects of early deprivation of nerve growth factor: some similarities with familial dysautonomia

Female rats immunized with mouse nerve growth factor develop an antibody (anti-NGF) which reaches offspring through the placenta and via the milk. Pups exposed to maternal anti-NGF have fewer dorsal root and sympathetic neurons. When the offspring are examined on a wide variety of behavioral tests, they exhibit severe deficits in response to stress (ulceration, corticosterone levels), and mild deficits on some sensory and cognitive tasks. Exploratory and motor functions, however, are relatively normal. The pathologic and behavioral profiles of the animals closely mimic the sensory and sympathetic aspects of familial dysautonomia.

A new type of non-progressive sensory neuropathy in children with atypical dysautonomia

Three cases of non-progressive, sensory neuropathy with dysautonomia are presented. Light and electron microscopy on whole sural nerve biopsies revealed an almost total lack of myelinated nerve fibres. The total fibre count was also reduced as was the total number of Schwann cell nuclei. No degenerative phenomena were seen within the nerve fibres. The aberrations are probably caused by a maldevelopment of the neural crest implying a stunted proliferation and growth of sensory and autonomous neurones as well as a reduced proliferation of Schwann cells. Since the morphology and clinical features differ from that in other cases of sensory neuropathy with dysautonomia the three present cases are considered to represent a new type of the disease.