Enhancing the action of serotonin by three different mechanisms prevents spontaneous seizure-induced mortality in Dravet mice

OBJECTIVE

Sudden unexpected death in epilepsy (SUDEP) is an underestimated complication of epilepsy. Previous studies have demonstrated that enhancement of serotonergic neurotransmission suppresses seizure-induced sudden death in evoked seizure models. However, it is unclear whether elevated serotonin (5-HT) function will prevent spontaneous seizure-induced mortality (SSIM), which is characteristic of human SUDEP. We examined the effects of 5-HT-enhancing agents that act by three different pharmacological mechanisms on SSIM in Dravet mice, which exhibit a high incidence of SUDEP, modeling human Dravet syndrome.

METHODS

Dravet mice of both sexes were evaluated for spontaneous seizure characterization and changes in SSIM incidence induced by agents that enhance 5-HT-mediated neurotransmission. Fluoxetine (a selective 5-HT reuptake inhibitor), fenfluramine (a 5-HT releaser and agonist), SR 57227 (a specific 5-HT3 receptor agonist), or saline (vehicle) was intraperitoneally administered over an 8-day period in Dravet mice, and the effect of these treatments on SSIM was examined.

RESULTS

Spontaneous seizures in Dravet mice generally progressed from wild running to tonic seizures with or without SSIM. Fluoxetine at 30 mg/kg, but not at 20 or 5 mg/kg, significantly reduced SSIM compared with the vehicle control. Fenfluramine at 1-10 mg/kg, but not .2 mg/kg, fully protected Dravet mice from SSIM, with all mice surviving. Compared with the vehicle control, SR 57227 at 20 mg/kg, but not at 10 or 5 mg/kg, significantly lowered SSIM. The effect of these drugs on SSIM was independent of sex.

SIGNIFICANCE

Our data demonstrate that elevating serotonergic function by fluoxetine, fenfluramine, or SR 57227 significantly reduces or eliminates SSIM in Dravet mice in a sex-independent manner. These findings suggest that deficits in serotonergic neurotransmission likely play an important role in the pathogenesis of SSIM, and fluoxetine and fenfluramine, which are US Food and Drug Administration-approved medications, may potentially prevent SUDEP in at-risk patients.

Response to Singh et al. 2023: It is premature for a unified hypothesis of sudden unexpected death in epilepsy: A great amount of research is still needed to understand the multisystem cascade

In response to the comments by Singh and colleagues about our recent paper proposing a unified hypothesis of SUDEP, we definitely agree that more research is needed. This research should include studies in other models, including Dravet mice, emphasized by Singh et al. However, we strongly believe the hypothesis is timely, because it is based on the continuing progress on SUDEP-related research on serotonin (5-HT) and adenosine as well as neuroanatomical findings.We propose testing of 5-HT enhancing drugs, neurotoxicity blocking drugs, such as N-methyl-D-aspartate (NMDA) antagonists and periaqueductal gray (PAG) electrical stimulation for SUDEP prevention. There are FDA-approved drugs that enhance the action of 5-HT, including fluoxetine and fenfluramine, which is approved for Dravet syndrome. NMDA antagonists, including memantine and ketamine, are also approved for other disorders. PAG electrical stimulation, which is proposed to activate a suffocation alarm, is also approved to treat other conditions and is known to enhance respiration. Experiments using these methods are currently being carried out in animal studies. If these approaches are validated in SUDEP models, treatments could be evaluated relatively quickly in patients with epilepsy (PWE) who exhibit a biomarker for high SUDEP risk, such as peri-ictal respiratory abnormalities. An example of such a study is the ongoing clinical trial of a selective serotonin reuptake inhibitor in PWE. Although, gene-based therapies may ultimately become treatments of choice to prevent SUDEP, as Singh et al suggested, one or more of the approaches we proposed could become temporizing treatments before gene-based therapies can be available. Establishing genetic treatments would require extensive time for each of the genetic abnormalities associated with SUDEP, and too many PWE are likely to die in the meantime.The temporizing treatments may help to reduce the incidence of SUDEP sooner, which is urgently needed.

A unified hypothesis of SUDEP: Seizure-induced respiratory depression induced by adenosine may lead to SUDEP but can be prevented by autoresuscitation and other restorative respiratory response mechanisms mediated by the action of serotonin on the periaqueductal gray

Sudden unexpected death in epilepsy (SUDEP) is a major cause of death in people with epilepsy (PWE). Postictal apnea leading to cardiac arrest is the most common sequence of terminal events in witnessed cases of SUDEP, and postconvulsive central apnea has been proposed as a potential biomarker of SUDEP susceptibility. Research in SUDEP animal models has led to the serotonin and adenosine hypotheses of SUDEP. These neurotransmitters influence respiration, seizures, and lethality in animal models of SUDEP, and are implicated in human SUDEP cases. Adenosine released during seizures is proposed to be an important seizure termination mechanism. However, adenosine also depresses respiration, and this effect is mediated, in part, by inhibition of neuronal activity in subcortical structures that modulate respiration, including the periaqueductal gray (PAG). Drugs that enhance the action of adenosine increase postictal death in SUDEP models. Serotonin is also released during seizures, but enhances respiration in response to an elevated carbon dioxide level, which often occurs postictally. This effect of serotonin can potentially compensate, in part, for the adenosine-mediated respiratory depression, acting to facilitate autoresuscitation and other restorative respiratory response mechanisms. A number of drugs that enhance the action of serotonin prevent postictal death in several SUDEP models and reduce postictal respiratory depression in PWE. This effect of serotonergic drugs may be mediated, in part, by actions on brainstem sites that modulate respiration, including the PAG. Enhanced activity in the PAG increases respiration in response to hypoxia and other exigent conditions and can be activated by electrical stimulation. Thus, we propose the unifying hypothesis that seizure-induced adenosine release leads to respiratory depression. This can be reversed by serotonergic action on autoresuscitation and other restorative respiratory responses acting, in part, via the PAG. Therefore, we hypothesize that serotonergic or direct activation of this brainstem site may be a useful approach for SUDEP prevention.

Serotonin 5-HT4 receptors play a critical role in the action of fenfluramine to block seizure-induced sudden death in a mouse model of SUDEP

RATIONALE

Our previous study showed that the recently approved anticonvulsant drug, fenfluramine, which enhances the release of serotonin (5-hydroxytryptamine, 5-HT) in the brain, prevents seizure-induced respiratory arrest (S-IRA) in the DBA/1 mouse model of sudden unexpected death in epilepsy (SUDEP). The present study examined the role of 5-HT receptor subtypes in mediating the effect of this agent by combined administration of fenfluramine with selective 5-HT receptor antagonists prior to seizure in DBA/1 mice.

METHODS

Fenfluramine (15 mg/kg, i.p.) was administered to primed DBA/1 mice, and audiogenic seizure (Sz) was induced 16 h later. Thirty min prior to Sz induction a selective antagonist acting on 5-HT_1A, 5-HT₂, 5-HT₃ 5-HT₄, 5-HT_5A, 5-HT₆ or 5-HT₇ receptors at a sub-toxic dose was administered, and changes in seizure-induced behaviors were evaluated. Follow-up studies examined the effect of administration of a 5-HT₄ receptor agonist, BIMU 8, as well as the effect of co-administration of ineffective doses of fenfluramine and BIMU-8 on Sz behaviors.

RESULTS

The 5-HT₄ antagonist (GR125487) was the only 5-HT receptor antagonist that was able to reverse the action of fenfluramine to block Sz and S-IRA. Treatment with the 5-HT₄ receptor agonist (BIMU-8), or co-administration of ineffective doses of BIMU-8 and fenfluramine significantly reduced the incidence of S-IRA and tonic Sz in DBA/1 mice. The antagonists for 5-HT₃, 5-HT_5A 5-HT₆, and 5-HT₇ receptors did not significantly affect the action of fenfluramine. However, the 5-HT_1A and the 5-HT₂ antagonists enhanced the anticonvulsant effects of fenfluramine.

CONCLUSIONS

These findings suggest that the action of fenfluramine to prevent seizure-induced sudden death in DBA/1 mice is mediated primarily by activation of 5-HT₄ receptors. These studies are the first to indicate the therapeutic potential of 5-HT₄ receptor agonists either alone or in combination with fenfluramine for preventing SUDEP. Enhancement of the anticonvulsant effect of fenfluramine by 5-HT_1A and 5-HT₂ antagonists may involve presynaptic actions of these antagonists. Thus, the Sz and S-IRA blocking actions of fenfluramine involve complex interactions with several 5-HT receptor subtypes. These data also provide further support for the serotonin hypothesis of SUDEP.

Simultaneous cardiac and respiratory inhibition during seizure precedes death in the DBA/1 audiogenic mouse model of SUDEP

This study was designed to evaluate cardiac and respiratory dysfunction in a mouse model of sudden unexpected death in epilepsy i.e., SUDEP. We simultaneously monitored respiration via plethysmography and the electrocardiogram via telemetry before, during, and after an audiogenic seizure. DBA/1 mice responded to an acoustic stimulus with one or two cycles of circling and jumping before entering a clonic/tonic seizure. This was followed by death unless the mice were resuscitated by mechanical ventilation using room air. During the initial clonic phase, respiration declined and cardiac rhythm is slowed. By the tonic phase, respiration had ceased, atrial P-waves were absent or dissociated from the QRS complex, and heart rate had decreased from 771±11 to 252±16 bpm. Heart rate further deteriorated terminating in asystole unless the mice were resuscitated at the end of the tonic phase which resulted in abrupt recovery of P-waves and a return to normal sinus rhythm, associated with gasping. Interestingly, P-waves were preserved in the mice treated with methylatropine during the pre-ictal period (to block parasympathetic stimulation) and heart rate remained unchanged through the end of the tonic phase (765±8 vs. 748±21 bpm), but as in control, methylatropine treated mice died from respiratory arrest. These results demonstrate that a clonic/tonic seizure in the DBA/1 mouse results in abrupt and simultaneous respiratory and cardiac depression. Although death clearly results from respiratory arrest, our results suggest that seizure activates two central nervous system pathways in this model-one inhibits respiratory drive, whereas the other inhibits cardiac function via vagal efferents. The abrupt and simultaneous recovery of both respiration and cardiac function with mechanical ventilation within an early post-ictal timeframe shows that the vagal discharge can be rapidly terminated. Understanding the central mechanism associated with the abrupt cardiorespiratory dysfunction and equally abrupt recovery may provide clues for therapeutic targets for SUDEP.

Postictal serotonin levels are associated with peri-ictal apnea

OBJECTIVE

To determine the relationship between serum serotonin (5-HT) levels, ictal central apnea (ICA), and postconvulsive central apnea (PCCA) in epileptic seizures.

METHODS

We prospectively evaluated video EEG, plethysmography, capillary oxygen saturation (SpO₂), and ECG for 49 patients (49 seizures) enrolled in a multicenter study of sudden unexpected death in epilepsy (SUDEP). Postictal and interictal venous blood samples were collected after a clinical seizure for measurement of serum 5-HT levels. Seizures were classified according to the International League Against Epilepsy 2017 seizure classification. We analyzed seizures with and without ICA (n = 49) and generalized convulsive seizures (GCS) with and without PCCA (n = 27).

RESULTS

Postictal serum 5-HT levels were increased over interictal levels for seizures without ICA (p = 0.01), compared to seizures with ICA (p = 0.21). In patients with GCS without PCCA, serum 5-HT levels were increased postictally compared to interictal levels (p < 0.001), but not in patients with seizures with PCCA (p = 0.22). Postictal minus interictal 5-HT levels also differed between the 2 groups with and without PCCA (p = 0.03). Increased heart rate was accompanied by increased serum 5-HT levels (postictal minus interictal) after seizures without PCCA (p = 0.03) compared to those with PCCA (p = 0.42).

CONCLUSIONS

The data suggest that significant seizure-related increases in serum 5-HT levels are associated with a lower incidence of seizure-related breathing dysfunction, and may reflect physiologic changes that confer a protective effect against deleterious phenomena leading to SUDEP. These results need to be confirmed with a larger sample size study.

Neural activity in the periaqueductal gray and other specific subcortical structures is enhanced when a selective serotonin reuptake inhibitor selectively prevents seizure-induced sudden death in the DBA/1 mouse model of sudden unexpected death in epilepsy

OBJECTIVE

Sudden unexpected death in epilepsy (SUDEP) is a critical issue in epilepsy, and DBA/1 mice are a useful animal model of this devastating epilepsy sequela. The serotonin hypothesis for SUDEP proposes that modifying serotonergic function significantly alters susceptibility to seizure-induced respiratory arrest (S-IRA). Agents that enhance serotonergic function, including a selective serotonin reuptake inhibitor, fluoxetine, selectively prevent S-IRA in DBA/1 mice. This study examined fluoxetine-induced changes in brain activity using manganese-enhanced magnetic resonance imaging (MEMRI) to reveal sites in the DBA/1 mouse brain where fluoxetine acts to prevent S-IRA.

METHODS

DBA/1 mice were subjected to audiogenic seizures (Sz) after saline or fluoxetine (45 mg/kg, intraperitoneal) administration. Control DBA/1 mice received fluoxetine or saline, but Sz were not evoked. A previous MEMRI study established the regions of interest (ROIs) for Sz in the DBA/1 mouse brain, and the present study examined MEMRI differences in the ROIs of these mouse groups.

RESULTS

The neural activity in several ROIs was significantly increased in fluoxetine-treated DBA/1 mice that exhibited Sz but not S-IRA when compared to the saline-treated mice that exhibited both Sz and respiratory arrest. These structures included the periaqueductal gray (PAG), amygdala, reticular formation (sensorimotor-limbic network), Kölliker-Fuse nucleus, facial-parafacial group (respiratory network), and pontine raphe. Of these ROIs, only the PAG showed significantly decreased neural activity with saline pretreatment when seizure-induced respiratory arrest occurred as compared to saline treatment without seizure.

SIGNIFICANCE

The PAG is known to play an important compensatory role for respiratory distress caused by numerous exigent situations in normal animals. The pattern of fluoxetine-induced activity changes in the present study suggests that PAG may be the most critical target for fluoxetine's action to prevent seizure-induced sudden death. These findings have potential clinical importance, because there is evidence of anomalous serotonergic function and PAG imaging abnormalities in human SUDEP.

Fenfluramine, a serotonin-releasing drug, prevents seizure-induced respiratory arrest and is anticonvulsant in the DBA/1 mouse model of SUDEP

OBJECTIVE

Prevention of sudden unexpected death in epilepsy (SUDEP) is a critical goal for epilepsy therapy. The DBA/1 mouse model of SUDEP exhibits an elevated susceptibility to seizure-induced death in response to electroconvulsive shock, hyperthermia, convulsant drug, and acoustic stimulation. The serotonin hypothesis of SUDEP is based on findings that treatments which modify serotonergic function significantly alter susceptibility to seizure-induced sudden death in several epilepsy models, including DBA/1 mice. Serotonergic abnormalities have also recently been observed in human SUDEP. Fenfluramine is a drug that enhances serotonin release in the brain. Recent studies have found that the addition of fenfluramine improved seizure control in patients with Dravet syndrome, which has a high incidence of SUDEP. Therefore, we investigated the effects of fenfluramine on seizures and seizure-induced respiratory arrest (S-IRA) in DBA/1 mice.

METHODS

The dose and time course of the effects of fenfluramine (i.p.) on audiogenic seizures (Sz) induced by an electric bell in DBA/1 mice were determined. Videos of Sz-induced behaviors were recorded for analysis. Statistical significance (P < 0.05) was evaluated using the chi-square test.

RESULTS

Sixteen hours after administration of 15 mg/kg of fenfluramine, a high incidence of selective block of S-IRA susceptibility (P < 0.001) occurred in DBA/1 mice without blocking any convulsive behavior. Thirty minutes after 20-40 mg/kg of fenfluramine, significant reductions of seizure incidence and severity, as well as S-IRA susceptibility occurred, which were long-lasting (≥48 hours). The median effective dose (ED₅₀ ) of fenfluramine for significantly reducing Sz at 30 minutes was 21 mg/kg.

SIGNIFICANCE

This study presents the first evidence for the effectiveness of fenfluramine in reducing seizure incidence, severity, and S-IRA susceptibility in a mammalian SUDEP model. The ability of fenfluramine to block S-IRA selectively suggests the potential usefulness of fenfluramine in prophylaxis of SUDEP. These results further confirm and extend the serotonin hypothesis of SUDEP.

Deficient post-ictal cardiorespiratory compensatory mechanisms mediated by the periaqueductal gray may lead to death in a mouse model of SUDEP

Post-ictal cardiorespiratory failure is implicated as a major cause of sudden unexpected death in epilepsy (SUDEP) in patients. The DBA/1 mouse model of SUDEP is abnormally susceptible to fatal seizure-induced cardiorespiratory failure (S-CRF) induced by convulsant drug, hyperthermia, electroshock, and acoustic stimulation. Clinical and pre-clinical studies have implicated periaqueductal gray (PAG) abnormalities in SUDEP. Recent functional neuroimaging studies observed that S-CRF resulted in selective changes in PAG neuronal activity in DBA/1 mice. The PAG plays a critical compensatory role for respiratory distress caused by numerous physiological challenges in non-epileptic individuals. These observations suggest that abnormalities in PAG-mediated cardiorespiratory modulation may contribute to S-CRF in DBA/1 mice. To evaluate this, electrical stimulation (20 Hz, 20-100 μA, 10 s) was presented in the PAG of anesthetized DBA/1 and C57BL/6 (non-epileptic) control mice, and post-stimulus changes in respiration [inter-breath interval (IBI)] and heart rate variability (HRV) were examined. The post-stimulus period was considered analogous to the post-ictal period when S-CRF occurred in previous DBA/1 mouse studies. PAG stimulation caused significant intensity-related decreases in IBI in both mouse strains. However, this effect was significantly reduced in DBA/1 vis-a-vis C57BL/6 mice. These changes began immediately following cessation of stimulation and remained significant for 10 s. This time period is critical for initiating resuscitation to successfully prevent seizure-induced death in previous DBA/1 mouse experiments. Significant post-stimulus increases in HRV were also seen at ≥60 μA in the PAG in C57BL/6 mice, which were absent in DBA/1 mice. These data along with previous neuroimaging findings suggest that compensatory cardiorespiratory modulation mediated by PAG is deficient, which may be important to the susceptibility of DBA/1 mice to S-CRF. These observations suggest that correcting this deficit pharmacologically or by electrical stimulation may help to prevent S-CRF. These findings further support the potential importance of PAG abnormalities to human SUDEP.

Serum serotonin levels in patients with epileptic seizures

Profound cardiovascular and/or respiratory dysfunction is part of the terminal cascade in sudden unexpected death in epilepsy (SUDEP). Central control of ventilation is mediated by brainstem rhythm generators, which are influenced by a variety of inputs, many of which use the modulatory neurotransmitter serotonin to mediate important inputs for breathing. The aim of this study was to investigate epileptic seizure-induced changes in serum serotonin levels and whether there are potential implications for SUDEP. Forty-one epileptic patients were pooled into 2 groups based on seizure type as (1) generalized tonic-clonic seizures (GTCS) of genetic generalized epilepsy and focal to bilateral tonic-clonic seizures (FBTCS; n = 19) and (2) focal seizures (n = 26) based on clinical signs using surface video-electroencephalography. Postictal serotonin levels were statistically significantly higher after GTCS and FBTCS compared to interictal levels (P = .002) but not focal seizures (P = .941). The change in serotonin (postictal-interictal) was inversely associated with a shorter duration of tonic phase of generalized seizures. The interictal serotonin level was inversely associated with a shorter period of postictal generalized electroencephalographic suppression. These data suggest that peripheral serum serotonin levels may play a role in seizure features and earlier postseizure recovery; these findings merit further study.

Optogenetic activation of 5-HT neurons in the dorsal raphe suppresses seizure-induced respiratory arrest and produces anticonvulsant effect in the DBA/1 mouse SUDEP model

Sudden unexpected death in epilepsy (SUDEP) is a devastating epilepsy complication. Seizure-induced respiratory arrest (S-IRA) occurs in many witnessed SUDEP patients and animal models as an initiating event leading to death. Thus, understanding the mechanisms underlying S-IRA will advance the development of preventive strategies against SUDEP. Serotonin (5-HT) is an important modulator for many vital functions, including respiration and arousal, and a deficiency of 5-HT signaling is strongly implicated in S-IRA in animal models, including the DBA/1 mouse. However, the brain structures that contribute to S-IRA remain elusive. We hypothesized that the dorsal raphe (DR), which sends 5-HT projections to the forebrain, is implicated in S-IRA. The present study used optogenetics in the DBA/1 mouse model of SUDEP to selectively activate 5-HT neurons in the DR. Photostimulation of DR 5-HT neurons significantly and reversibly reduced the incidence of S-IRA evoked by acoustic stimulation. Activation of 5-HT neurons in the DR suppressed tonic seizures in most DBA/1 mice without altering the seizure latency and duration of wild running and clonic seizures evoked by acoustic stimulation. This suppressant effect of photostimulation on S-IRA is independent of seizure models, as optogenetic stimulation of DR also reduced S-IRA induced by pentylenetetrazole, a proconvulsant widely used to model human generalized seizures. The S-IRA-suppressing effect of photostimulation was increased by 5-hydroxytryptophan, a chemical precursor for 5-HT synthesis, and was reversed by ondansetron, a specific 5-HT3 receptor antagonist, indicating that reduction of S-IRA by photostimulation of the DR is specifically mediated by enhanced 5-HT neurotransmission. Our findings suggest that deficits in 5-HT neurotransmission in the DR are implicated in S-IRA in DBA/1 mice, and that targeted intervention in the DR is potentially useful for prevention of SUDEP.

Abnormalities of serotonergic neurotransmission in animal models of SUDEP

Sudden unexpected death in epilepsy (SUDEP) is a devastating event, and both DBA/1 and DBA/2 mice have been shown to be relevant animal models for studying SUDEP. DBA mice exhibit seizure-induced respiratory arrest (S-IRA), leading to cardiac arrest and subsequent sudden death after generalized audiogenic seizures (AGSs). This sequence of terminal events is also observed in the majority of witnessed human SUDEP cases. Several pathophysiological mechanisms, including respiratory/cardiac dysfunction, have been proposed to contribute to human SUDEP. Several (but not all) selective serotonin (5-HT) reuptake inhibitors (SSRIs), including fluoxetine, can reversibly block S-IRA, and abnormal expression of 5-HT receptors is found in the brainstem of DBA mice. DBA mice, which do not initially show S-IRA, exhibit S-IRA after treatment with a nonselective 5-HT antagonist. These studies suggest that abnormalities of 5-HT neurotransmission are involved in the pathogenesis of S-IRA in DBA mice. Serotonergic (5-HT) transmission plays an important role in normal respiration, and DBA mice exhibiting S-IRA can be resuscitated using a rodent ventilator. It is important and interesting to know if fluoxetine blocks S-IRA in DBA mice by enhancing respiratory ventilation. To test this, the effects of breathing stimulants, doxapram, and 5,6,7,8-tetrahydropyrido[4,3-d]pyrimidine (PK-THPP) were compared with the effects of fluoxetine on S-IRA in DBA/1 mice. Although fluoxetine reduces the incidence of S-IRA in DBA/1 mice, as reported previously, the same dose of fluoxetine fails to enhance baseline respiratory ventilation in the absence of AGSs. Doxapram and PK-THPP augment the baseline ventilation in DBA/1 mice. However, these breathing stimulants are ineffective in preventing S-IRA in DBA/1 mice. These data suggest that fluoxetine blocks S-IRA in DBA/1 mice by cellular/molecular mechanisms other than enhancement of basal ventilation. Future research directions are also discussed. This article is part of a Special Issue entitled "Genetic and Reflex Epilepsies, Audiogenic Seizures and Strains: From Experimental Models to the Clinic".

Specific subcortical structures are activated during seizure-induced death in a model of sudden unexpected death in epilepsy (SUDEP): A manganese-enhanced magnetic resonance imaging study

Sudden unexpected death in epilepsy (SUDEP) is a major concern for patients with epilepsy. In most witnessed cases of SUDEP generalized seizures and respiratory failure preceded death, and pre-mortem neuroimaging studies in SUDEP patients observed changes in specific subcortical structures. Our study examined the role of subcortical structures in the DBA/1 mouse model of SUDEP using manganese-enhanced magnetic resonance imaging (MEMRI). These mice exhibit acoustically-evoked generalized seizures leading to seizure-induced respiratory arrest (S-IRA) that results in sudden death unless resuscitation is rapidly instituted. MEMRI data in the DBA/1 mouse brain immediately after acoustically-induced S-IRA were compared to data in C57 (control) mice that were exposed to the same acoustic stimulus that did not trigger seizures. The animals were anesthetized and decapitated immediately after seizure in DBA/1 mice and after an equivalent time in control mice. Comparative T1 weighted MEMRI images were evaluated using a 14T MRI scanner and quantified. We observed significant increases in activity in DBA/1 mice as compared to controls at previously-implicated auditory (superior olivary complex) and sensorimotor-limbic [periaqueductal gray (PAG) and amygdala] networks and also in structures in the respiratory network. The activity at certain raphe nuclei was also increased, suggesting activation of serotonergic mechanisms. These data are consistent with previous findings that enhancing the action of serotonin prevents S-IRA in this SUDEP model. Increased activity in the PAG and the respiratory and raphe nuclei suggest that compensatory mechanisms for apnea may have been activated by S-IRA, but they were not sufficient to prevent death. The present findings indicate that changes induced by S-IRA in specific subcortical structures in DBA/1 mice are consistent with human SUDEP findings. Understanding the changes in brain activity during seizure-induced death in animals may lead to improved approaches directed at prevention of human SUDEP.

Alcohol withdrawal in epileptic rats - Effects on postictal depression, respiration, and death

Patients with epilepsy are at risk of sudden unexpected death in epilepsy (SUDEP). The most common series of events in witnessed cases of SUDEP is a generalized convulsive seizure followed by terminal apnea. Risk factors for SUDEP include prolonged postictal depression (PID), as well as alcohol abuse. The present study examined these issues in a genetic epilepsy model that exhibits generalized convulsive audiogenic seizures (AGSz) but rarely exhibits seizure-induced death, the genetically epilepsy-prone rats (GEPR-9s). We evaluated the effect of ethanol withdrawal (ETX) in GEPR-9s on respiration patterns, duration of PID, and the incidence of seizure-induced death. Audiogenic seizures were induced in GEPR-9s and in normal Sprague-Dawley rats, which were subjected to a 4-day binge ethanol protocol, 18-24h after the last ethanol dose. Following the tonic seizures, all GEPR-9s exhibited PID, characterized by loss of the righting reflex and respiratory distress (RD), which were absent during ETX seizures in the normal rats. During ETX, GEPR-9s exhibited significant increases in the duration of PID and RD, compared with vehicle-treated GEPR-9s. A significant increase in the incidence of death following seizure in GEPR-9s subjected to ETX was observed, compared with that in vehicle-treated GEPR-9s and normal rats subjected to ETX. Death in GEPR-9s was preceded by prolonged seizures because, in part, of the emergence of post-tonic generalized clonus. These results indicate that ETX induced significant increases in the duration of PID and RD, which contributed to the greater incidence of mortality in GEPR-9s compared with that in vehicle-treated GEPR-9s and normal rats. These experiments observed an elevated risk of sudden death associated with alcohol withdrawal in a genetic epilepsy model that had previously been identified as a risk factor in human SUDEP.

Serotonergic agents act on 5-HT3 receptors in the brain to block seizure-induced respiratory arrest in the DBA/1 mouse model of SUDEP

Drugs that enhance the action of serotonin (5-hydroxytrypamine, 5-HT), including several selective serotonin reuptake inhibitors (SSRIs), reduce susceptibility to seizure-induced respiratory arrest (S-IRA) that leads to death in the DBA/1 mouse model of sudden unexpected death in epilepsy (SUDEP). However, it is not clear if specific 5-HT receptors are important in the action of these drugs and whether the brain is the major site of action of these agents in this SUDEP model. The current study examined the actions of agents that affect the 5-HT₃ receptor subtype on S-IRA and whether intracerebroventricular (ICV) microinjection of an SSRI would reduce S-IRA susceptibility in DBA/1 mice. The data indicate that systemic administration of SR 57227, a 5-HT₃ agonist, was effective in blocking S-IRA in doses that did not block seizures, and the S-IRA blocking effect of the SSRI, fluoxetine, was abolished by coadministration of a 5-HT₃ antagonist, ondansetron. Intracerebroventricular administration of fluoxetine in the present study was also able to block S-IRA without blocking seizures. These findings suggest that 5-HT₃ receptors play an important role in the block of S-IRA by serotonergic agents, such as SSRIs, which is consistent with the abnormal expression of 5-HT₃ receptors in the brainstem of DBA mice observed previously. Taken together, these data indicate that systemically administered serotonergic agents act, at least, in part, in the brain, to reduce S-IRA susceptibility in DBA/1 mice and that 5-HT₃ receptors may be important to this effect.

From unwitnessed fatality to witnessed rescue: Pharmacologic intervention in sudden unexpected death in epilepsy

The mechanisms of sudden unexpected death in epilepsy (SUDEP) have been difficult to define, as most cases occur unwitnessed, and physiologic recordings have been obtained in only a handful of cases. However, recent data obtained from human cases and experimental studies in animal models have brought us closer to identifying potential mechanisms. Theories of SUDEP should be able to explain how a seizure starting in the forebrain can sometimes lead to changes in brainstem cardiorespiratory control mechanisms. Herein we focus on three major themes of work on the causes of SUDEP. First, evidence is reviewed identifying postictal hypoventilation as a major contributor to the cause of death. Second, data are discussed that brainstem serotonin and adenosine pathways may be involved, as well as how they may contribute. Finally, parallels are drawn between SIDS and SUDEP, and we highlight similarities pointing to the possibility of shared pathophysiology involving combined failure of respiratory and cardiovascular control mechanisms. Knowledge about the causes of SUDEP may lead to potential pharmacologic approaches for prevention. We end by describing how translation of this work may result in future applications to clinical care.

Targeting Neuronal Networks with Combined Drug and Stimulation Paradigms Guided by Neuroimaging to Treat Brain Disorders

Improved therapy of brain disorders can be achieved by focusing on neuronal networks, utilizing combined pharmacological and stimulation paradigms guided by neuroimaging. Neuronal networks that mediate normal brain functions, such as hearing, interact with other networks, which is important but commonly neglected. Network interaction changes often underlie brain disorders, including epilepsy. "Conditional multireceptive" (CMR) brain areas (e.g., brainstem reticular formation and amygdala) are critical in mediating neuroplastic changes that facilitate network interactions. CMR neurons receive multiple inputs but exhibit extensive response variability due to milieu and behavioral state changes and are exquisitely sensitive to agents that increase or inhibit GABA-mediated inhibition. Enhanced CMR neuronal responsiveness leads to expression of emergent properties--nonlinear events--resulting from network self-organization. Determining brain disorder mechanisms requires animals that model behaviors and neuroanatomical substrates of human disorders identified by neuroimaging. However, not all sites activated during network operation are requisite for that operation. Other active sites are ancillary, because their blockade does not alter network function. Requisite network sites exhibit emergent properties that are critical targets for pharmacological and stimulation therapies. Improved treatment of brain disorders should involve combined pharmacological and stimulation therapies, guided by neuroimaging, to correct network malfunctions by targeting specific network neurons.

Serotonin and sudden death: differential effects of serotonergic drugs on seizure-induced respiratory arrest in DBA/1 mice

In the DBA/1 mouse model of sudden unexpected death in epilepsy (SUDEP), administration of a selective serotonin (5-HT) reuptake inhibitor (SSRI), fluvoxamine, completely suppressed seizure-induced respiratory arrest (S-IRA) at 30 min after administration (i.p.) in a dose-related manner without blocking audiogenic seizures (AGSz), but another SSRI, paroxetine, reduced S-IRA but with a delayed (24 h) onset and significant toxicity. A serotonin-norepinephrine reuptake inhibitor, venlafaxine, reduced S-IRA incidence, but higher doses were ineffective. A selective 5-HT7 agonist, AS-19, was totally ineffective in reducing S-IRA. In developing DBA/1 mice that had not previously experienced AGSz, administration of a nonselective 5-HT antagonist, cyproheptadine, induced a significantly greater incidence of S-IRA than that of saline. This study confirms that certain drugs that enhance the activation of 5-HT receptors are able to prevent S-IRA, but not all serotonergic drugs are equally effective, which may be relevant to the potential use of these drugs for SUDEP prevention. Serotonergic antagonists may be problematic in patients with epilepsy.

Effects of age, sex, and sertraline administration on seizure-induced respiratory arrest in the DBA/1 mouse model of sudden unexpected death in epilepsy (SUDEP)

DBA/1 mice are susceptible to audiogenic seizure-induced respiratory arrest (S-IRA), leading to death, which is a model of human sudden unexpected death in epilepsy (SUDEP). Female DBA/1 mice exhibited 71% susceptibility to S-IRA on the third daily test when seizure testing began at postnatal day (PND) 24-30, which was slightly (>10%) but not significantly lower than males. When initial seizure testing was delayed (to >7 weeks of age), DBA/1 mice of both sexes exhibited significantly reduced S-IRA susceptibility, as compared to mice tested initially at PND 24-30. These sex and age issues had not been previously evaluated and may be important for the future use of this SUDEP model. We also observed that 30 min after administering a selective serotonin reuptake inhibitor (SSRI), sertraline (40, 50, or 75 mg/kg i.p.), a significantly reduced S-IRA incidence in DBA/1 mice occurred without blocking seizures, which may be relevant to SUDEP prevention.

Brain regional amino acid levels in seizure susceptible rats: Changes related to sound-induced seizures

Regional brain amino acid levels have been determined by HPLC, following microwave fixation, in seizure susceptible (University of Arizona, Audiogenic seizure-susceptible, AGS) and non-seizure susceptible Sprague-Dawley rats. Glutamine content is significantly lower in cerebellum, hippocampus, striatum, substantia nigra, colliculi and brain stem reticular formation in AGS rats. Aspartate levels are also reduced (by 33%) in striatum, substantia nigra and inferior colliculus, and glutamate is reduced in hippocampus and striatum. Other differences include a slight fall in taurine content (in striatum) and an increase in GABA content (in hippocampus). Measurements of amino acid levels in AGS rats during the course of a seizure induced by sound show increases in aspartate and glutamate content in some brain regions (including the inferior colliculus). Potassium-evoked [(3)H] d-aspartate release from hippocampal slices did not differ between the seizure-susceptible and seizure-resistant rat strains. It is proposed (i) that changes in the level and turnover of excitatory amino acid transmitters in AGS rats occur as a consequence of a primary biochemical defect that probably involves impaired neuronal membrane transport, and (ii) that altered function in excitatory synapses in the inferior colliculus, substantia nigra and reticular formation contributes importantly to the seizure susceptibility.

The amygdala to periaqueductal gray pathway: plastic changes induced by audiogenic kindling and reversal by gabapentin

Repeated, periodic induction of AGS (AGS kindling) in GEPR-9s increases seizure duration and induces an additional generalized clonus phase [post-tonic clonus (PTC)], which involves expansion of the localized brainstem AGS network to the amygdala. The pathway between central amygdala (CeA) and ventrolateral periaqueductal gray (vlPAG) is implicated in several disorders, including pain and anxiety. This pathway is also implicated in the network of audiogenic seizures (AGS) in genetically epilepsy-prone rats (GEPR-9s). We examined AGS kindling-induced changes in vlPAG extracellular action potentials evoked by electrical stimuli in CeA in awake, behaving GEPR-9s, using chronically-implanted stimulation electrodes in CeA and microwire recording electrodes in vlPAG. The effect of gabapentin, an anticonvulsant drug that is also effective in pain and anxiety disorders, on the CeA to vlPAG pathway in AGS-kindled GEPR-9s was also evaluated. Electrical stimulation in CeA evoked consistent, short latency and intensity-dependent vlPAG neuronal firing increases. However, in AGS-kindled GEPR-9s these responses showed a precipitous firing increase with increasing stimulus intensity, as compared to non-kindled GEPR-9s. Gabapentin (50mg/kg, i.p.) significantly reduced vlPAG neuronal responses to CeA stimulation to pre-AGS-kindled levels and reversibly blocked PTC in AGS-kindled GEPR-9s. These data suggest that the amygdala to vlPAG pathway may be critical in mediating the emergence of PTC during AGS kindling. The ability of gabapentin to suppress this pathway may be important for its anticonvulsant effects in AGS-kindled GEPR-9s, and this effect may contribute to gabapentin's effectiveness in anxiety and pain in which the amygdala to PAG pathway is also implicated.

Prevention of seizure-induced sudden death in a chronic SUDEP model by semichronic administration of a selective serotonin reuptake inhibitor

DBA/1 mice are a chronically susceptible model of sudden unexpected death in epilepsy (SUDEP) that exhibit chronic audiogenic generalized convulsive seizures (GCSs), leading to death from respiratory arrest (RA) if not resuscitated. Serotonin (5-HT) normally enhances respiration in response to elevated CO(2) levels, which occur during GCSs in humans. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, increase 5-HT availability. We examined whether fluoxetine can block GCS-induced sudden death in DBA/1 mice. Fluoxetine (15-70 mg/kg ip) was administered acutely with seizure induction at 30minutes or semichronically in five daily doses (20mg/kg/day) with induction after 5 days. Acute fluoxetine (45 or 70 mg/kg) significantly reduced the incidence of RA without blocking seizure susceptibility. Semichronic fluoxetine did not block seizures, but significantly reduced seizure-induced RA, which is consistent with effects of SSRIs on respiration in patients with epilepsy [Bateman LM, Li DS,LiN TC, Seyal M. Epilepsia 2010;51:2211-4]. These findings suggest that treatment with SSRIs should be evaluated for reducing the incidence of SUDEP in patients.

Differences in serotonin receptor expression in the brainstem may explain the differential ability of a serotonin agonist to block seizure-induced sudden death in DBA/2 vs. DBA/1 mice

DBA mice are models of sudden unexpected death in epilepsy (SUDEP) that exhibit audiogenic generalized convulsive seizures (GCS), ending in death due to respiratory arrest (RA). Serotonin (5-HT) normally enhances respiration in response to elevated CO(2) levels, which occur during GCS in patients. Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), blocks GCS-induced SUDEP in both DBA/2 and DBA/1 mice. This study examined the effects of a 5-HT(2B/2C) agonist (m-chlorophenylpiperazine, mCPP) to test the generality of serotonergic effects on DBA mice. In DBA/2 mice mCPP pre-treatment [5 or 10 (but not 2) mg/kg, i.p.] significantly reduced RA incidence without blocking seizure susceptibility. However, in DBA/1 mice mCPP in doses up to 40mg/kg was ineffective in blocking seizure-induced RA, and 60mg/kg was toxic. The cause of this strain difference was perplexing. Previous studies showed that brainstem 5-HT receptor protein expression was abnormal in DBA/2 mice. Therefore, expression of 5-HT receptor proteins in the medial-caudal brainstem of DBA/1 mice was evaluated using Western blots. In DBA1/mice 5-HT(2C) and 5-HT(3B) receptor expression levels were significantly reduced, as seen previously in DBA/2 mice. However, 5-HT(2B) receptor expression was also reduced in DBA/1 mice, contrasting with the 5-HT(2B) receptor elevation seen in DBA/2 mice. This difference may explain the differential effects of the 5-HT(2B/2C) agonist in these SUDEP models. mCPP blocked RA in DBA/2 mice and concomitantly reduced tonic seizures, which also occurs. Fluoxetine is the only agent tested that blocks RA selectively in these SUDEP models, which may be clinically relevant.

Post-ictal analgesia in genetically epilepsy-prone rats is induced by audiogenic seizures and involves cannabinoid receptors in the periaqueductal gray

Post-ictal depression of consciousness occurs after generalized convulsive seizures, and includes analgesia, lasting for hours after electrically or chemically induced seizures in animals. The brain sites and mechanisms, mediating post-ictal analgesia, are unclear. The ventrolateral periaqueductal gray (PAG) is an important neuronal network site for mediating analgesia and also in generalized seizures, particularly in genetically epilepsy-prone rats (GEPRs). Endocannabinoids are implicated in mediating analgesia in several brain sites, including the PAG, and generalized seizures result in endocannabinoid release. This study evaluated if post-ictal analgesia occurs in GEPRs, following audiogenic seizures (AGS), and whether this analgesia involves endocannabinoid actions in PAG. Analgesia was evaluated, using thermal stimulation to evoke nociception, measuring changes in paw withdrawal latencies (PWLs) induced by AGS. Endocannabinoid involvement in post-ictal analgesia in GEPRs was evaluated, using focal bilateral microinjection of a cannabinoid (CB1) receptor antagonist (AM251) into PAG. AGS induced a significant increase in PWLs, lasting for ≥120min. Microinjection of AM251 (100 and 200, but not 50 pmol/side) into PAG significantly decreased post-ictal analgesia in GEPRs. Endocannabinoids are also known to activate transient receptor potential vanilloid (TRPV1) receptors, but PAG microinjection of a TRPV1 receptor antagonist (capsazepine) did not affect post-ictal analgesia in GEPRs. These results indicate that AGS in GEPRs induce post-ictal analgesia, which is the first observation of this phenomenon in a genetic epilepsy model. These findings suggest an important role of PAG in post-ictal analgesia. The results also suggest that CB1 receptors in PAG are critical for mediating post-ictal analgesia in GEPRs.

DBA/1 mice exhibit chronic susceptibility to audiogenic seizures followed by sudden death associated with respiratory arrest

One proposed cause of sudden unexpected death in epilepsy (SUDEP) in patients is generalized convulsive seizures with respiratory malfunction. We evaluated DBA/1 mice as a chronic SUDEP model. In DBA/1 mice, audiogenic seizures induced by acoustic stimulation resulted in generalized convulsive seizures followed by respiratory arrest from postnatal day (PND) 21 to 100. The incidence of respiratory arrest susceptibility increased, reaching approximately 90-100% by three to seven daily seizures when testing began on PND 21-30. Respiratory arrest was reversible with resuscitation in approximately 98% of mice, which allows repeated seizure testing. Electrocardiographic activity in DBA/1 mice was detectable for approximately 4-6 minutes after respiratory arrest, indicating that death is likely due to respiratory cessation, as cardiac changes occur later. These findings suggest that DBA/1 mice are a useful chronic SUDEP model. These mice die suddenly from respiratory arrest after generalized convulsive seizures until reaching PND >or=100, allowing testing of chronic preventive treatments for SUDEP.

Seizure susceptibility is associated with altered protein expression of voltage-gated calcium channel subunits in inferior colliculus neurons of the genetically epilepsy-prone rat

The inferior colliculus (IC) is the consensus site for seizure initiation in the genetically epilepsy-prone rat (GEPR). We have previously reported that the current density of high threshold voltage-activated (HVA) calcium (Ca(2+)) channels was markedly enhanced in IC neurons of the GEPR-3 (moderate seizure severity substrain of the GEPR). The present study examines whether subunit protein levels of HVA Ca(2+) channels are altered in IC neurons that exhibit enhanced Ca(2+) current density. Quantification shows that the levels of protein expression of the Ca(2+) channel pore-forming alpha1D (L-type) and alpha1E subunits (R-type) were significantly increased in IC neurons of seizure-naive GEPR-3s (SN-GEPR-3s) compared to control Sprague-Dawley (SD) rats. Significant increases and decreases in the levels of protein expression of Ca(2+) channel regulatory beta3 and alpha2delta subunits occurred in IC neurons of SN-GEPR-3s compared to control SD rats, respectively. No changes occurred in the protein expression of Ca(2+) channel pore-forming alpha1A (P/Q-type), alpha1B (N-type) and alpha1C (L-type) subunits in IC neurons of SN-GEPR-3s compared to control SD rats. A single seizure selectively enhanced protein expression of Ca(2+) channel alpha1A subunits in IC neurons of GEPR-3s. Thus, up-regulation of Ca(2+) channel alpha1D and alpha1E subunits may represent the molecular mechanisms for the enhanced current density of L- and R-type of HVA Ca(2+) channels in IC neurons of the GEPR, and may contribute to the genetic basis of their enhanced seizure susceptibility. The up-regulation of Ca(2+) channel alpha1A subunits induced by seizures may contribute to the increasing IC neuronal excitability that results from repetitive seizures in the GEPR.

Protein expression of small conductance calcium-activated potassium channels is altered in inferior colliculus neurons of the genetically epilepsy-prone rat

The genetically epilepsy-prone rat (GEPR) exhibits inherited predisposition to sound stimuli-induced generalized tonic-clonic seizures (audiogenic reflex seizures) and is a valid model to study the physiopathology of epilepsy. In this model, the inferior colliculus (IC) exhibits enhanced neuronal firing that is critical in the initiation of reflex audiogenic seizures. The mechanisms underlying IC neuronal hyperexcitability that leads to seizure susceptibility are not as yet fully understood. The present report shows that the levels of protein expression of SK1 and SK3 subtypes of the small conductance Ca2+-activated K+ channels were significantly decreased, while SK2 channel proteins were increased in IC neurons of seizure-naive GEPR-3s (SN-GEPR-3), as compared to control Sprague-Dawley rats. No significant change was found in the expression of BK channel proteins in IC neurons of SN-GEPR-3s. Single episode of reflex audiogenic seizures in the GEPR-3s did not significantly alter the protein expression of SK1-3 and BK channels in IC neurons compared to SN-GEPR-3s. Thus, downregulation of SK1 and SK3 channels and upregulation of SK2 channels provide direct evidence that these Ca2+-activated K+ channels play important roles in IC neuronal hyperexcitability that leads to inherited seizure susceptibility in the GEPR.

Development of a therapeutics curriculum to enhance knowledge of fourth-year medical students about clinical uses and adverse effects of drugs

BACKGROUND

Enhanced clinical pharmacology and therapeutics education of medical students is important for improving effective and safe drug therapy. Increased education about pharmacovigilance is needed because serious drug-induced adverse effects are increasing. Fostering the needed scientific approach to prescribing requires knowledge of evidence-based drug therapy, based on understanding clinical trials. Therapeutic agents with novel mechanisms of action are increasingly available, and an unbiased understanding of the risks and benefits of novel agents is also important. These issues can be addressed in clinical pharmacology courses. However, many medical schools lack sufficient clinical pharmacologists to teach such courses. The Southern Illinois University Medical School faculty implemented an Advanced Therapeutics course to address these issues.

DESCRIPTION

Development of this course involved defining appropriate content and organizing preclinical pharmacology and clinical faculty into teaching teams. The course was offered to 4th-year medical students and covered clinical trial information, and cutting-edge therapeutic developments. The "ABCs of Pharmacology" is a mental algorithm that was presented in the sophomore year and reintroduced in this course. This algorithm emphasizes pharmacovigilance, which stresses the balance between positive and negative effects of pharmacological agents. General principles of clinical pharmacology and therapeutics were covered by a clinical pharmacologist. Most sessions on specific disease treatment involved an integrated presentation by a preclinical pharmacologist and a clinician with expertise in that topic, often in the context of clinical cases. Other important topics were emphasized, which reinforce individualization of therapy, including pharmacogenomics that may determine idiosyncratic responses. Feedback during and following the course was obtained via questionnaires.

EVALUATION

This approach was well received by participating students and graduates. Most students rated this course as a valuable experience.

CONCLUSION

This approach appears useful for educating medical students about therapeutics at medical schools that lack sufficient clinical pharmacology faculty to mount such a course.

Calcium channel dysfunction in inferior colliculus neurons of the genetically epilepsy-prone rat

Voltage-gated calcium (Ca(2+)) channels are thought to play an important role in epileptogenesis and seizure generation. Here, using the whole cell configuration of patch-clamp techniques, we report on the modifications of biophysical and pharmacological properties of high threshold voltage-activated Ca(2+) channel currents in inferior colliculus (IC) neurons of the genetically epilepsy-prone rats (GEPR-3s). Ca(2+) channel currents were measured by depolarizing pulses from a holding potential of - 80 mV using barium (Ba(2+)) as the charge carrier. We found that the current density of high threshold voltage-activated Ca(2+) channels was significantly larger in IC neurons of seizure-naive GEPR-3s compared to control Sprague-Dawley rats, and that seizure episodes further enhanced the current density in the GEPR-3s. The increased current density was reflected by both a - 20 mV shifts in channel activation and a 25% increase in the non-inactivating fraction of channels in seizure-naive GEPR-3s. Such changes were reduced by seizure episodes in the GEPR-3s. Pharmacological analysis of the current density suggests that upregulation of L-, N- and R-type of Ca(2+) channels may contribute to IC neuronal hyperexcitability that leads to seizure susceptibility in the GEPR-3s.

The Majchrowicz binge alcohol protocol: an intubation technique to study alcohol dependence in rats

Binge drinking of alcohol is an important public health issue, and experimental studies are needed to understand the pathophysiological mechanisms of this problem and develop improved approaches to treatment. This unit presents a validated and widely used method to model binge alcohol drinking in rats. It consists of three daily intragastric administrations of ethanol to rats for 4 days. Ethanol is initially administered at 5 g/kg, and then each subsequent dose is determined based on the degree of intoxication the rat exhibits prior to each dose. The behavior of the animal is graded based on a well-described scale. After the fourth day, various aspects of the ethanol withdrawal syndrome can be observed over a predictable time course and additional protocols can be employed to study mechanisms of specific aspects of withdrawal and treatments to prevent them. One specific behavior observed during ethanol withdrawal and described here is sound-induced (audiogenic) convulsive seizure.

Electrical stimulation therapies for CNS disorders and pain are mediated by competition between different neuronal networks in the brain

CNS neuronal networks are known to control normal physiological functions, including locomotion and respiration. Neuronal networks also mediate the pathophysiology of many CNS disorders. Stimulation therapies, including localized brain and vagus nerve stimulation, electroshock, and acupuncture, are proposed to activate "therapeutic" neuronal networks. These therapeutic networks are dormant prior to stimulatory treatments, but when the dormant networks are activated they compete with pathophysiological neuronal networks, disrupting their function. This competition diminishes the disease symptoms, providing effective therapy for otherwise intractable CNS disorders, including epilepsy, Parkinson's disease, chronic pain, and depression. Competition between stimulation-activated therapeutic networks and pathophysiological networks is a major mechanism mediating the therapeutic effects of stimulation. This network interaction is hypothesized to involve competition for "control" of brain regions that contain high proportions of conditional multireceptive (CMR) neurons. CMR regions, including brainstem reticular formation, amygdala, and cerebral cortex, have extensive connections to numerous brain areas, allowing these regions to participate potentially in many networks. The participation of CMR regions in any network is often variable, depending on the conditions affecting the organism, including vigilance states, drug treatment, and learning. This response variability of CMR neurons is due to the high incidence of excitatory postsynaptic potentials that are below threshold for triggering action potentials. These subthreshold responses can be brought to threshold by blocking inhibition or enhancing excitation via the paradigms used in stimulation therapies. Participation of CMR regions in a network is also strongly affected by pharmacological treatments (convulsant or anesthetic drugs) and stimulus parameters (strength and repetition rate). Many studies indicate that treatment of unanesthetized animals with antagonists (bicuculline or strychnine) of inhibitory neurotransmitter (GABA or glycine) receptors can cause CMR neurons to become consistently responsive to external inputs (e.g., peripheral nerve, sensory, or electrical stimuli in the brain) to which these neurons did not previously respond. Conversely, agents that enhance GABA-mediated inhibition (e.g., barbiturates and benzodiazepines) or antagonize glutamate-mediated excitation (e.g., ketamine) can cause CMR neurons to become unresponsive to inputs to which they responded previously. The responses of CMR neurons exhibit extensive short-term and long-term plasticity, which permits them to participate to a variable degree in many networks. Short-term plasticity subserves termination of disease symptoms, while long-term plasticity in CMR regions subserves symptom prevention. This network interaction hypothesis has value for future research in CNS disease mechanisms and also for identifying therapeutic targets in specific brain networks for more selective stimulation and pharmacological therapies.

Role of the amygdala in ethanol withdrawal seizures

Ethanol withdrawal (ETX) after induction of ethanol dependence results in a syndrome that includes enhanced seizure susceptibility. During ETX in rodents, generalized audiogenic seizures (AGS) can be triggered by intense acoustic stimulation. Previous studies have implicated specific brainstem nuclei in the neuronal network that initiates and propagates AGS during ETX. Although ethanol and ETX are known to affect amygdala neurons, involvement of the amygdala in the network subserving AGS is unclear. Since ethanol and ETX affect N-methyl-d-aspartate (NMDA) receptors in the amygdala, the present study evaluated the effect of focally microinjecting a NMDA antagonist into the amygdala of rats treated with a binge protocol (intragastric administration of ethanol 3 times daily for 4 days). Separate experiments examined extracellular neuronal firing in the amygdala. Cannulae or microwire electrodes were chronically implanted into the amygdala, and changes in seizure behaviors and/or extracellular action potentials were evaluated. Bilateral focal microinjection of a NMDA antagonist, 2-amino-7-phosphonoheptanoate (AP7), into either central nucleus or lateral nucleus of the amygdala (LAMG) significantly reduced AGS. The doses of AP7 and time course of effect were similar in each site, suggesting that both amygdala nuclei participate in the AGS network. Acoustic responses of LAMG neurons were significantly decreased 1 h after the first ethanol dose and also during ETX, as compared to pre-binge controls. However, LAMG neurons consistently exhibited rapid tonic firing during the generalized tonic convulsions of AGS. These findings suggest a critical role of the amygdala in the ETX seizure network in generating tonic convulsions during AGS.

Excitatory amino acid receptor-mediated responses in periaqueductal gray neurons are increased during ethanol withdrawal

The ventrolateral periaqueductal gray (PAG) is critical for propagation in the neuronal network for ethanol withdrawal (ETX) seizures, and ethanol is known to alter glutamate effects. This study evaluated changes in glutamate antagonist effects on PAG neurophysiology in brain slices from rats treated with ethanol in vivo. Spontaneous action potentials were rare in control PAG neurons but common during ETX. Spontaneous excitatory postsynaptic potential (EPSP) frequency was increased during ETX, and an AMPA antagonist, 6,7-dinitroquinoxaline-2,3-dione (DNQX) was more effective in suppressing this activity than an NMDA antagonist, 2-amino-7-phosphonoheptanoate (AP7). EPSPs evoked by stimulation of dorsolateral PAG were decreased by AP7 or DNQX in ETX and control neurons. EPSPs of ETX neurons were significantly less sensitive than controls to blockade by AP7 and DNQX. Paired-pulse facilitation of EPSPs was significantly increased during ETX, but paired-pulse inhibition occurred in controls. Thus, PAG hyperexcitability during ETX results from alterations of both NMDA and AMPA receptor-mediated neurotransmission, which may contribute importantly to ETX seizures. These results differ from previous findings in the seizure-initiating site for ETX seizures, inferior colliculus (IC), where NMDA receptor-mediated mechanisms dominate excitability increases during ETX. This dichotomy may be related to the different role played by IC and PAG in the ETX seizure network.

Sleep, temperature, activity, and prolactin phenotypes of genetically epilepsy-prone rats

Sleep-wake disturbances are common in epilepsy, yet the potential adverse effect of seizures on sleep is not well characterized. Genetically epilepsy-prone rats (GEPRs) are a well-studied model of genetic susceptibility to audiogenic seizures. To assess their suitability for investigating relationships between seizures and disordered sleep, we characterized the sleep, activity, and tempera ture patterns of 2 GEPR strains (designated 3 and 9) and Sprague-Dawley (SD) rats in the basal state, after forced wakefulness, and after exposure to sound-induced seizures at light onset and dark onset. Because of observed differences in rapid-eye-movement sleep (REMS), we also assessed serum levels of prolactin, which is implicated in REMS regulation. The data reveal that under basal conditions, the GEPR3 strain shows less SWS and REMS, higher core temperatures, and higher serum prolactin concentrations than do GEPR9 and SD strains. All 3 strains respond similarly to enforced sleep loss. Seizures induced at light onset delay the onset of SWS in both GEPR strains. Seizures induced at dark onset do not significantly alter sleep. Genotype assessment indicates that although both GEPR strains are inbred (that is, homozygous at 107 genetic markers), they differ from each other at 74 of 107 loci. Differences in basal sleep, temperature, and prolactin between GEPR3 and GEPR9 strains suggest different homeostatic regulation of these functions. Our detection of concurrent alterations in sleep, temperature, and prolactin in these 2 GEPR strains implicates the hypothalamus as a likely site for anatomic or physiologic variation in the control of these homeostatic processes.

Evidence supporting a role of serotonin in modulation of sudden death induced by seizures in DBA/2 mice

PURPOSE

Sudden unexpected death in epilepsy (SUDEP) is a serious concern for epilepsy patients. DBA/2 mice are proposed as a SUDEP model, because these mice exhibit respiratory arrest (RA) after audiogenic seizures (AGSs), and RA is also implicated in human SUDEP. Respiratory mechanisms are modulated, in part, by serotonin. Therefore we evaluated the effects of serotoninergic agents on RA incidence in DBA/2 mice.

METHODS

DBA/2 mice (75%) exhibited AGS and RA, and approximately 99% of animals could be resuscitated. The mice exhibiting RA were given a selective serotonin reuptake inhibitor, fluoxetine, 24 h after the initial AGS, and RA susceptibility was evaluated 30 min later. Ten percent of DBA/2 mice exhibited tonic hindlimb extension (TE) without RA, and a serotonin antagonist (cyproheptadine) was administered to these mice.

RESULTS

Fluoxetine (15-25 mg/kg, i.p.) significantly reduced the incidence of RA in DBA/2 mice after AGSs, and this effect was reversible by 72 h. Only the 25-mg/kg dose reduced AGS severity. In mice exhibiting TE without RA, the incidence of RA was significantly increased 30 min after cyproheptadine (1-2 mg/kg i.p.). Most of these mice exhibited AGSs without RA again by 72 h.

CONCLUSIONS

These findings indicate that fluoxetine reduced RA in DBA/2 mice at doses that did not reduce seizure severity. Because DBA/2 mice are a proposed model for human SUDEP, these data support evaluation of fluoxetine for SUDEP prevention in the patient population most susceptible to SUDEP. The data raise concern about the use of serotonin antagonists in this patient population.

Pontine reticular formation neurons are implicated in the neuronal network for generalized clonic seizures which is intensified by audiogenic kindling

The caudal pontine reticular formation nucleus (cPRF) is implicated in seizure propagation to the spinal cord in several forms of generalized convulsive seizures, including audiogenic seizures (AGS). Focal microinjection studies implicate cPRF as a requisite neuronal network site subserving generalized AGS in the moderate severity substrain of genetically epilepsy-prone rats (GEPR-3s). AGS in GEPR-3s culminate in generalized clonus, but daily repetition of AGS (AGS kindling) results in an additional seizure behavior, facial and forelimb (F and F) clonus, not seen prior to kindling. This study examined cPRF neuronal firing changes and seizure behaviors during AGS in GEPR-3s. We examined extracellular cPRF neuronal responses to acoustic stimuli (12 kHz) and observed neuronal firing during AGS. cPRF neurons exhibited onset responses to acoustic stimuli before and after AGS kindling. After AGS kindling, increased neuronal firing occurred, and response latencies were prolonged. Tonic neuronal firing occurred during generalized clonus, which changed to burst firing after AGS kindling. Burst firing also occurred during F and F clonus. Increased neuronal firing and the change from tonic to burst firing suggest that AGS kindling involves increased cPRF excitability. These data support an important role for cPRF neurons in generation of generalized clonus in unkindled GEPR-3s, which is increased by AGS kindling. The increased cPRF response latency might reflect a greater role of rostral components of the AGS neuronal network in transmission of acoustic responses to cPRF. This study also suggests that cPRF neurons may be involved in F and F clonus, which was unexpected since F and F clonus is thought to originate primarily in forebrain structures.

Evidence for the perirhinal cortex as a requisite component in the seizure network following seizure repetition in an inherited form of generalized clonic seizures

Perirhinal cortex (PRh) is strongly implicated in neuronal networks subserving forebrain-driven partial onset seizures, but whether PRh plays a role in generalized onset seizures is unclear. The moderate seizure severity substrain of genetically epilepsy-prone rats (GEPR-3s) exhibits generalized onset clonic audiogenic seizures (AGS), but following repetitive AGS (AGS kindling), an additional behavior, facial and forelimb (F&F) clonus emerges immediately following generalized clonus. F&F clonus is thought to be driven from forebrain structures. The present in vivo study used PRh focal blockade or extracellular PRh neuronal recording with simultaneous behavioral observations to examine the role played by PRh in AGS neuronal networks before and after AGS kindling in GEPR-3s. Bilateral microinjection of an NMDA receptor antagonist [2-amino-7-phosphonoheptanoic acid, AP7 (0.2-7.5 nmol/side)] into PRh did not affect generalized clonus before or after AGS kindling. However, complete and reversible blockade of only the F&F clonic seizure behavior was induced by AP7 (1 and 7.5 nmol) in AGS-kindled GEPR-3s. Significant increases in PRh neuronal responses to acoustic stimuli occurred after AGS kindling. Tonic PRh neuronal firing patterns appeared during generalized clonus before and after AGS kindling. During F&F clonus, burst firing, an indicator of increased excitability, appeared in PRh neurons. These neurophysiological and microinjection findings support a critical role of PRh in generation of this AGS kindling-induced convulsive behavior. These data are the first indication that PRh participates importantly in the neuronal network for AGS as a result of AGS kindling and demonstrate a previously unknown involvement of PRh in generalized onset seizures.

Neurons in the amygdala play an important role in the neuronal network mediating a clonic form of audiogenic seizures both before and after audiogenic kindling

Previous studies showed that neuronal network nuclei for behaviorally different forms of audiogenic seizure (AGS) exhibit similarities and important differences. The amygdala is involved differentially in tonic AGS as compared to clonic AGS networks. The role of the lateral amygdala (LAMG) undergoes major changes after AGS repetition (AGS kindling) in tonic forms of AGS. The present study examined the role of LAMG in a clonic form of AGS [genetically epilepsy-prone rats (GEPR-3s)] before and after AGS kindling using bilateral microinjection and chronic neuronal recordings. AGS kindling in GEPR-3s results in facial and forelimb (F&F) clonus, and this behavior could be blocked following bilateral microinjection of a NMDA antagonist (2-amino-7-phosphonoheptanoate) without affecting generalized clonus. Higher AP7 doses blocked both generalized clonus and F&F clonus. LAMG neurons in GEPR-3s exhibited only onset type neuronal responses both before and after AGS kindling, unlike LAMG neurons in normal rats and a tonic form of AGS. A significantly greater LAMG neuronal firing rate occurred after AGS kindling at high acoustic intensities. The latency of LAMG neuronal firing increased significantly after AGS kindling. Burst firing occurred during wild running and generalized clonic behaviors before and after AGS kindling. Burst firing also occurred during F&F clonus after AGS kindling. These findings indicate that LAMG neurons play a critical role in the neuronal network for generalized clonus as well as F&F clonus in GEPR-3s, both before and after AGS kindling, which contrasts markedly with the role of LAMG in tonic AGS.

Integrative Neurobiology of the Alcohol Withdrawal Syndrome???From Anxiety to Seizures

This article represents the proceedings of a symposium presented at the 2003 Research Society on Alcoholism meeting in Ft. Lauderdale, Florida, organized and chaired by Carl L. Faingold. The presentations were (1) Overview, by Carl L. Faingold; (2) Stress, Multiple Alcohol Withdrawals, and Anxiety, by Darin Knapp; (3) Relationship Between Genetic Differences in Alcohol Drinking and Alcohol Withdrawal, by Julia Chester; (4) Neuronal Mechanisms in the Network for Alcohol Withdrawal Seizures: Modulation by Excitatory Amino Acid Receptors, by Carl L. Faingold; and (5) Treatment of Acute Alcohol Withdrawal and Long-Lasting Alterations in Hippocampal Neuronal Networks, by Larry P. Gonzalez. The presentations emphasized the importance of using intact behaving animals to advance the understanding of the human alcohol withdrawal syndrome. This involves applying and amplifying the neurophysiological and neurotransmitter findings observed in vitro to the network-based neurobiological mechanisms that are involved in several important aspects of the specific behaviors observed clinically. The symposium provided evidence that the organizational aspects of neuronal networks in the intact nervous system add another nexus for the action of alcohol and drugs to treat alcohol withdrawal that may not be readily studied in isolated neural elements used in in vitro approaches.

Emergent properties of CNS neuronal networks as targets for pharmacology: application to anticonvulsant drug action

CNS drugs may act by modifying the emergent properties of complex CNS neuronal networks. Emergent properties are network characteristics that are not predictably based on properties of individual member neurons. Neuronal membership within networks is controlled by several mechanisms, including burst firing, gap junctions, endogenous and exogenous neuroactive substances, extracellular ions, temperature, interneuron activity, astrocytic integration and external stimuli. The effects of many CNS drugs in vivo may critically involve actions on specific brain loci, but this selectivity may be absent when the same neurons are isolated from the network in vitro where emergent properties are lost. Audiogenic seizures (AGS) qualify as an emergent CNS property, since in AGS the acoustic stimulus evokes a non-linear output (motor convulsion), but the identical stimulus evokes minimal behavioral changes normally. The hierarchical neuronal network, subserving AGS in rodents is initiated in inferior colliculus (IC) and progresses to deep layers of superior colliculus (DLSC), pontine reticular formation (PRF) and periaqueductal gray (PAG) in genetic and ethanol withdrawal-induced AGS. In blocking AGS, certain anticonvulsants reduce IC neuronal firing, while other agents act primarily on neurons in other AGS network sites. However, the NMDA receptor channel blocker, MK-801, does not depress neuronal firing in any network site despite potently blocking AGS. Recent findings indicate that MK-801 actually enhances firing in substantia nigra reticulata (SNR) neurons in vivo but not in vitro. Thus, the MK-801-induced firing increases in SNR neurons observed in vivo may involve an indirect effect via disinhibition, involving an action on the emergent properties of this seizure network.

Glutamatergic activation of the amygdala differentially mimics the effects of audiogenic seizure kindling in two substrains of genetically epilepsy-prone rats

Comparisons of neuronal network mechanisms in closely related inherited seizure models are providing novel insights into epileptogenic pathophysiology. Genetically epilepsy-prone rats (GEPRs) exist in two substrains that inherit long-term susceptibility to behaviorally distinct audiogenic seizures (AGS). GEPR-3s exhibit generalized clonic AGS, while GEPR-9s exhibit generalized tonic AGS. After AGS kindling the tonic AGS of GEPR-9s is followed by generalized posttonic clonus (PTC), while the generalized clonic AGS is followed by facial and forelimb (F&F) clonus in GEPR-3s. PTC and F&F clonus are very rare in GEPRs before AGS kindling. The neuronal network subserving AGS in GEPR-9s lies exclusively in brainstem sites, but amygdala (AMG) and other sites are recruited into the network after AGS kindling. The present study attempted to mimic the effects of AGS kindling by bilaterally microinjecting subconvulsive doses of N-methyl-D-aspartate (NMDA) into the AMG of nonkindled GEPRs. NMDA (10 nmol/side) microinjected into AMG reversibly induced susceptibility to F&F clonus immediately following generalized clonic AGS in most nonkindled GEPR-3s. NMDA (7.5 nmol/side), microinjected into AMG temporarily induced susceptibility to generalized PTC immediately following tonic AGS in most nonkindled GEPR-9s. No seizures were induced in normal rats by these treatments, and no seizures were seen in GEPRs with these NMDA doses except those induced by acoustic stimuli. These findings support a critical role in AGS kindling for the AMG in the neuronal networks for both forms of AGS. However, the behavioral effect of the treatment was different in the two AGS substrains, suggesting interrelated but not identical pathophysiological mechanisms in these closely related epilepsy models.

Identification of the requisite brain sites in the neuronal network subserving generalized clonic audiogenic seizures

Comparative studies of neuronal networks that subserve convulsions in closely-related epilepsy models are revealing instructive data about the pathophysiological mechanisms that govern these networks. Studies of audiogenic seizures (AGS) in genetically epilepsy-prone rats (GEPRs) and related forms of AGS demonstrate important network similarities and differences. Two substrains of GEPRs exist, GEPR-9s, exhibiting tonic AGS, and GEPR-3s, exhibiting clonic AGS. The neuronal network for tonic AGS resides exclusively in brainstem nuclei, but forebrain sites, including the amygdala (AMG), are recruited after repetitive AGS induction. The neuronal network for clonic AGS remains to be investigated. The present study examined the neuronal network for clonic AGS in GEPR-3s by microinjecting a competitive NMDA receptor antagonist, D,L-2-amino-7-phosphonoheptanoic acid (AP7), into the central nucleus of inferior colliculus (ICc), deep layers of superior colliculus (DLSC), periaqueductal grey (PAG), or caudal pontine reticular formation (cPRF), which are implicated in tonic AGS networks. Microinjections into AMG and perirhinal cortex (PRh), which are not implicated in AGS, were also done. AGS in GEPR-3s were blocked reversibly after microinjections into ICc, DLSC, PAG or cPRF. However, AGS were also blocked by AP7 in AMG but not PRh. The sites in which AP7 blocks AGS are implicated as requisite components of the clonic AGS network, and these data support a critical role for NMDA receptors in clonic AGS modulation. The brainstem nuclei of the clonic AGS network are identical to those subserving tonic AGS. However, the requisite involvement of AMG in the clonic AGS network, which is not seen in tonic AGS, is surprising and suggests important mechanistic differences between clonic and tonic forms of AGS.

Neurons in the periaqueductal gray are critically involved in the neuronal network for audiogenic seizures during ethanol withdrawal

The periaqueductal gray (PAG) is implicated in the network subserving audiogenic seizures (AGS). AGS are seen during ethanol withdrawal (ETX), and the present study examined effects of focal NMDA receptor blockade in PAG during ETX and PAG neuronal firing changes associated with ETX. Bilateral cannulae or microwire electrodes were chronically implanted into PAG. Ethanol was administered intragastrically at 8-h intervals for 4 days, resulting in AGS susceptibility during ETX. Microinjection of a competitive NMDA receptor antagonist, DL-2-amino-7-phosphonoheptanoic acid (AP7) (2 and 5 but not 1 nmol/side), into the PAG suppressed AGS, in part, reversibly. In microwire experiments spontaneous and acoustically evoked PAG neuronal responses in behaving rats were reduced significantly 1 h after initial administration of ethanol. During ETX, when the animals were susceptible to AGS, significant increases in spontaneous and acoustically evoked PAG neuronal firing occurred. PAG neurons exhibited burst firing 2-4 s prior to the tonic-clonic phase of AGS and tonic repetitive firing during this seizure phase, which ceased during post-ictal depression. Increased NMDA receptor function in PAG may be important to the aberrant PAG neuronal firing in AGS, since previous studies observed upregulation of NMDA receptors during ETX, and the present study observed that focal microinjection of a NMDA antagonist into PAG blocked AGS.

Synaptic plasticity in the pathway from the medial geniculate body to the lateral amygdala is induced by seizure repetition

Repeated induction of generalized audiogenic seizures (AGS) (AGS kindling) induces expansion of the seizure network and evokes additional convulsive behaviors. The medial geniculate body (MGB) and amygdala are implicated in the network expansion induced by AGS kindling, although these sites are not required for AGS before kindling. A recent study indicated that amygdala neuronal responses are greatly increased by AGS kindling. The present study examined the effects of AGS kindling on the thalamo-amygdala pathway in genetically epilepsy-prone rats (GEPR-9s) by examining the neuronal responses in lateral amygdala (LAMG) to electrical stimulation in MGB in vivo. AGS kindling in GEPR-9s involved 14 AGS in response to twice daily acoustic stimulation. Sham-kindled normals received the mean stimulation parameters presented to kindled animals. Spontaneous LAMG extracellular action potentials (APs) and APs evoked by electrical stimuli in the MGB were examined in ketamine-anesthetized rats. The mean spontaneous LAMG firing in kindled GEPR-9s was significantly elevated as compared to non-kindled GEPRs, sham-kindled and non-kindled normals. LAMG firing evoked by MGB stimuli in kindled GEPR-9s was significantly elevated, and a significant mean threshold reduction was also observed in kindled GEPR-9s, as compared to other animal groups. These changes may be due to enhanced glutamate receptor-mediated excitation and/or compromised GABA receptor-mediated inhibition in AMG, as previously reported in electrical kindling in the amygdala. These findings indicate that AGS kindling increases the efficacy of the thalamo-amygdala pathway in GEPR-9s, suggesting that synaptic plasticity in this portion of the expanded neuronal network is an important pathophysiological mechanism subserving AGS kindling.

Teaching pharmacology within a multidisciplinary organ system-based medical curriculum

We have described how the pharmacology of agents that act on the central nervous system (CNS) and endocrine system were incorporated into a case-based, multidisciplinary, integrated sophomore medical curriculum at Southern Illinois University School of Medicine (SIUSM). Faculty members from the Departments of Pharmacology, Pathology, Internal Medicine, Psychiatry, and Neurology were major participants in the CNS block, and faculty with primary expertise in radiology, epidemiology, and immunology also participated. Integrated sessions involving the entire class were organized around brief patient cases, which were given to the students in advance of the session. During the sessions, each patient case was presented by a physician or pathologist who briefly described symptoms, history, physical findings, differential diagnosis, and the classification of the subtypes of the particular class of disorder. The pathophysiology of the disease was discussed, and the pharmacology of agents to be considered for therapy was presented in the context of the Pharmacology Mental Algorithm, a systematic and rational approach to drug therapy. The session was completed by a clinician who added further clinically relevant information, which was followed by a question-and-answer period involving all faculty participants. The CNS block was presented over a 1-month period and included standardized patients and real patients who consistently exhibited specific disease findings, and these patient-oriented sessions were followed with small group tutorial sessions. Single discipline large-group sessions were also used to present material that is introductory or unique to a particular discipline. Student knowledge was assessed, using integrated evaluations based on case vignettes with multiple-choice questions provided by each discipline. The goal of the examination was to evaluate knowledge base in the discipline areas and its application to clinical problem-solving. A practical evaluation of each student's patient examination skills in CNS was also performed by clinicians. Feedback from the students on the organ system activities was obtained using a questionnaire. Development of these sessions required leadership and a considerable amount of time to organize, improve, and update sessions. The integrated approach largely eliminated the use of conflicting terminology and redundancy of material common with separate presentations on the same subject by different disciplines. The multidisciplinary, case-based sessions were perceived to be instructive, valuable learning experiences, based on formal and informal student and faculty feedback.