Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Detection of dendritic cell subsets in the tumor microenvironment by multiplex immunohistochemistry

Dendritic cells (DCs) are essential in antitumor immunity. In humans, three main DC subsets are defined: two types of conventional DCs (cDC1s and cDC2s) and plasmacytoid DCs (pDCs). To study DC subsets in the tumor microenvironment (TME), it is important to correctly identify them in tumor tissues. Tumor-derived DCs are often analyzed in cell suspensions in which spatial information about DCs which can be important to determine their function within the TME is lost. Therefore, we developed the first standardized and optimized multiplex immunohistochemistry panel, simultaneously detecting cDC1s, cDC2s, and pDCs within their tissue context. We report on this panel's development, validation, and quantitative analysis. A multiplex immunohistochemistry panel consisting of CD1c, CD303, X-C motif chemokine receptor 1, CD14, CD19, a tumor marker, and DAPI was established. The ImmuNet machine learning pipeline was trained for the detection of DC subsets. The performance of ImmuNet was compared with conventional cell phenotyping software. Ultimately, frequencies of DC subsets within several tumors were defined. In conclusion, this panel provides a method to study cDC1s, cDC2s, and pDCs in the spatial context of the TME, which supports unraveling their specific roles in antitumor immunity.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Editor's Choice - Therapeutic Options and Outcomes in Midaortic Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE

Midaortic syndrome (MAS) is narrowing of the distal thoracic and or abdominal aorta with congenital, inflammatory, or idiopathic aetiology. If left untreated, the prognosis is poor due to hypertensive complications. Follow up data after treatment are sparse, contrary to aortic coarctation. This study aimed to investigate hypertension during follow up after medical, endovascular, and surgical therapy in juveniles and adults.

DATA SOURCES

A meta-analysis of case series and reports was performed, focusing on the incidence of hypertension during the follow up of juvenile (i.e., age 0-17 years) and adult MAS patients after medical, endovascular, or surgical therapy.

REVIEW METHODS

Search queries were performed in PubMed, Embase, and Web of Science, and eligible articles underwent quality control. Descriptive statistics were reported based on available data, and individual patient data meta-analyses were performed using a one stage approach, accounting for clustering by case series or decades of reporting for case reports. For the meta-analysis, missing outcome and aetiology data were multiply imputed.

RESULTS

The number of juveniles and adults who underwent endovascular therapy (33.7% vs. 27.3%; p = .42) and surgery (52.2% vs. 58.0%; p = .46) was similar. At baseline, 92.4% of juveniles and 87.5% of adults were hypertensive, decreasing to 23.2% and 24.1% during a follow up of 23 months (juveniles) and 18 months (adults), respectively. More hypertension was found compared with surgery in juveniles after endovascular therapy (38.1% vs. 10.8%; p = .020). Meta-analysis also demonstrated a trend for hypertension after endovascular therapy in juveniles, whereas hypertension was more prevalent following surgery in adults compared with endovascular therapy or medication.

CONCLUSION

This review and meta-analysis investigated therapeutic options for MAS in juveniles and adults. It found that complications and hypertension during follow up were more common in juveniles after endovascular treatment, whereas surgery in adults was associated with more hypertension.

Poster No. 111 Therapeutic Options and Outcomes in Mid Aortic Syndrome A systematic review and meta-analysis

Objective

Mid-Aortic Syndrome (MAS) is narrowing of the distal thoracic and/or abdominal aorta with congenital, inflammatory or idiopathic aetiology. If untreated, prognosis is poor due to hypertensive complications yet follow-up data are sparse. The aim of this study was to investigate hypertension during follow-up after medical, endovascular, and surgical therapy.

Design and methods

A meta-analysis of case series and reports, focusing on the incidence of hypertension during the follow-up of juvenile (0–17 years) and adult MAS patients after medical, endovascular or surgical therapy. Search queries were performed in PubMed, Embase, and Web of Science; eligible articles underwent quality control. Descriptive statistics were reported based on available data, individual patient data meta-analyses were performed using a one-stage approach, accounting for clustering by case series or decades of reporting for case reports. For the meta-analysis, missing outcome and aetiology data were multiply imputed.

Results

The number of juveniles and adults who underwent endovascular therapy (33.7% versus 27.3%; P = .42) and surgery (52.2% versus 58.0%; P = .46) was similar. At baseline, 92.4% of juveniles and 87.5% of adults were hypertensive, decreasing to 23.2% and 24.1% during a follow-up of 23 (juveniles) and 18 (adults) months. In juveniles, after endovascular therapy more hypertension was found compared to surgery (38.1% versus 10.8%; P = .020). Meta-analysis demonstrated a trend for hypertension after endovascular therapy in juveniles, whereas hypertension was more prevalent following surgery in adults compared to endovascular therapy or medication.

Conclusions

Complications and hypertension in MAS during follow-up were more common in juveniles after endovascular treatment, whereas surgery in adults was associated with more hypertension.

Paired primary and metastatic lesions of patients with ipilimumab-treated melanoma: high variation in lymphocyte infiltration and HLA-ABC expression whereas tumor mutational load is similar and correlates with clinical outcome

BACKGROUND

Immune checkpoint inhibitors (ICI) can lead to long-term responses in patients with metastatic melanoma. Still many patients with melanoma are intrinsically resistant or acquire secondary resistance. Previous studies have used primary or metastatic tumor tissue for biomarker assessment. Especially in melanoma, metastatic lesions are often present at different anatomical sites such as skin, lymph nodes, and visceral organs. The anatomical site may directly affect the tumor microenvironment (TME). To evaluate the impact of tumor evolution on the TME and on ICI treatment outcome, we directly compared paired primary and metastatic melanoma lesions for tumor mutational burden (TMB), HLA-ABC status, and tumor infiltrating lymphocytes (TILs) of patients that received ipilimumab.

METHODS

TMB was analyzed by sequencing primary and metastatic melanoma lesions using the TruSight Oncology 500 assay. Tumor tissues were subjected to multiplex immunohistochemistry to assess HLA-ABC status and for the detection of TIL subsets (B cells, cytotoxic T cells, helper T cells, and regulatory T cells), by using a machine-learning algorithm.

RESULTS

While we observed a very good agreement between TMB of matched primary and metastatic melanoma lesions (intraclass coefficient=0.921), such association was absent for HLA-ABC status, TIL density, and subsets thereof. Interestingly, analyses of different metastatic melanoma lesions within a single patient revealed that TIL density and composition agreed remarkably well, rejecting the hypothesis that the TME of different anatomical sites affects TIL infiltration. Similarly, the HLA-ABC status between different metastatic lesions within patients was also comparable. Furthermore, high TMB, of either primary or metastatic melanoma tissue, directly correlated with response to ipilimumab, whereas lymphocyte density or composition did not. Loss of HLA-ABC in the metastatic lesion correlated to a shorter progression-free survival on ipilimumab.

CONCLUSIONS

We confirm the link between TMB and HLA-ABC status and the response to ipilimumab-based immunotherapy in melanoma, but no correlation was found for TIL density, neither in primary nor metastatic lesions. Our finding that TMB between paired primary and metastatic melanoma lesions is highly stable, demonstrates its independency of the time point and location of acquisition. TIL and HLA-ABC status in metastatic lesions of different anatomical sites are highly similar within an individual patient.

The Emergence of Hierarchical Somatosensory Processing in Late Prematurity

The somatosensory system has a hierarchical organization. Information processing increases in complexity from the contralateral primary sensory cortex to bilateral association cortices and this is represented by a sequence of somatosensory-evoked potentials recorded with scalp electroencephalographies. The mammalian somatosensory system matures over the early postnatal period in a rostro-caudal progression, but little is known about the development of hierarchical information processing in the human infant brain. To investigate the normal human development of the somatosensory hierarchy, we recorded potentials evoked by mechanical stimulation of hands and feet in 34 infants between 34 and 42 weeks corrected gestational age, with median postnatal age of 3 days. We show that the shortest latency potential was evoked for both hands and feet at all ages with a contralateral somatotopic source in the primary somatosensory cortex (SI). However, the longer latency responses, localized in SI and beyond, matured with age. They gradually emerged for the foot and, although always present for the hand, showed a shift from purely contralateral to bilateral hemispheric activation. These results demonstrate the rostro-caudal development of human somatosensory hierarchy and suggest that the development of its higher tiers is complete only just before the time of normal birth.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Risk factors for tick exposure in suburban settings in the Northeastern United States

Prevention of tick-borne diseases requires an understanding of when and where exposure to ticks is most likely. We used an epidemiologic approach to define these parameters for residents of a Lyme-endemic region. Two persons in each of 500 Connecticut households were asked to complete a log each night for one week during June, 2013. Participants recorded their whereabouts in 15min increments (indoors, outdoors in their yard, outdoors on others' private property, or outdoors in public spaces) and noted each day whether they found a tick on themselves. Demographic and household information was also collected. Logs were completed for 934 participants in 471 households yielding 51,895 time-place observations. Median participant age was 49 years (range 2-91 years); 52% were female. Ninety-one participants (9.8%) reported finding a tick during the week, with slightly higher rates among females and minors. Household factors positively associated with finding a tick included having indoor/outdoor pets (odds ratio (OR)=1.7; 95% confidence interval (CI): 1.1-2.9), the presence of a bird feeder in the yard (OR=1.9; CI:1.2-3.2), and presence of an outdoor dining area (OR=2.2; CI:1.1-4.3). Individual factors associated with finding a tick on a given day were bathing or showering (OR=3.7; CI:1.3-10.3) and hours spent in one's own yard (OR=1.2, CI:1.1-1.3). Nineteen participants found ticks on multiple days, more than expected assuming independence (p<0.001). Participants who found ticks on multiple days did not spend more time outdoors but were significantly more likely to be male than those finding ticks on a single day (p<0.03). Our findings suggest that most tick exposures in the study area occurred on private property controlled by the respective homeowner. Interventions that target private yards are a logical focus for prevention efforts.

Initial implementation and evaluation of a Hepatitis C treatment clinical decision support system (CDSS): a nurse practitioner-driven quality improvement initiative

BACKGROUND

Clinician compliance with clinical guidelines in the treatment of patients with Hepatitis C (HCV) has been reported to be as low as 18.5%. Treatment is complex and patient compliance is often inconsistent thus, active clinician surveillance and support is essential to successful outcomes. A clinical decision support system (CDSS) embedded within an electronic health record can provide reminders, summarize key data, and facilitate coordination of care. To date, the literature is bereft of information describing the implementation and evaluation of a CDSS to support HCV treatment.

OBJECTIVE

The purpose of this case report is to describe the design, implementation, and initial evaluation of an HCV-specific CDSS while piloting data collection metrics and methods to be used in a larger study across multiple practices.

METHODS

The case report describes the design and implementation processes with preliminary reporting on impact of the CDSS on quality indicator completion by comparing the pre-CDSS group to the post-CDSS group.

RESULTS

The CDSS was successfully designed and implemented using an iterative, collaborative process. Pilot testing of the clinical outcomes of the CDSS revealed high rates of quality indicator completion in both the pre- and post-CDSS; although the post-CDSS group received a higher frequency of reminders (4.25 per patient) than the pre-CDSS group (.25 per patient).

CONCLUSIONS

This case report documents the processes used to successfully design and implement an HCV CDSS. While the small sample size precludes generalizability of findings, results did positively demonstrate the feasibility of comparing quality indicator completion rates pre-CDSS and post-CDSS. It is recommended that future studies include a larger sample size across multiple providers with expanded outcomes measures related to patient outcomes, staff satisfaction with the CDSS, and time studies to evaluate efficiency and cost effectiveness of the CDSS.

Electrophysiological measurements and analysis of nociception in human infants

Pain is an unpleasant sensory and emotional experience. Since infants cannot verbally report their experiences, current methods of pain assessment are based on behavioural and physiological body reactions, such as crying, body movements or changes in facial expression. While these measures demonstrate that infants mount a response following noxious stimulation, they are limited: they are based on activation of subcortical somatic and autonomic motor pathways that may not be reliably linked to central sensory processing in the brain. Knowledge of how the central nervous system responds to noxious events could provide an insight to how nociceptive information and pain is processed in newborns.

The heel lancing procedure used to extract blood from hospitalised infants offers a unique opportunity to study pain in infancy. In this video we describe how electroencephalography (EEG) and electromyography (EMG) time-locked to this procedure can be used to investigate nociceptive activity in the brain and spinal cord.

This integrative approach to the measurement of infant pain has the potential to pave the way for an effective and sensitive clinical measurement tool.

Functional circuitry of a unique cerebellar specialization: the valvula cerebelli of a mormyrid fish

The valvula cerebelli of the mormyrid electric fish is a useful site for the study of cerebellar function. The valvula forms a part of the electrosensory-electromotor system of this fish, a system that offers many possibilities for the study of sensory-motor integration. The valvula also has a number of histological features not present in mammals which facilitate investigation of cerebellar circuitry and its plasticity. This initial study characterizes the basic physiology and pharmacology of cells in the valvula using an in vitro slice preparation. Intrinsic properties and synaptic responses of Purkinje cells and other cell types were examined. We found that Purkinje cells fire a small narrow Na(+) spike and a large broad Ca(2+) spike, generated in the axon initial segment and dendritic-soma region, respectively. Purkinje cells respond to parallel fiber inputs with graded excitatory postsynaptic potentials (EPSPs) and to climbing fiber inputs with all-or-none EPSPs. Efferent cells, Golgi cells, and deep stellate cells all fire a single type of large narrow spike and respond only to parallel fiber inputs. Both parallel fiber and climbing fiber responses in Purkinje cells appear to be entirely mediated by AMPA-type glutamate receptors, whereas parallel fiber responses in efferent cells and stellate cells include AMPA and NMDA components. In addition, a strong synaptic inhibition was uncovered in both Purkinje cells and efferent cells in response to the focal stimulation of parallel fibers. Dual cell recordings indicate that deep stellate cells contribute at least partially to this inhibition. We conclude that despite its unique histology, the local functional circuitry of the mormyrid valvula cerebelli is largely similar to that of the mammalian cerebellum. Thus, what is learned concerning the functioning of the mormyrid valvula cerebelli may be expected to be informative about cerebellar function in general.

Isolation, identification, and synthesis of 2-carboxyarabinitol 1-phosphate, a diurnal regulator of ribulose-bisphosphate carboxylase activity

The diurnal change in activity of ribulose 1,5-bisphosphate (Rbu-1,5-P(2)) carboxylase [3-phospho-D-glycerate carboxy-lyase (dimerizing); EC 4.1.1.39] of leaves of Phaseolus vulgaris is regulated (in part) by mechanisms that control the level of an endogenous inhibitor that binds tightly to the activated (carbamoylated) form of Rbu-1,5-P(2) carboxylase. This inhibitor was extracted from leaves and copurified with the Rbu-1,5-P(2) carboxylase of the leaves. Further purification by ion-exchange chromatography, adsorption to purified Rbu-1,5-P(2) carboxylase, barium precipitation, and HPLC separation yielded a phosphorylated compound that was a strong inhibitor of Rbu-1,5-P(2) carboxylase. The compound was analyzed by GC/MS, (13)C NMR, and (1)H NMR and shown to be 2-carboxyarabinitol 1-phosphate [(2-C-phosphohydroxymethyl)-D-ribonic acid]. Verification of structure was obtained by comparison of the inhibitory activity of the isolated compound with that of 2-carboxy-D-arabinitol 1-phosphate synthesized in vitro. This compound (but not 2-carboxy-D-arabinitol 5-phosphate) inhibited Rbu-1,5-P(2) carboxylase in a way that was kinetically identical to that of the isolated, naturally occurring compound. The structure of the isolated compound differs from the Rbu-1,5-P(2) carboxylase transition-state analogue 2-carboxyarabinitol 1,5-bisphosphate only by the lack of the C-5 phosphate group. This difference results in a higher binding constant for the monophosphate (K(d) = 32 nM) compared with the bisphosphate (K(d) < 10 pM). The less tightly bound compound acts in a light-dependent, reversible regulation of Rbu-1,5-P(2) carboxylase activity in vivo.

Quantitative fit assessment of tibial nail designs using 3D computer modelling

Intramedullary nailing is the standard fixation method for displaced diaphyseal fractures of the tibia in adults. The bends in modern tibial nails allow for an easier insertion, enhance the 'bone-nail construct' stability, and reduce axial malalignments of the main fragments. Anecdotal clinical evidence indicates that current nail designs do not fit optimally for patients of Asian origin. The aim of this study was to develop a method to quantitatively assess the anatomical fitting of two different nail designs for Asian tibiae by utilising 3D computer modelling. We used 3D models of two different tibial nail designs (ETN (Expert Tibia Nail) and ETN-Proximal-Bend, Synthes), and 20 CT-based 3D cortex models of Japanese cadaver tibiae. With the aid of computer graphical methods, the 3D nail models were positioned inside the medullary cavity of the intact 3D tibia models. The anatomical fitting between nail and bone was assessed by the extent of the nail protrusion from the medullary cavity into the cortical bone, in a real bone this might lead to axial malalignments of the main fragments. The fitting was quantified in terms of the total surface area, and the maximum distance by which the nail was protruding into the cortex of the virtual bone model. In all 20 bone models, the total area of the nail protruding from the medullary cavity was smaller for the ETN-Proximal-Bend (average 540 mm(2)) compared to the ETN (average 1044 mm(2)). Also, the maximum distance of the nail protruding from the medullary cavity was smaller for the ETN-Proximal-Bend (average 1.2mm) compared to the ETN (average 2.7 mm). The differences were statistically significant (p<0.05) for both the total surface area and the maximum distance measurements. By utilising computer graphical methods it was possible to conduct a quantitative fit assessment of different nail designs. The ETN-Proximal-Bend shows a statistical significantly better intramedullary fit with less cortical protrusion than the original ETN. In addition to the application in implant design, the developed method could potentially be suitable for pre-operative planning enabling the surgeon to choose the most appropriate nail design for a particular patient.

Quantification of the genetic component of basal C-reactive protein expression in SLE nuclear families

C-reactive protein (CRP) is a heritable acute-phase plasma protein also expressed at low, basal, levels in healthy individuals. Elevated basal CRP has been associated with increased cardiovascular risk, while CRP dysregulation may be a feature of systemic lupus erythematosus (SLE). In this cohort of 496 Caucasian SLE families we estimated basal CRP heritability, h(2)= 27.7%. We typed a dense map of CRP single nucleotide polymorphisms (SNPs) and found that seven were associated with basal CRP using both a regression approach and an orthogonal family-based test (P = 0.001-0.011), as were haplotypes carrying the minor allele of these SNPs. SNPs in the interleukin-1beta and interleukin-6 genes were associated with basal CRP. No association was seen between CRP genotype and SLE. Using a variance components approach we estimated that the CRP genotype accounted for only 15% of the total genetic component of basal CRP variation, perhaps explaining the limited evidence of association between CRP and disease. Most of the genetic determinants of basal CRP variation therefore remain unknown. Multiple genes may be involved and identifying them will provide an insight into pathways regulating CRP expression, highlight potential cardiovascular disease and SLE candidates and improve the ability of basal CRP to predict cardiovascular risk.

Activation of a sensorimotor pathway in response to a water temperature drop in a teleost fish

When common carp, Cyprinus carpio L., experience a rapid temperature drop, the cerebral blood volume is strongly reduced to dampen the temperature drop in the brain. Simultaneously, the preoptic area and pituitary gland are activated to launch whole-body adaptive responses. However, the preferred reaction of fish to a temperature change is an escape reaction,which implies activation of a sensorimotor pathway. Here, we used blood oxygenation level-dependent (BOLD)- and cerebral blood volume (CBV)-weighted functional magnetic resonance imaging (fMRI) to identify a sensorimotor pathway, during a 10°C temperature drop in common carp. Transient activation was observed in the region where the sensory root of the trigeminal nerve enters the brain, and in the valvula cerebelli. In both regions,metabolic activity increased (increased deoxyhemoglobin content demonstrated by a decreased BOLD signal) within 30 s after the onset of the temperature drop, peaked after 2-3 min, and then decreased, even though the temperature continued to drop for another 2 min. These brain structures appear to respond to temperature change, rather than to the absolute temperature. Thus, during a temperature drop, the sensorimotor pathway consisting of the trigeminal nerve,the primary sensory trigeminal nucleus, the valvula cerebelli and some motornuclei, is active, in line with perception of temperature change in the buccal cavity, leading to motor activity for escape. This pathway operates in parallel to an acclimation pathway, which involves the preoptic area to pituitary gland pathway.

Myelinated dendrites in the mormyrid electrosensory lobe

This is the third paper in a series on the morphology, immunohistochemistry, and synaptology of the mormyrid electrosensory lateral line lobe (ELL). The ELL is a highly laminated, cerebellum-like structure in the rhombencephalon that subserves an active electric sense: Objects in the nearby environment are detected on the basis of changes in the reafferent electrosensory signals that are generated by the animal's own electric organ discharge. This paper concentrates on the intermediate (cell and fiber) layer of the medial zone of the ELL and pays particular attention to the large multipolar neurons of this layer (LMI cells). LMI cells are gamma-aminobutyric acid (GABA)ergic and have one axon and three to seven proximal dendrites that all become myelinated after their last proximal branching point. The axon projects to the contralateral homotopic region and has ipsilateral collaterals. Both ipsilaterally and contralaterally, it terminates in the deep and superficial granular layers. The myelinated dendrites end in the deep granular layer, where they most likely do not make postsynaptic specializations, but do make presynaptic specializations, similar to those of the LMI axons. Because it is not possible to distinguish between axonal and dendritic LMI terminals in the granular layer, the authors refer to both as LMI terminals. These are densely filled with small, flattened vesicles and form large appositions with ELL granular cell somata and dendrites with symmetric synaptic membrane specializations. LMI cells do not receive direct electrosensory input on their somata, but electrophysiological recordings suggest that they nevertheless respond strongly to electrosensory signals (Bell [1990] J. Neurophysiol. 63:303-318). Consequently, the authors speculate that the myelinated dendrites of LMI cells are excited ephaptically (i.e., by electric field effects) by granular cells, which, in turn, are excited via mixed synapses by mormyromast primary afferents. The authors suggest that this ephaptic activation of the GABAergic presynaptic terminals of the myelinated dendrites may trigger immediate synaptic release of GABA and, thus, may provide a very fast local feedback inhibition of the excited granular cells in the center of the electrosensory receptive field. Subsequent propagation of the dendritic excitation down the myelinated dendrites to the somata and axon hillocks of LMI cells probably generates somatic action potentials, resulting in the spread of inhibition through axonal terminals to a wide region around the receptive field center and in the contralateral ELL. Similar presynaptic myelinated dendrites that subserve feedback inhibition, until now, have not been described elsewhere in the brain of vertebrates.

Sodium phosphate enhances plasmid DNA expression in vivo

Intramuscular injection of plasmid DNA results in myofiber cell expression of proteins encoded by the DNA. The preferred vehicle for plasmid DNA injections has been saline (154 mM sodium chloride) or PBS (154 mM NaCl plus 10 mM sodium phosphate). Here, it is shown that injection of luciferase or beta-galactosidase encoding plasmid DNA in a 150 mM sodium phosphate vehicle into murine muscle resulted in a two- to seven-fold increase in transgene expression compared with DNA injected in saline or PBS. When the DNA encoded secreted alkaline phosphatase, preproinsulin or interferon, sodium phosphate vehicle increased their serum levels by two- to four-fold. When the DNA encoded mouse erythropoietin, sodium phosphate vehicle increased hematocrits by two-fold compared with DNA injected in saline. When the DNA encoded influenza nucleoprotein, sodium phosphate increased anti-nucleoprotein antibody titers by two-fold. The expression of luciferase from plasmid DNA instilled into lung was increased five-fold compared with that in vehicle without sodium phosphate. Incubation of plasmid DNA with muscle extract or serum showed that sodium phosphate protected the DNA from degradation. Thus, a change from sodium chloride to sodium phosphate vehicle can enhance the expression of plasmid DNA in a tissue, possibly by inhibiting DNA degradation. Gene Therapy (2000) 7, 1171-1182.

Structural organization of the mormyrid electrosensory lateral line lobe

The electrosensory lateral line lobe (ELL) of mormyrid teleosts is the first central stage in electrosensory input processing. It is a well-developed structure with six main layers, located in the roof of the rhombencephalon. Its main layers are, from superficial to deep, the molecular, ganglionic, plexiform, granular, intermediate and deep fiber layers. An important input arises from electroreceptors, but corollary electromotor command signals and proprioceptive, mechanosensory lateral line and descending electrosensory feedback inputs reach the ELL as well. The ELL input is processed by at least 14 cell types, which frequently show plastic responses to different inputs. The large ganglionic and large fusiform cells are the ELL projection cells. They are glutamatergic and project to the isthmic preeminential nucleus and the midbrain lateral toral nucleus. Interneurons are located in all ELL layers and are mostly GABAergic. The most remarkable interneurons are large multipolar cells in the intermediate layer, which have myelinated dendrites making presynaptic terminals contacting granular cells. With respect to the synaptic organization and microcircuitry of the ELL, a number of qualitative and quantitative aspects have been elucidated using electron microscopical and intracellular labeling techniques. However, the pathways by which primary afferent input influences the ELL projection cells are still undetermined: primary afferents do not seem to contact large fusiform or large ganglionic cells directly, but seem to terminate exclusively on granular cells, the axonal properties of which are not known. Consequently, more information of the structural organization of the ELL is still necessary for a detailed understanding of the neural basis of the plastic electrosensory input processing in mormyrids.

The paraventricular organ of mormyrid fish: uptake or release of intraventricular biogenic amines?

The paraventricular organ of Gnathonemus petersii was investigated with light and electronmicroscopical techniques. It contains high concentrations of dopamine, noradrenaline and serotonin, but the synthesizing enzymes are not or hardly present. Consequently, the cerebrospinal fluid-contacting neurons might pick up their biogenic amines from the ventricular fluid. Dense subependymal axonal plexuses in the everted telencephalon probably release these substances into the ventricle. However, electronmicroscopical observations suggest release rather than uptake by the paraventricular organ. The possible significance of intraventricular release, transport and uptake of biogenic amines is discussed.

Fast and accurate method for quantitating E. coli host-cell DNA contamination in plasmid DNA preparations

Plasmid DNA is being used successfully as a gene delivery vector in a variety of clinical applications. Similar to other pharmaceutical products for clinical use, the plasmid vectors must meet rigorous purity standards. One important contaminant is the DNA of the host cell used to produce the plasmids. We have developed a new method to accurately quantitate E. coli host-cell DNA in plasmid preparations. This method is based on kinetic PCR using the ABI PRISM 7700 with 23S rDNA as a target. This precise assay is significantly faster and has a lower limit of quantitation than the currently used Southern-based methods.

Epilepsy in very preterm infants: neonatal cranial ultrasound reveals a high-risk subcategory

The aim of this study was to investigate the association between epilepsy and perinatal brain injury in a cohort of 610 infants born preterm at <33 weeks' gestation. The prevalence of epilepsy in this cohort was 4.3% as determined by a postal questionnaire survey. Most children with epilepsy (16 of 24) had high-risk cranial ultrasound lesions including haemorrhagic parenchymal infarction (HPI), posthaemorrhagic hydrocephalus, and cystic periventricular leukomalacia (PVL). Of all the children in our cohort with high-risk brain lesions, those with epilepsy were more likely to have HPI and significantly less likely to have cystic PVL, although it is possible that PVL was not noticed in some cases. Children with epilepsy and high-risk cranial ultrasound lesions also showed more cognitive impairment than children with high-risk lesions but no epilepsy, which suggested more cortical grey-matter damage. We suggest that brain injury has occurred outside the confines of the periventricular white matter in this group of preterm infants with epilepsy.

Cerebral blood flow is independent of mean arterial blood pressure in preterm infants undergoing intensive care

OBJECTIVE

Preterm infants are often presumed to have a pressure passive cerebral circulation implying that a low mean arterial blood pressure (MABP) results in reduced cerebral perfusion. The aim of this study was to determine whether cerebral blood flow (CBF) was compromised in preterm infants whose MABP fell below 30 mm Hg (4 kPa).

METHODS

Thirty preterm infants undergoing intensive care were studied within the first 24 hours of life. CBF was measured using near infrared spectroscopy. The infants were analyzed in two groups on the basis of their MABP at the time of study: group 1 had a MABP below 30 mm Hg and group 2 more than 30 mm Hg. CBF in the two groups was compared.

RESULTS

There was no significant difference in the mean CBF between the two groups. In group 1 the median MABP was 27.2 mm Hg (range, 23.7-29.9 mm Hg) and CBF was 13.9 (standard deviation, +/-6.9) mL . 100 g-1 . min-1. In group 2 the median MABP was 35.3 mm Hg (range, 30.1-39.3 mm Hg) and CBF was 12.3 (standard deviation, +/-6.4) mL . 100 g-1 . min-1. Mortality and incidence of cranial ultrasound scan abnormalities were also not significantly different.

CONCLUSION

These results indicate that preterm infants undergoing intensive care are able to maintain adequate cerebral perfusion at a MABP in the range of 23.7 to 39.3 mm Hg.

Plasticity in the stress-regulating circuit: decreased input from the bed nucleus of the stria terminalis to the hypothalamic paraventricular nucleus in Wistar rats following adrenalectomy

The bed nucleus of the stria terminalis is involved in the stress-regulating circuit by funnelling limbic information to the hypothalamic paraventricular nucleus. Since adrenalectomy influences both limbic structures (by inducing cell death in the hippocampus) and the hypothalamic paraventricular nucleus (by increased corticotrophin-releasing hormone synthesis), we investigated whether the bed nucleus of the stria terminalis is also influenced by adrenalectomy. For this purpose, we analysed and compared the projections from the bed nucleus of the stria terminalis to the hypothalamic paraventricular nucleus in normal and adrenalectomized rats by anterograde tracer injections in the bed nucleus of the stria terminalis. Quantitative analysis of the fibre pattern in the hypothalamic paraventricular nucleus of normal rats revealed a homogeneous distribution of fibres of the bed nucleus of the stria terminalis over the different subdivisions of the hypothalamic paraventricular nucleus. In adrenalectomized rats, the absolute fibre density was significantly lower in the whole hypothalamic paraventricular nucleus (1.17 +/- 0.27 10(-3) microm/microm3 in adrenalectomized rats versus 2.59 +/- 0.24 10(-3) microm/microm3 in normal rats; P < 0.01) and all its subdivisions. The largest decrease of fibre density was found in the corticotrophin-releasing hormone-rich part of the hypothalamic paraventricular nucleus (relative fibre density; adrenalectomized rats: 0.602 +/- 0.106, versus 1.095 +/- 0.019 in normal rats, P < 0.01). These results show a loss of input from the bed nucleus of the stria terminalis to the hypothalamic paraventricular nucleus, and particularly to the corticotrophin-releasing hormone neurons, following adrenalectomy. The data suggest that this pathway within the stress-regulating circuit is functionally affected by corticosteroids in adult rats and may imply that human disorders associated with corticosteroid imbalance are allied to a changed circuitry in the brain.

Interneurons of the ganglionic layer in the mormyrid electrosensory lateral line lobe: morphology, immunohistochemistry, and synaptology

This is the second paper in a series that describes the morphology, immunohistochemistry, and synaptology of the mormyrid electrosensory lateral line lobe (ELL). The ELL is a highly laminated cerebellum-like structure in the rhombencephalon that subserves an active electric sense: Objects in the nearby environment of the fish are detected on the basis of changes in the reafferent electrosensory signals that are generated by the animal's own electric organ discharge. The present paper describes interneurons in the superficial (molecular, ganglionic, and plexiform) layers of the ELL cortex that were analyzed in the light and electron microscopes after Golgi impregnation, intracellular labeling, neuroanatomical tracing, and gamma-aminobutyric acid (GABA) immunohistochemistry. The most numerous interneurons in the ganglionic layer are GABAergic medium-sized ganglionic (MG) cells and small ganglionic (SG) cells. MG cells have 10-20 spiny apical dendrites in the molecular layer, a cell body of 10-12 microns diameter in the ganglionic layer, a single basal dendrite that gives rise to fine, beaded, axon-like branches in either the plexiform layer (MG1 subtype) or the deeper granular layer (MG2 subtype), and an axon that terminates in the plexiform layer. Their apical dendritic tree has 12,000-22,000 spines that are contacted by GABA-negative terminals, and it receives, 1,250-2,500 GABA-positive contacts on the smooth dendritic surface between the spines. The average ratio of GABA-negative to GABA-positive contacts on the interneuron apical dendrites (14:1) is significantly higher than that for the efferent projection cells that have been described previously (Grant et al. [1996] J. Comp. Neurol., this issue). The somata and basal dendrites of MG cells receive a low to moderate density of GABAergic synaptic input, and their axons make GABAergic synaptic contacts with the somata and cell bodies of MG as well as with large ganglionic (LG) cells. SG cells probably represent immature, growing MG cells. Other interneurons in the superficial ELL layers include GABAergic stellate cells in the molecular layer, two types of non-GABAergic cells with smooth dendrites in the deep molecular layer that are named thick-smooth dendrite cells and deep molecular layer cells, and horizontal cells that are encountered particularly in the plexiform layer. Comparison with the ELL of waveform gymnotiform fish, which is another group of active electrolocating teleosts that has been investigated thoroughly, shows striking differences. In these fish, no GABAergic interneurons are found in the ganglionic (pyramidal) layer of the ELL, and GABA-negative interneurons with smooth dendrites in the molecular layer also seem to be lacking. At present, the phylogenetic origin of the described superficial interneurons in the mormyrid ELL is uncertain.

Projection neurons of the mormyrid electrosensory lateral line lobe: morphology, immunohistochemistry, and synaptology

This paper describes the morphological, immunohistochemical, and synaptic properties of projection neurons in the highly laminated medial and dorsolateral zones of the mormyrid electrosensory lateral line lobe (ELL). These structures are involved in active electrolocation, i.e., the detection and localization of objects in the nearby environment of the fish on the basis of changes in the reafferent electrosensory signal generated by the animal's own electric organ discharge. Electrosensory, corollary electromotor command-associated signals (corollary discharges), and a variety of other inputs are integrated within the ELL microcircuit. The organization of ELL projection neurons is analyzed at the light and electron microscopic levels based on Golgi impregnations, intracellular labeling, neuroanatomical tracer techniques, and gamma-aminobutyric acid (GABA), gamma-aminobutyric acid decarboxylase (GAD), and glutamate immunohistochemistry. Two main types of ELL projection neurons have been distinguished in mormyrids: large ganglionic (LG) and large fusiform (LF) cells. LG cells have a multipolar cell body (average diameter 13 microns) in the ganglionic layer, whereas LF cells have a fusiform cell body (on average, about 10 x 20 microns) in the granular layer. Apart from the location and shape of their soma, the morphological properties of these cell types are largely similar. They are glutamaterigic and project to the midbrain torus semicircularis, where their axon terminals make axodendritic synaptic contacts in the lateral nucleus. They have 6-12 apical dendrites in the molecular layer, with about 10,000 spines contacted by GABA-negative terminals and about 3,000 GABA-positive contacts on the smooth dendritic surface between the spines. Their somata and short, smooth basal dendrites, which arborize in the plexiform layer (LG cells) or in the granular layer (LF cells), are densely covered with GABA-positive, inhibitory terminals. Correlation with physiological data suggests that LG cells are I units, which are inhibited by stimulation of the center of their receptive fields, and LF cells are E units, excited by electric stimulation of the receptive field center. Comparison with the projection neurons of the ELL of gymnotiform fish, which constitute another group of active electrolocating teleosts, shows some striking differences, emphasizing the independent development of the ELL in both groups of teleosts.

Assessing and overcoming situational obstacles to dietary adherence in adolescents with IDDM

PURPOSE

To develop and evaluate a tool for assessing selected aspects of dietary adherence in adolescents with diabetes mellitus (IDDM).

METHODS

The Situational Obstacles to Dietary Adherence Questionnaire (SODA) is a 30-item inventory that yields a total self-efficacy score and scales that measure cognitive and behavioral coping strategies. Alternative forms of the SODA were administered at the beginning and end of a summer camp for youngsters with IDDM in order to obtain evidence for its reliability and validity, and to evaluate the impact of an educational intervention. The program consisted of two 50-minute small group sessions intended to help adolescents with IDDM improve their ability to cope with challenging dietary situations. Using the method of anchored instruction, the campers first viewed a video about a teenager with diabetes who faces common situations that make diabetes self-management difficult. Group problem-solving sessions led by a registered dietitian were used to help campers learn more effective ways to solve dietary problems.

RESULTS AND CONCLUSIONS

Results suggested that the SODA has reasonable reliability and validity. In addition, anchored instruction improved dietary self-efficacy and changed young adolescents' estimates of how often they would use selected cognitive and behavioral strategies to solve dietary problems.

An improved plasmid DNA expression vector for direct injection into skeletal muscle

In previous work, the direct injection of 50 micrograms of a plasmid DNA vector encoding firefly luciferase (VR1205) into murine quadriceps muscle produced an average of 6.5 ng of luciferase per muscle at 7 days postinjection. In this report, various elements of the VR1205 vector were modified to increase gene expression levels or to eliminate undesired viral sequences. Expression of the modified vectors was then compared to VR1205 using the intramuscular injection assay. In general, modifications to promoter, enhancer, and intronic sequences either decreased luciferase expression levels or had no effect. However, modifications to the polyadenylation and transcriptional termination sequences, plasmid backbone elements, and the luciferase gene itself each increased luciferase expression levels. The best-expressing vector, designated VR1255, contained a combination of these incrementally beneficial changes. A single intramuscular injection of 50 micrograms of VR1255 produced 300 ng of luciferase at 7 days postinjection, an expression level 46-fold higher than the VR1205 vector (or 22-fold higher, excluding modifications to the luciferase gene) and 154-fold higher than a commercially available luciferase expression vector. Thus, VR1255 represents an improved plasmid DNA vector that may be useful for gene therapy applications.

Quality assurance in a nursing home

The private nursing home sector must be accountable to its consumers and staff. This article describes an initiative to canvas the views of residents' next of kin and care staff as a basis for quality assurance mechanisms. The authors describe the process, its results and the changes in care provision which have been brought about.

The hypothalamic paraventricular nucleus in two types of Wistar rats with different stress responses. I. Morphometric comparison

The present study evaluates the role of the hypothalamic paraventricular nucleus (PVH) in stress regulation by a morphometric comparison of the vascular, neuronal and synaptic properties of this nucleus in two lines of Wistar rats. It has been previously reported that these two lines of rats, indicated as APO-SUS (apomorphine-susceptible) and APO-UNSUS (apomorphine-unsusceptible) rats on the basis of their reactivity to a subcutaneous injection of apomorphine, display a variety of pharmacological and behavioral differences, including differences in their stress-coping mechanisms (Cools et al., Neuropsychobiology, 28 (1993) 100-105). The results show a similar vascular and neuronal organization of the PVH in both lines, but distinct synaptic differences. The PVH (0.12 mm3 volume with about 15,000 neurons on one side) has an overall vascular density of 5.6%, with significant differences between subdivisions (parvocellular central part: 8.3%, parvocellular dorsal/ventral/posterior part: 4.6-5.3%), which means that vascularity is a useful tool to delineate subdivisions in the parvocellular PVH. The neuronal density of 132 x 10(3)/mm3 as found in the present study is two times higher than reported in a previous study Possible reasons for this discrepancy are extensively discussed. The most significant finding of the present study is the observation that APO-SUS rats have a significantly higher synaptic density (158 x 10(6)/mm3) in the PVH than APO-UNSUS rats (108 x 10(6)/mm3). It is discussed in which way this synaptic difference may be correlated with the different activity of the hypothalamo-pituitary-adrenal axis in both lines of Wistar rats.

The hypothalamic paraventricular nucleus in two types of Wistar rats with different stress responses. II. Differential Fos-expression

The present study investigates the role of corticotropin-releasing hormone (CRH) neurons in stress regulation by a comparison of stress induced Fos-immunoreactivity and CRH-immunoreactivity in the hypothalamic paraventricular nucleus (PVH) of APO-SUS (apomorphine-susceptible), APO-UNSUS (apomorphine-unsusceptible), normal Wistar and adrenalectomized Wistar (ADX) rats. The first two types represent a good model to study the role of the PVH in stress regulation, since they show different stress responses and a differential synaptic organization of the PVH. After placement on an open field for 15 min all rats showed an increase in the number of Fos-immunoreactive nuclei compared to control handling. Interestingly, open field stress, but not control handling, induces significantly fewer Fos-immunoreactive nuclei in the PVH of APO-SUS rats (1255 +/- 49) compared to APO-UNSUS rats (1832 +/- 201). Experiments with ADX rats revealed that 93% of the CRH-immunoreactive neurons contained a Fos-immunoreactive nucleus, which suggests that the differential Fos-expression in APO-SUS and APO-UNSUS rats represents a differential activation of the CRH neurons. This hypothesis is discussed in relation to reported differences in stress responses, stress-induced ACTH levels and synaptic organization of the PVH.

Microcircuitry of the mormyrid electrosensory lateral line lobe

The mormyrid electrosensory lateral line lobe (ELL) is a laminated structure in the dorsal rhombencephalon receiving topographically ordered primary sensory input from electroreceptors and corollary signals from the electromotor command nucleus. The structural basis of the integration of these and other inputs was investigated at the light and electron microscopical level using neuroanatomical tracers, immunohistochemistry and Golgi-impregnations. The ELL contains at least 14 distinct cell types. These include small granule cells receiving primary afferent input, GABA-ergic spiny interneurons and glutamatergic projection neurons integrating sensory input and descending feedback, and deep intrazonal neurons. Present knowledge of the synaptic organization of the ELL afferents and cell types allows for a preliminary scheme of its microcircuitry.

The role of motor command feedback in electrosensory processing

Sensory motor-coordination and the descending modulation of sensory perception can be particularly well studied in the mormyrid electrosensory lateral line lobe (ELL). In this first order sensory processing network, electroreceptive primary afferent input is integrated with a corollary discharge signal which modulates neuron excitability immediately after the generation of an electric organ discharge. Corollary discharge feedback to the electrosensory lobe allows the brain to distinguish between reafferent sensory input, generated by autostimulation of cutaneous electroreceptors (resulting from the fish's own electric discharge) and exafferent sensory input, evoked by stimulation of the same cutaneous electroreceptors by an external electric source. Mechanisms of this type define the context of incoming sensory information and are the first step in the dynamic regulation of perception. The corollary discharge pathway originates from a collateral branch of the electromotor command neuron axons. It is relayed via bulbar and mesencephalic command-associated nuclei and reaches the ELL by way of projections from the cerebellar posterior granular eminence to the superficial layer of the ELL, and from juxtalobar and juxtalemniscal nuclei to the deeper layers of ELL. ELL is a geometrically organized laminar structure containing a variety of cell types. A number of them combine a spiny dendritic tree in the superficial molecular layer with non-spiny basal dendrites in plexiform or deeper layers. Sensory input may reach the basal dendrites of these neurons either directly or indirectly, via granule cells in the deeper layers of ELL, on which the primary afferent fibers terminate. All neurons recorded intracellularly in the ELL show strong interaction between electrosensory and corollary discharge input. Corollary discharge gating of sensory processing is plastic and depends on dynamic sensory-motor association.

Tyrosine hydroxylase-immunoreactive cell groups in the brain of the teleost fish Gnathonemus petersii

Different antibodies against tyrosine hydroxylase (TH) were used to obtain detailed information about the distribution, morphology and chemical differentiation of catecholaminergic neurons in the highly differentiated brain of the electric mormyrid fish Gnathonemus petersii. The results show that the distribution of catecholaminergic neurons is much more widespread than was previously thought on the basis of dopamine and noradrenaline immunohistochemistry. Tyrosine hydroxylase-immunoreactive neurons were observed not only in clearly dopaminergic regions (the suprachiasmatic nucleus, the magnocellular hypothalamic nucleus and the area postrema) and noradrenergic cell groups (the locus coeruleus and inferior reticular cell group), but also in regions that do not, or only fragmentarily, display dopamine or noradrenaline immunoreactivity, including the ventral and intermediate telencephalon, the anterior and posterior preoptic cell group, the ventromedial thalamus, the pretectal region and the nucleus of the solitary tract, suggesting that they either represent depleted dopaminergic cell groups or L-dihydroxy phenylalanine-producing nuclei. Most TH-immunoreactive neurons are rather small (< 10 microns) and have only a few slender processes, but neurons in the magnocellular hypothalamic nucleus and the inferior reticular formation are multipolar and larger (10-20 microns), while those of the locus coeruleus are even more than 20 microns in diameter. The hypothalamic paraventricular organ, which is strongly dopamine and noradrenaline immunoreactive, displays minimal TH immunoreactivity, suggesting that its cerebrospinal fluid-contacting neurons do not synthesize catecholamines, but acquire them from external sources. Comparison with other teleosts shows that the catecholaminergic system in the brain of Gnathonemus is similarly organized as in Carassius, Gasterosteus, Anguilla and Aperonotus, with some variations that may partly be due to technical reasons, and partly reflect true species differences. However, TH-immunoreactive neurons in the midbrain tegmentum were not observed, confirming previous conclusions that a major difference between teleosts and mammals concerns the absence of dopaminergic midbrain groups and correlated mesencephalo-telencephalic projections in teleosts.