Singapore Undiagnosed Disease Program: Genomic Analysis aids Diagnosis and Clinical Management

OBJECTIVE

Use next-generation sequencing (NGS) technology to improve our diagnostic yield in patients with suspected genetic disorders in the Asian setting.

DESIGN

A diagnostic study conducted between 2014 and 2019 (and ongoing) under the Singapore Undiagnosed Disease Program. Date of last analysis was 1 July 2019.

SETTING

Inpatient and outpatient genetics service at two large academic centres in Singapore.

PATIENTS

Inclusion criteria: patients suspected of genetic disorders, based on abnormal antenatal ultrasound, multiple congenital anomalies and developmental delay.

EXCLUSION CRITERIA

patients with known genetic disorders, either after clinical assessment or investigations (such as karyotype or chromosomal microarray).

INTERVENTIONS

Use of NGS technology-whole exome sequencing (WES) or whole genome sequencing (WGS).

MAIN OUTCOME MEASURES

(1) Diagnostic yield by sequencing type, (2) diagnostic yield by phenotypical categories, (3) reduction in time to diagnosis and (4) change in clinical outcomes and management.

RESULTS

We demonstrate a 37.8% diagnostic yield for WES (n=172) and a 33.3% yield for WGS (n=24). The yield was higher when sequencing was conducted on trios (40.2%), as well as for certain phenotypes (neuromuscular, 54%, and skeletal dysplasia, 50%). In addition to aiding genetic counselling in 100% of the families, a positive result led to a change in treatment in 27% of patients.

CONCLUSION

Genomic sequencing is an effective method for diagnosing rare disease or previous 'undiagnosed' disease. The clinical utility of WES/WGS is seen in the shortened time to diagnosis and the discovery of novel variants. Additionally, reaching a diagnosis significantly impacts families and leads to alteration in management of these patients.

Restricted nature of adult neural stem cells: re-evaluation of their potential for brain repair

Neural stem cells (NSCs) in the walls of the lateral ventricles continue to produce new neurons and oligodendrocytes throughout life. The identification of NSCs, long-range neuronal migration, and the integration of new neurons into fully formed mature neural circuits-all in the juvenile or adult brain-has dramatically changed concepts in neurodevelopment and suggests new strategies for brain repair. Yet, the latter has to be seen in perspective: NSCs in the adult are heterogeneous and highly regionally specified; young neurons derived from these primary progenitors migrate and integrate in specific brain regions. Neurogenesis appears to have a function in brain plasticity rather than brain repair. If similar processes could be induced in regions of the brain that are normally not a target of new neurons, therapeutic neuronal replacement may one day reinstate neural circuit plasticity and possibly repair broken neural circuits.

Axons take a dive: Specialized contacts of serotonergic axons with cells in the walls of the lateral ventricles in mice and humans

In the walls of the lateral ventricles of the adult mammalian brain, neural stem cells (NSCs) and ependymal (E1) cells share the apical surface of the ventricular-subventricular zone (V-SVZ). In a recent article, we show that supraependymal serotonergic (5HT) axons originating from the raphe nuclei in mice form an extensive plexus on the walls of the lateral ventricles where they contact E1 cells and NSCs. Here we further characterize the contacts between 5HT supraependymal axons and E1 cells in mice, and show that suprependymal axons tightly associated to E1 cells are also present in the walls of the human lateral ventricles. These observations raise interesting questions about the function of supraependymal axons in the regulation of E1 cells.

Axonal control of the adult neural stem cell niche

The ventricular-subventricular zone (V-SVZ) is an extensive germinal niche containing neural stem cells (NSCs) in the walls of the lateral ventricles of the adult brain. How the adult brain's neural activity influences the behavior of adult NSCs remains largely unknown. We show that serotonergic (5HT) axons originating from a small group of neurons in the raphe form an extensive plexus on most of the ventricular walls. Electron microscopy revealed intimate contacts between 5HT axons and NSCs (B1) or ependymal cells (E1) and these cells were labeled by a transsynaptic viral tracer injected into the raphe. B1 cells express the 5HT receptors 2C and 5A. Electrophysiology showed that activation of these receptors in B1 cells induced small inward currents. Intraventricular infusion of 5HT2C agonist or antagonist increased or decreased V-SVZ proliferation, respectively. These results indicate that supraependymal 5HT axons directly interact with NSCs to regulate neurogenesis via 5HT2C.

Outcome of adult critically ill patients mechanically ventilated on general medical wards

OBJECTIVE. A significant number of critically ill mechanically ventilated patients are not admitted to the Intensive Care Unit but are cared for on general wards. This study looked at the outcome of these patients. DESIGN. Case series. SETTING. A 1100-bed tertiary hospital in Hong Kong. PATIENTS. All adult patients admitted in a 2.5-year period who received invasive mechanical ventilation on general medical wards without admission to Intensive Care Unit or other special care areas. INTERVENTIONS. Invasive mechanical ventilation. MAIN OUTCOME MEASURES. The observed number of deaths, the expected number of deaths as derived from the Mortality Probability Model II system admission model, and other morbidity measures. RESULTS. Among 755 patients studied, the observed number of deaths was 673, which amounts to a mortality of 89.1%. The expected number of deaths was 570. The risk-standardised mortality ratio was 1.18 (95% confidence interval, 1.09-1.28; P<0.0005). Patients with chronic obstructive pulmonary disease had the lowest mortality rate of 70.8% (P<0.005). The post-cardiac arrest subgroup had the highest mortality of 99.0%. CONCLUSIONS. There was a worse-than-predicted survival in the absence of Intensive Care Unit care for the critically ill patients who received mechanical ventilation on general wards. Patients with chronic obstructive pulmonary disease warranted more Intensive Care Unit admissions. Early discontinuation of invasive support should be seriously considered in the post-cardiac arrest patients.

Basic fibroblast growth factor modulates cell cycle of human umbilical cord-derived mesenchymal stem cells

BACKGROUND

Mesenchymal stem cells (MSC) have great potential in regenerative medicine, immunotherapy and gene therapy due to their unique properties of self-renewal, high plasticity, immune modulation and ease for genetic modification. However, production of MSC at sufficient clinical scale remains an issue as in vitro generation of MSC inadequately fulfils the demand with respect to patients.

OBJECTIVES

This study has aimed to establish optimum conditions to generate and characterize MSC from human umbilical cord (UC-MSC).

MATERIALS AND METHODS

To optimize MSC population growth, basic fibroblast growth factor (bFGF) was utilized in culture media. Effects of bFGF on expansion kinetics, cell cycle, survival of UC-MSC, cytokine secretion, expression of early stem-cell markers and immunomodulation were investigated.

RESULTS

bFGF supplementation profoundly enhanced UC-MSC proliferation by reducing population doubling time without altering immunophenotype and immunomodulatory function of UC-MSC. However, cell cycle studies revealed that bFGF drove the cells into the cell cycle, as a higher proportion of cells resided in S phase and progressed into M phase. Consistent with this, bFGF was shown to promote expression of cyclin D proteins and their relevant kinases to drive UC-MSC to transverse cell cycle check points, thus, committing the cells to DNA synthesis. Furthermore, supplementation with bFGF changed the cytokine profiles of the cells and reduced their apoptotic level.

CONCLUSION

Our study showed that bFGF supplementation of UC-MSC culture enhanced the cells' growth kinetics without compromising their nature.

Mesenchymal stem cells inhibit proliferation of lymphoid origin haematopoietic tumour cells by inducing cell cycle arrest

We have previously shown that mesenchymal stem cells (MSC) inhibit tumour cell proliferation, thus promising a novel therapy for treating cancers. In this study, MSC were generated from human bone marrow samples and characterised based on standard immunophenotyping. When MSC were co-cultured with BV173 and Jurkat tumour cells, the proliferation of tumour cells were profoundly inhibited in a dose dependent manner mainly via cell to cell contact interaction. Further cell cycle analysis reveals that MSC arrest tumour cell proliferation in G0/G1 phase of cell cycle thus preventing the entry of tumour cells into S phase of cell cycle.

Osteonecrosis of the jaw after oral bisphosphonate for osteoporosis

Bisphosphonates are a common treatment for osteoporosis. Osteonecrosis of the jaw has been associated with the use of bisphosphonates, usually when they have been used parenterally to treat malignancies. Cases associated with oral bisphosphonate as a treatment for osteoporosis are less frequent. We describe two patients exhibiting the clinical manifestations of bisphosphonate-associated osteonecrosis of the jaw. A brief review of the literature on the incidence, possible risk factors, and practice guidelines is also presented.

Cord blood-derived mesenchymal stem cell does not stimulate nor inhibits T lymphocytes activation

The immune modulatory properties of mesenchymal stem cell (MSC) had brought a new insight in cell-based neotherapy. However, recent works of MSC are focused exclusively on bone marrow-derived MSC. We evaluated the immunogenicity of cord blood-derived MSC (CB-MSC) on T lymphocytes. Human peripheral blood mononuclear cells (PBMC) were prepared by density gradient separation and culture with the presence or absence of CB-MSC. PBMC were collected for activation analysis by flow cytometry at 24-, 48-, and 72- hours. The results showed that, CB-MSC does not stimulate nor inhibit T lymphocyte activation.

Interstitial carbonic anhydrase (CA) activity in brain is attributable to membrane-bound CA type IV

We tested the hypothesis that extracellular membrane-bound carbonic anhydrase (CA) type IV is responsible for the regulation of interstitial pH (pH(o)) transients in brain. Rat hippocampal slices were incubated in phosphatidylinositol-specific phospholipase C (PI-PLC), which cleaves the link of CA IV to the external face of plasma membranes. Then evoked alkaline pH(o) shifts were studied in a recording chamber, using pH microelectrodes. Incubation fluid was saved for later analysis. The ability to buffer a rapid alkaline load was reduced markedly in PI-PLC-treated tissue as compared with adjacent, paired control slices. The effect of benzolamide (a poorly permeant CA inhibitor) on evoked pH(o) shifts was diminished greatly in the PI-PLC-treated tissue, consistent with the washout of interstitial CA. Treatment of the incubation fluid with SDS abolished nearly all of the CA activity in fluid from controls, whereas an SDS-insensitive component remained in the fluid from PI-PLC-treated slices. These data suggested that CA type II (which is blocked by SDS) leaked from injured glial cells in both slice preparations, whereas CA type IV (which is insensitive to SDS) was liberated selectively into the fluid from PI-PLC-treated tissue. Western blot analysis was consistent with this interpretation, demonstrating a predominance of CA IV in the incubation fluid from PI-PLC-treated tissue and variable amounts of CA II in fluid from PI-PLC-treated and control slices. These results demonstrate that interstitial CA activity brain is attributable principally to membrane-bound CA IV.

Modulation of spreading depression by changes in extracellular pH

Spreading depression (SD) and related phenomena have been implicated in hypoxic-ischemic injury. In such settings, SD occurs in the presence of marked extracellular acidosis. SD itself can also generate changes in extracellular pH (pH(o)), including a pronounced early alkaline shift. In a hippocampal slice model, we investigated the effect of interstitial acidosis on the generation and propagation of SD in the CA1 stratum radiatum. In addition, a carbonic anhydrase inhibitor (benzolamide) was used to decrease buffering of the alkaline shift to investigate its role in the modulation of SD. pH(o) was lowered by a decrease in saline HCO(3)(-) (from 26 to 13 to 6.5 mM at 5% CO(2)), or by an increase in the CO(2) content (from 5 to 15% in 26 mM HCO(3)(-)). Recordings with pH microelectrodes revealed respective pHo values of 7.23 +/- 0. 13, 6.95 +/- 0.10, 6.67 +/- 0.09, and 6.97 +/- 0.12. The overall effect of acidosis was an increase in the threshold for SD induction, a decrease in velocity, and a shortened SD duration. This inhibition was most pronounced at the lowest pH(o) (in 6.5 mM HCO(3)(-)) where SD was often blocked. The effects of acidosis were reversible on return to control saline. Benzolamide (10 microM) caused an approximate doubling of the early alkaline shift to an amplitude of 0.3-0.4 U pH. The amplified alkalosis was associated with an increased duration and/or increased velocity of the wave. These effects were most pronounced in acidic media (13 mM HCO(3)(-)/5% CO(2)) where benzolamide increased the SD duration by 55 +/- 32%. The initial velocity (including time for induction) and propagation velocity (measured between distal electrodes) were enhanced by 35 +/- 25 and 26 +/- 16%, respectively. Measurements of [Ca(2+)](o) demonstrated an increase in duration of the Ca(2+) transient when the alkaline shift was amplified by benzolamide. The augmentation of SD caused by benzolamide was blocked in media containing the N-methyl-D-aspartate (NMDA) receptor antagonist DL-2-amino-5-phosphonovaleric acid. These data indicate that the induction and propagation of SD is inhibited by a fall in baseline pH characteristic of ischemic conditions and that the early alkaline shift can remove this inhibition by relieving the proton block on NMDA receptors. Under ischemic conditions, the intrinsic alkalosis may therefore enable SD and thereby contribute to NMDA receptor-mediated injury.

Activity-dependent pH shifts in hippocampal slices from normal and carbonic anhydrase II-deficient mice

The type II isoform of carbonic anhydrase is abundant in astrocytes and oligodendroglia. To explore whether the expression of the type II isoform is required for interstitial carbonic anhydrase activity, we studied extracellular pH transients in hippocampal slices from mutant mice devoid of carbonic anhydrase type II and from wild-type littermates. Stimulation of the Schaffer collateral afferents evoked similar extracellular pH transients in the CA1 stratum pyramidale, consisting of a predominant alkaline shift and little or no subsequent acidosis. After 5-s stimulus trains at 10 Hz, alkaline shifts were not significantly different in carbonic anhydrase II-deficient and wild-type preparations, averaging 0.09 +/- 0.04 and 0.08 +/- 0.04 unit pH, respectively. Addition of 1.5 microM benzolamide amplified the alkaline shifts by 385 +/- 146 and 345 +/- 75% in the mutant and wild-type preparations, respectively. Dose response studies with benzolamide displayed similar sensitivity to this carbonic anhydrase inhibitor over a concentration range of 0. 03-10 microM. These data indicate that interstitial carbonic anhydrase activity is effectively unaltered in brains devoid of carbonic anhydrase type II. The results are consistent with the interpretation that a distinct extracellular isoform of carbonic anhydrase exists in brain.

Extracellular pH changes and accompanying cation shifts during ouabain-induced spreading depression

Interstitial ionic shifts that accompany ouabain-induced spreading depression (SD) were studied in rat hippocampal and cortical slices in the presence and absence of extracellular Ca(2+). A double-barreled ion-selective microelectrode specific for H(+), K(+), Na(+), or Ca(2+) was placed in the CA1 stratum radiatum or midcortical layer. Superfusion of 100 microM ouabain caused a rapid, negative, interstitial voltage shift (2-10 mV) after 3-5 min. The negativity was accompanied by a rapid alkaline transient followed by prolonged acidosis. In media containing 3 mM Ca(2+), the alkalosis induced by ouabain averaged 0.07 +/- 0.01 unit pH. In media with no added Ca(2+) and 2 mM EGTA, the alkaline shift was not significantly different (0.09 +/- 0.02 unit pH). The alkaline transient was unaffected by inhibiting Na(+)-H(+) exchange with ethylisopropylamiloride (EIPA) or by blocking endoplasmic reticulum Ca(2+) uptake with thapsigargin or cyclopiazonic acid. Alkaline transients were also observed in Ca(2+)-free media when SD was induced by microinjecting high K(+). The late acidification accompanying ouabain-induced SD was significantly reduced in Ca(2+)-free media and in solutions containing EIPA. The ouabain-induced SD was associated with a rapid but relatively modest increase in [K(+)](o). In the presence of 3 mM external Ca(2+), the mean peak elevation of [K(+)](o) was 12 +/- 0.62 mM. In Ca(2+)-free media, the elevation of [K(+)](o) had a more gradual onset and reached a significantly larger peak value, which averaged 22 +/- 1.1 mM. The decrease in [Na(+)](o) that accompanied ouabain-induced SD was somewhat greater. The [Na(+)](o) decreased by averages of 40 +/- 7 and 33 +/- 3 mM in Ca(2+) and Ca(2+)-free media, respectively. In media containing 1.2 mM Ca(2+), ouabain-induced SD was associated with a substantial decrease in [Ca(2+)](o) that averaged 0.73 +/- 0. 07 mM. These data demonstrate that in comparison with conventional SD, ouabain-induced SD exhibits ion shifts that are qualitatively similar but quantitatively diminished. The presence of external Ca(2+) can modulate the phenomenon but is irrelevant to the generation of the SD and its accompanying alkaline pH transient. Significance of these results is discussed in reference to the propagation of SD and the generation of interstitial pH changes.

Endogenous pH shifts facilitate spreading depression by effect on NMDA receptors

Rapid extracellular alkalinizations accompany normal neuronal activity and have been implicated in the modulation of N-methyl-D-aspartate (NMDA) receptors. Particularly large alkaline transients also occur at the onset of spreading depression (SD). To test whether these endogenous pH shifts can modulate SD, the alkaline shift was amplified using benzolamide, a poorly permeant inhibitor of interstitial carbonic anhydrase. SD was evoked by microinjection of 1.2 M KCl into the CA1 stratum radiatum of rat hippocampal slices and recorded by a proximal double-barreled pH microelectrode and a distal potential electrode. In Ringer solution of pH 7.1 containing picrotoxin (but not at a bath pH of 7.4), addition of 10 microM benzolamide increased the SD alkaline shift from 0.20 +/- 0.07 to 0.38 +/- 0.17 unit pH (means +/- SE). This was correlated with a significant shortening of the latency and an increase in the conduction velocity by 26 +/- 16%. In the presence of the NMDA receptor antagonist DL-2-amino-5-phosphonovaleric acid (APV), benzolamide still amplified the alkaline transient, however, its effect on the SD latency and propagation velocity was abolished. The intrinsic modulation of SD by its alkaline transient may play an important role under focal ischemic conditions by removing the proton block of NMDA receptors where interstitial acidosis would otherwise limit NMDA receptor activity.

Activity-evoked extracellular pH shifts in slices of rat dorsal lateral geniculate nucleus

Activity-dependent extracellular pH shifts were studied in slices of the rat dorsal lateral geniculate nucleus (dLGN) using double-barreled pH-sensitive microelectrodes. In 26 mM HCO3--buffered media, afferent activation (10 Hz, 5 s) elicited an early alkaline shift of 0.04+/-0.02 pH units associated with a later, slow acid shift of 0.05+/-0.03 pH units. Extracellular pH shifts in the ventral lateral geniculate nucleus were rare, and limited to acidifications of approximately 0.02 pH units. The alkaline shift in the dLGN increased in the presence of benzolamide (1-2 microM), an extracellular carbonic anhydrase inhibitor. The mean alkaline shift in benzolamide was 0.10+/-0.05 pH units. In 26 mM HEPES-buffered saline, the alkaline response averaged 0.09+/-0.03 pH units. The alkaline shifts persisted in 100 microM picrotoxin (PiTX) but were blocked by 25 microM CNQX/50 microM APV. If stimulation intensity was raised in the presence of CNQX/APV, a second alkalinization arose, presumably due to direct activation of dLGN neurons. The direct responses were amplified by benzolamide, and blocked by either 0 Ca2+/EGTA, Cd2+ or TTX. In 0 Ca2+, addition of 500 microM-5 mM Ba2+ restored the alkalosis. Alkaline shifts evoked with extracellular Ba2+ were larger and faster than those elicited by equimolar Ca2+. In summary, synchronous activation in the dLGN results in an extracellular H+ sink, via a Ca2+-dependent mechanism, similar to activity-dependent alkaline shifts in hippocampus.

Presynaptic injection of syntaxin-specific antibodies blocks transmission in the squid giant synapse

A polyclonal antibody, raised against the squid (Loligo pealei) syntaxin I, inhibited Ca2+-dependent interaction of syntaxin with synaptotagmin C2A domain in vitro. Presynaptic injection of the anti-Loligo syntaxin IgG into the squid giant synapse blocked synaptic transmission without affecting the presynaptic action potential or the voltage-gated calcium current responsible for transmitter release. Repetitive presynaptic stimulation produced a gradual decrease in the amplitude of the postsynaptic potential as the synaptic block progressed, indicating that the antibody interferes with vesicular fusion. Confocal microscopy of the fluorescein-labelled anti-Loligo syntaxin IgG showed binding at the synaptic active zone, while ultrastructurally, an increase in synaptic vesicular numbers in synapses blocked when this antibody was observed. These results implicate syntaxin in the vesicular fusion step of transmitter release in concert with synaptotagmin.

Attitudes of the Singapore public to actions suggesting child abuse

OBJECTIVE

The aim was to ascertain the views of the Singapore public on the acceptability of actions of an abusive nature.

METHOD

In-depth interviews were carried out with 401 randomly sampled respondents in relation to a range of actions. Questions were asked concerning the acceptability of 18 actions, whether circumstances might justify eight of them, how respondents felt about reporting child abuse and whether they could recall any case they had come across.

RESULTS

Respondents strongly disapproved of sexually motivated acts, and were more disapproving of physical abuse or neglect than of emotional abuse or neglect. Circumstances did affect how the less extreme actions were viewed. Respondents supported reporting child abuse, but were somewhat against mandatory reporting. They were able to recall details of a number of possible cases.

CONCLUSION

We argue that definitions of child abuse should be general and not tied to specific actions, since the effects of actions may vary across cultures, and should be treated as an empirical matter. This allows a research agenda that focuses on the consequences of actions rather than issues of definition.

Ondansetron for prevention of postoperative nausea and vomiting following minor oral surgery: a double-blind randomized study

The efficacy and safety of ondansetron in preventing postoperative nausea and vomiting following minor oral surgery was evaluated in a prospective randomized double-blind study. Of a total of seventy-seven patients, randomly 38 had 4 mg of ondansetron and 39 had normal saline as placebo intravenously immediately prior to induction of anaesthesia. A standard general anaesthetic with thiopentone, suxamethonium, fentanyl, nitrous oxide and isoflurane was employed. Postoperatively nausea was assessed verbally and on a visual analog scale at 1, 4 and 24 hours from the time of awakening. Episodes of vomiting were recorded. Eight patients (21.1%) in the ondansetron group compared to 19 (48.7%) in the placebo group had nausea (P < 0.05) and 1 (2.6%) in the ondansetron group compared with 9 (23.1%) in the placebo group vomited (P < 0.05). Patients who vomited twice or more and the number who required a rescue antiemetic were significantly fewer in the ondansetron group (P < 0.05). Cardiovascular parameters were stable and showed no significant difference in the two groups. There were no significant adverse effects that could be directly attributable to ondansetron.

A comparison of patient and anaesthetist controlled midazolam sedation for dental surgery

Thirty healthy Hong Kong Chinese patients between the ages of 15 and 31 years with bilaterally impacted lower third molar teeth, scheduled for surgical removal were studied. All the patients presented twice (for the right and left sides) and received, on separate occasions, patient or anaesthetist-controlled midazolam sedation allocated using a randomised, crossover design. Both techniques provided reliable sedation with verbal contact maintained, minimal changes in respiratory and cardiovascular function, good operating conditions and a high degree of patient satisfaction. The majority of patients (67%) thought they could sedate themselves better on a subsequent visit and were confident that they could do this more satisfactorily than the anaesthetist. An almost equal number preferred patient (n = 12) or anaesthetist (n = 13) controlled sedation, with the remainder having no preference. The total dose of midazolam was very similar in the two groups, 5.3 (SD 2.4) mg and 5.0 (SD 1.1) mg for patient and anaesthetist controlled sedation respectively.

Characterization of L-glutamate and kainate binding sites in the brain of a freshwater fish, Telapilia monsanbica

[3H]Kainate and L-[3H]glutamate binding sites in a rich source of kainate binding sites, fish brain, have been thoroughly analysed here for the purpose of studying the correlation between kainate binding sites and L-glutamate receptors in vertebrate CNS. The brain of a freshwater fish, Telapilia monsanbica, was found to contain three types of kainate binding sites: Type 1 sites (Kd = 1050 +/- 380 microM, Bmax = 4 +/- 4 pmol/mg), Type 2 sites (Kd = 133 +/- 20 nM, Bmax = 190 +/- 20 pmol/mg), and Type 3 sites (Kd = 23 +/- 15 nM, Bmax = 28 +/- 19 pmol/mg). The dissociation constants of L-glutamate to Type 1, 2 and 3 sites were, respectively, 0.28 +/- 0.04, 5.5 +/- 0.2 and 137 +/- 28 microM. Pharmacological characterization of these binding sites showed that Type 1 and 2 sites, respectively, corresponded to N-methyl-D-aspartate-subtype L-glutamate receptors and non-N-methyl-D-aspartate L-glutamate receptors. Autoradiographic studies showed that Type 1 and 2 sites were distributed widely in fish brain, indicating the involvement of L-glutamate receptors in various brain functions. Type 3 sites, on the other hand, were relatively insensitive to most endogenous amino acids and were only found in the molecular layer of cerebellum and torus longitudinalis. Type 3 sites possibly representing a distinctive class of receptor has been suggested by the results.