0491 Changes in Insomnia Symptoms are Associated with Improvements in Chronic Pain

Introduction

Depression and anxiety is known to associated with insomnia. Chronic pain is also well known to be associated with insomnia. However, relationship among insomnia and anxiety and depression is not well understood. Here We conducted a retrospective cohort study whether improvement insomnia could affect chronic pain release.

Methods

Patients with chronic pain suffering for more than three months, who first visited in our pain management clinic in Shiga University of Medical Science, Otsu, Japan during 09/25/2013-01/26/2017, were included in this study. Patients were asked to complete the same questionnaire at their first visit and six-month later.We designate pain release as 30% and over improvement in numerical rating scale (NRS) for pain release.We define improvement insomnia as subjects with Athene insomnia scale (AIS) ≥6 at the first visit became AIS <6 six-month later.We also evaluated patients’ psychotic conditions by Questionnaires for anxiety and depression: HADS (Anxiety and depression) and PCS (Pain Catastrophizing score) for negative cognition, respectively. We conducted logistic regression analysis as for dependent variable was pain release.

Results

Characteristics data: n=47, mean age: 53.53±15.45, male rate: 45%, BMI: 22.81±3.49, NRS: 5.45±1.85, AIS: 8.94±2.73, HADSA: 6.04±2.57, HADSD: 6.06±2.64, PCS: 30.70±8.70, housemate rate: 81%, more than junior college graduated level: 53%, employment rate: 62%, annual income over 4oo million yen /year: 62%, antidepressant use; 26%, benzodiazepine use:11%.Logistic Regression odds ratio (OR) with 95% confidence intervals (95%CI) for relationship of improvement insomnia and not with chronic pain were unadjusted OR: 3.600 (95%CI: 1.007-12.865) and adjusted OR: 3.078 (95%CI 0.779-12.161) (adjust for PCS.)

Conclusion

We showed improvement in insomnia can affect pain release in the pain therapy, and PCS improvement may be also association with chronic pain release.

Support

 

0453 Longitudinal Relationship Between Insomnia and Work Productivity in Japanese City Government Employees

Introduction

“Presenteeism” refers to the decrease in productivity in employees who are present but not functioning at full capacity due to illness or other medical conditions. It is reported that the cost of presenteeism to businesses is 10 times higher than absenteeism (away from work due to illness or disability). Relative presenteeism is a ratio of actual performance to the performance of most workers at the same job. We analyzed effects of insomnia and depression two years before on presenteeism in a Japanese working population.

Methods

Questionnaire survey was conducted as a part of a cohort study named “Night in Japan Home Sleep Monitoring Study (NinJaSleep Study)” in 2016 and 2018. Participants were the city government employees in a rural city in Shiga prefecture, Japan. Presenteeism, insomnia and depression were analyzed by WHO-HPQ (Health and Work Performance Questionnaire), ISI (insomnia severity index) and PHQ-9 (Patient Depression Questionnaire), respectively. Pearson correlation coefficient analyses were performed to determine the strength of the association between two variables. Logistic regression was performed to estimate the odds ratio (OR) and 95% confidence interval (CI) of poor relative presenteeism (the lowest tertile of the relative presenteeism scores) after 2-year follow up.

Results

1143 subjects (participation rate: 61.7%, 36.7% male, 44.5±11.4 years, BMI: 22.3±3.30) participated in both 2016 and 2018. Participants with poor productivity (poor relative presenteeism) in 2018 was significantly associated with ISI in 2016 (OR: 1.050, 95%CI: 1.010-1.090, p=0.013) but not with PHQ-9 in 2016 (OR: 1.008, 95%CI: 0.972-1.045, p=0.664) after adjusting for age, gender and BMI. Positive correlation was found between the total score of ISI and item 3 of PHQ-9 which asks insomnia or hypersomnia symptom (r=0.6122, P<0.0001).

Conclusion

Insomnia may be an independent risk factor for poor presenteeism. ISI may be useful to predict poor productivity in the future.

Support

Supported in part by a research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme Corp. / MSD K.K. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp. / MSD K.K.”

Association between apolipoprotein E epsilon4 and sleep-disordered breathing in adults

CONTEXT

Apolipoprotein E epsilon4(ApoE epsilon4) is a well-known risk factor for Alzheimer disease and cardiovascular disease. Sleep-disordered breathing occurs in Alzheimer disease patients and increases risks for cardiovascular disease. Complex interactions among sleep, brain pathology, and cardiovascular disease may occur in ApoE epsilon4 carriers.

OBJECTIVE

To study whether genetic variation at the level of ApoE is associated with sleep-disordered breathing or sleep abnormalities in the general population.

DESIGN, SETTING, AND PARTICIPANTS

Ongoing longitudinal cohort study of sleep disorders at a US university beginning in 1989, providing a population-based probability sample of 791 middle-aged adults (mean [SD] age, 49 [8] years; range, 32-68 years).

MAIN OUTCOME MEASURE

Nocturnal polysomnography to evaluate apnea-hypopnea index.

RESULTS

The probability of moderate-to-severe sleep-disordered breathing (apnea-hypopnea index >/=15%) was significantly higher in participants with epsilon4, independent of age, sex, body mass index, and ethnicity (12.0% vs 7.0%; P =.003). Mean (SEM) apnea-hypopnea index was also significantly higher in participants with ApoE epsilon4 (6.5 [0.6] vs 4.8 [0.3]; P =.01). These effects increased with the number of ApoE epsilon4 alleles carried.

CONCLUSIONS

A significant portion of sleep-disordered breathing is associated with ApoE epsilon4 in the general population.

Roles of GABAergic inhibition and NMDA receptor subunits in the spatio-temporal integration in the cerebellar cortex of mice

The cerebellar cortex consists of relatively small numbers of identified neuronal types, which form simple and well-defined layers. However, a direct high-resolution demonstration of spatio-temporal pattern of information transmission there has been lacking. Using an optical recording technique with a membrane-potential sensitive dye, we studied the spatio-temporal pattern of excitation propagation induced by white matter stimulation in the slice preparations. We focused on physiological roles of inhibitory synapses and N-methyl-D-aspartate (NMDA) receptors. White matter stimulation induced postsynaptic long-lasting depolarization in the granular layer and transient depolarization in the molecular layer, respectively. Inhibitory synapses modestly suppressed the amplitude of slow depolarization in the granular layer, whereas they exerted powerful lateral inhibition in the molecular layer. Using mutant mice deficient in NMDA receptor subunits NR2A and/or NR2C, we also demonstrated that the NR2A and NR2C subunits expressed in granule neurons contribute to the early and late components of slow depolarization respectively, and that both subunits cooperatively support the temporal summation of depolarization. Taking into account the anatomical organization of the cerebellar cortex, these results might suggest that the granular layer is specialized more in the temporal integration of input signals and the molecular layer in the spatial integration.

N-methyl-D-aspartate receptor subtype 2C is not involved in circadian oscillation or photoic entrainment of the biological clock in mice

Ishida et al. [1994: Neurosci Lett 166: 211-215] reported the circadian change of N-methyl-D-aspartate (NMDA) receptor subtype 2C mRNA and photic induction of this receptor's mRNA in the suprachiasmatic nucleus (SCN). Therefore, we investigated the role of NMDA receptor subtypes in the biological clock using NMDA receptor 2A (NR2A)- or 2C (NR2C)-deficient mice. However, NR2C-/- mice showed normal light-dark (LD)-entrained locomotor activity rhythms and free-running rhythms under constant darkness and also exhibited normal reentrainment to 6-hr LD shifts and phase delays with single light pulses. Thus, present results demonstrated no significant NR2C contribution to circadian oscillation and photic entrainment, even though expression of NR2C mRNA was highly observed in the SCN. On the other hand, the period of the free-running activity rhythm in NR2A-/- mice but not NR2C-/- mice was slightly longer than that in wild-type mice in spite of low expression of NR2A in the SCN. Furthermore, reentrainment to an LD advance in NR2A-/- mice was slower under low-intensity light conditions. Thus, we suggest that NR2A plays a role in determining the behavioral state that affects the circadian rhythm. In order to elucidate the role of NR2A and NR2C in the SCN, we examined NMDA-induced Ca(2+) elevations in the SCN of mutant mice using a Ca(2+) imaging method. A partial reduction in Ca(2+) elevation was observed in both NR2A-/- and NR2C-/- mice when high concentrations (100 or 300 microM) of NMDA were applied. The present results suggest that NR2A plays a weak role in oscillation or entrainment of the biological clock, and that NR2C does not participate in the functions of circadian oscillation and light entrainment.

Close linkage between calcium/calmodulin kinase II alpha/beta and NMDA-2A receptors in the lateral amygdala and significance for retrieval of auditory fear conditioning

The general mechanism underlying memory and learning is an area under intense investigation and debate, yet this mechanism still remains elusive. Auditory fear conditioning (when a tone is paired with a foot shock) is a simple associative form of learning for which many mechanistic details are known. Lesions of the lateral/basolateral nuclei of the amygdala result in the selective impairment of fear conditioning, indicating that this is a key region for this type of learning. Fear conditioning induces a lasting synaptic potentiation in the lateral nuclei of the amygdala. In addition, recent results from several laboratories suggest that N-methyl-D-aspartate (NMDA) receptor activation in the amygdala is required for the acquisition and expression of cue-conditioned fear responses using several kinds of antagonists. Little is known, however, about the signal transduction pathway and molecular substrate underlying fear conditioning. Here we use NMDA receptor-deficient mice to demonstrate that calmodulin-dependent kinase II, CaMKIIbeta, and CaMKIIalpha activation involves the NR2A subunit in the lateral/basolateral amygdala during memory retrieval following auditory fear conditioning. These results suggest that auditory fear conditioning involves a close linkage between NMDA2A receptors and the CaMKII cascade.

The sleep disorder canine narcolepsy is caused by a mutation in the hypocretin (orexin) receptor 2 gene

Narcolepsy is a disabling sleep disorder affecting humans and animals. It is characterized by daytime sleepiness, cataplexy, and striking transitions from wakefulness into rapid eye movement (REM) sleep. In this study, we used positional cloning to identify an autosomal recessive mutation responsible for this sleep disorder in a well-established canine model. We have determined that canine narcolepsy is caused by disruption of the hypocretin (orexin) receptor 2 gene (Hcrtr2). This result identifies hypocretins as major sleep-modulating neurotransmitters and opens novel potential therapeutic approaches for narcoleptic patients.

Construction and characterization of an eightfold redundant dog genomic bacterial artificial chromosome library

A large insert canine genomic bacterial artificial chromosome (BAC) library was built from a Doberman pinscher. Approximately 166,000 clones were gridded on nine high-density hybridization filters. Insert analysis of randomly selected clones indicated a mean insert size of 155 kb and predicted 8.1 coverage of the canine genome. Two percent of the clones were nonrecombinant. Chromosomal fluorescence in situ hybridization studies of 60 BAC clones indicated no chimerism. The library was hybridized with dog PCR products representing eight genes (ADA, TNFA, GCA, MYB, HOXA, GUSB, THY1, and TOP1). The resulting positive clones were characterized and shown to be compatible with an eightfold redundant library.

[Induction of noradrenergic supersensitivity following cordotomy in neonatal rat spinal motoneurons]

Patients with spinal cord lesions frequently show autonomic hyperreflexia. The mechanism of autonomic hyperreflexia has been thought to be an acute general autonomic overactivity in response to cutaneous or visceral stimuli, but it remains uncertain. Several kinds of experiments suggest that amplified spinal sympathetic reflexes in the decentralized cord are attributable to the denervation supersensitivity of denervated neurons, which is a well-known phenomenon in denervated muscle fibers. In the present study, changes in the supersensitivity of motoneurons after cordotomy were studied in the spinal cord of neonatal rats. Responses to bath-applied noradrenaline (NA) were recorded from a ventral root of the isolated spinal cord of 6-day-old rats. In normal spinal cords, NA induced depolarization in motoneurons dose-dependently. alpha 1-antagonist prazosin (3 microM) inhibited the deporalization induced by NA, and alpha 2-antagonist rauwolscine (1 microM) potentiated it. In one group of rats, cordotomy was performed 4 days after birth by complete transection of the spinal cord at vertebrate 8th-10th thoracic level, and NA response was examined two days later (when they were 6 days old). In cordotomized rats, NA-induced depolarization was increased with respect to both amplitude and duration. alpha 1- as well as alpha 2-antagonists inhibited the NA response in the spinalized rats. Especially, both antagonists shortened the duration of NA response as compared to normal level. It is concluded that the denervation supersensitivity to NA appears 2 days after cordotomy in the spinal motoneurons of neonatal rats and that the supersensitivity to NA is attributable to the upregulation of both alpha 1- and alpha 2-adrenoceptors on the motoneurons, indicating that a new type of alpha 2-adrenoceptor function appears.

Genetic studies in the sleep disorder narcolepsy

Narcolepsy is a chronic neurologic disorder characterized by excessive daytime sleepiness and abnormal manifestations of REM sleep including cataplexy, sleep paralysis, and hypnagogic hallucinations. Narcolepsy is both a significant medical problem and a unique disease model for the study of sleep. Research in human narcolepsy has led to the identification of specific HLA alleles (DQB1*0602 and DQA1*0102) that predispose to the disorder. This has suggested the possibility that narcolepsy may be an autoimmune disorder, a hypothesis that has not been confirmed to date. Genetic factors other than HLA are also likely to be involved. In a canine model of narcolepsy, the disorder is transmitted as a non-MHC single autosomal recessive trait with full penetrance (canarc-1). A tightly linked marker for canarc-1 has been identified, and positional cloning studies are under way to isolate canarc-1 from a newly developed canine genomic BAC library. The molecular cloning of this gene may lead to a better understanding of sleep mechanisms, as has been the case for circadian rhythms following the cloning of frq, per, and Clock.

Attenuation of focal cerebral infarct in mice lacking NMDA receptor subunit NR2C

Neuronal death following cerebral vascular occlusion may be caused in part by the action of glutamate acting through the NMDA receptor. Here we demonstrate that gene disruption of the NR2C subunit of the NMDA receptor attenuates focal cerebral ischemic injury after permanent MCA occlusion, and that a low level of NR2C is expressed and active in the cerebral cortex. NR2C-deficient mice do not show impairment of motor coordination or motor learning. Therefore the development of drugs selectively inhibiting NR2C may prove beneficial in the treatment of stroke and traumatic brain injuries.

Conditioned eyeblink response is impaired in mutant mice lacking NMDA receptor subunit NR2A

NMDA receptor channels, heteromeric assemblies of subunits with diverse subtypes, play critical roles in various kinds of synaptic plasticity underlying learning and memory. To elucidate the roles of subunits NR2A and NR2C in motor learning, we investigated acquisition of the classically conditioned eyeblink response in a delayed-conditioning paradigm by gene knockout mice. Mutant mice lacking NR2C exhibited no significant defect; however, early acquisition of the task was impaired in mutant mice lacking NR2A or both NR2A and NR2C. Based on the distribution of these subunits in brain, these results indicate that acquisition of the conditioned response does not depend on NMDA receptors in the cerebellar cortex, but that its early acquisition involves the hippocampus and/or cerebellar deep nuclei.

[Effects of toborinone on systemic circulation in patients under general anesthesia]

Patients with suppressed systemic circulation under general anesthesia received a 20-minute continuous infusion of toborinone at a rate of 5, 10, or 15 micrograms.kg-1.min-1, and the efficacy and safety of the drug were evaluated. Toborinone increased cardiac index (CI) and stroke volume index (SVI) dose-dependently, with significant increases at 10 and 15 micrograms.kg-1.min-1. An increase in CI was observed from 10 minutes after the start of infusion, with a return to the baseline value at 20-30 minutes after the completion of infusion. Toborinone did not affect heart rate at any dose tested, but the drug tended to decrease mean pulmonary arterial pressure, pulmonary capillary wedge pressure, and right atrial pressure. Mean arterial blood pressure tended to decrease after the start of infusion at all doses tested, and was significantly decreased at 20 minutes after the start of infusion at 10 and 15 micrograms.kg-1.min-1. Systemic vascular resistance and pulmonary vascular resistance decreased at all doses tested. T-wave amplitude on electrocardiaogram (ECG) and oxygen partial pressure in arterial blood decreased at 10 and 15 micrograms.kg-1.min-1. Toborinone increases cardiac output and decreases pre-load and after-load with no effects on heart rate, and, therefore, is thought to be a positive inotropic agent useful in the treatment of circulatory insufficiency. Due care should be exercised to monitor blood pressure, ECG, and arterial blood gas parameters of the patients. The effects of toborinone need to be further investigated in patients with complicated cardiac diseases under general anesthesia and in patients with circulatory insufficiency after surgery, including patients following extracorporeal circulation.

Continuous brachial plexus infusion of butorphanol-mepivacaine mixtures for analgesia after upper extremity surgery

We have recently reported that continuous administration of butorphanol into the brachial plexus neurovascular sheath provided superior analgesia compared with that obtained with continuous i.v. administration. Furthermore, we found that analgesia was most pronounced when a mixture of mepivacaine and butorphanol was given and that butorphanol alone ranked next. In this study, we increased the dose of butorphanol, compared with that used in our previous reports, and an initial bolus dose of butorphanol was administered into the brachial plexus neurovascular sheath just after surgery had ended. Thereafter, postoperative pain relief was estimated. In patients undergoing upper extremity surgery with continuous axillary brachial plexus block, group A received a bolus of 1 ml of physiological saline with 1.5% mepivacaine, 10 ml into the brachial plexus sheath followed by a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/ 72 h. Group B was given a bolus of butorphanol 1 mg (1 ml) with 1.5% mepivacaine, 10 ml into the brachial plexus sheath and a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/72 h. After operation, VAS scores did not differ between the two groups. The time to first use of supplementary analgesia did not differ significantly between the two groups and there were no significant differences in the number of patients who required supplementary analgesia. These results indicate that continuous butorphanol 2 mg day-1 with 0.5% mepivacaine provided sufficient postoperative analgesia after upper limb surgery.

Motor discoordination results from combined gene disruption of the NMDA receptor NR2A and NR2C subunits, but not from single disruption of the NR2A or NR2C subunit

NMDA receptors consist of two distinct classes of subunits. The NR1 subunit possesses all properties of the NMDA receptor-channel complex, whereas four NR2 subunits (NR2A-2D) potentiate and differentiate NMDA receptor responses by heteromeric assemblies with NR1. The mRNAs for the five NMDA receptor subunits are expressed in the cerebellum in a distinct temporospatial manner. To study functions of the NMDA receptors in the cerebellum, we generated knockout mice deficient in either NR2A or NR2C or both of these subunits. All three mutant mice developed normally and showed normal overall morphology of the cerebellum. The NMDA receptor-mediated components of EPSCs in granule cells, as assessed by whole-cell recordings of cerebellar slices, were reduced in NR2A- and NR2C-deficient mice and nearly abolished in mice lacking both NR2A and NR2C. The NR2A- and NR2C-deficient granule cells were different in the current-voltage relationship and time course of NMDA receptor responses. The NR2A and NR2C subunits thus contribute to distinct NMDA receptor-mediated excitatory transmission in mossy fiber-granule cell synapses in the mature cerebellum. Both NR2A- and NR2C-deficient mice showed no impaired movements in the motor coordination tasks tested. The mutant mice deficient in both NR2A and NR2C could also manage simple coordinated tasks, such as staying on a stationary or a slowly rotating rod, but failed more challenging tasks such as staying on a quickly rotating rod. These data demonstrate that the NMDA receptors play an active role in motor coordination.

Comparison of continuous brachial plexus infusion of butorphanol, mepivacaine and mepivacaine-butorphanol mixtures for postoperative analgesia

We have reported recently that continuous administration of butorphanol into the brachial plexus sheath provided analgesia of a quality superior to that of continuous i.v. administration. In the present study, we have compared postoperative pain relief produced by continuous infusion of one of three types of solution into the axillary sheath: opioid alone, local anaesthetic alone or a mixture of local anaesthetic and opioid. In patients undergoing upper extremity surgery with continuous axillary brachial plexus block, we injected one of the three solutions into the axillary neurovascular sheath: butorphanol 2 mg (group B), 0.5% mepivacaine alone (group M) and 0.5% mepivacaine-butorphanol (group MB); the volume of each solution was 50 ml, administered at a rate of 50 ml per 24 h. At 3 h after operation, visual analogue scale (VAS) scores were significantly higher in group M than in group MB (P < 0.01), and higher in group B than in group MB (P < 0.05).

[Changes in dementia rating scale scores of elderly patients with femoral neck fracture during perioperative period]

We evaluated changes in dementia rating scale scores in the revised version of Hasegawa's dementia scale (HDS-R), and rated dementia, 2 days before and 7 days after surgery in the elderly patients with femoral neck fracture. The 50 patients examined ranged in age from 70 years to 101 years. A perfect score in the HDS-R is 30 points, and a score below 20 points strongly suggests dementia. The results were as follows. In septuagenarian and octogenarian patients, the scale score was higher after surgery than the value before the surgery. Although the preoperative and postoperative scores of the patients who had been under epidural anesthesia were not significantly different, the score of patients who had been under general anesthesia was higher in the postoperative period than in the preoperative period. In octogenarian patients, there was a negative correlation between "postoperative score minus preoperative score" and "the number of the days from suffering fracture to surgery". These results showed that general anesthesia is more advantageous than epidural anesthesia from the viewpoint of the intellectual faculty in septuagenarian and octogenarian patients with femoral neck fracture, and it is within the bounds of possibility that the intellectual faculty may decline if an octogenarian patient is operated after a long delay from the occurrence of fracture. To prevent this decline, patients must be operated on as soon as possible.

[A case of atopic dermatitis treated with stellate ganglion block--the change of serum IgE and blood eosinophil levels]

Stellate ganglion block (SGB) therapy was tried on a patient with severe adult type atopic dermatitis. SGB was performed 102 times in total and clinical symptoms improved gradually. Serum IgE and blood eosinophil levels, which correlate with disease severity, increased gradually following repeated SGB. After a series of SGB was stopped, clinical symptoms became worse and serum IgE and blood eosinophil levels increased again. We conclude that although SGB is presumably one of the effective therapies for severe adult type atopic dermatitis, it might be difficult to improve atopic constitution entirely because the patient was not cured completely following repeated SGB.

IV compared with brachial plexus infusion of butorphanol for postoperative analgesia

In a randomized, double-blind, controlled study, we have compared two groups of patients receiving either continuous systemic i.v. or continuous brachial plexus infusion of butorphanol for analgesia after operations on the upper extremities. Twenty-two patients undergoing elective upper extremity surgery were allocated randomly to one of two groups to receive either butorphanol i.v. and saline injected into the brachial plexus sheath (i.v. group) or butorphanol injected into the brachial plexus sheath and saline i.v. (brachial plexus group). After surgery on the upper extremity under continuous axillary brachial plexus block, each patient received a continuous infusion of butorphanol either i.v. or into the brachial plexus sheath at a dose of 83.3 micrograms h-1. Concurrently, a saline infusion was given via the alternate route. Patients rated their pain on a 10-cm visual analogue scale (VAS). VAS scores in the two groups did not differ up to 6 h and 24 h after operation. From 9 h until 24 h after operation, pain scores were significantly higher in the i.v. group than in the brachial plexus group. The VAS score 9 h after operation was 3.3 (SD 2.7) in the i.v. group and 0.6 (0.9) in the brachial plexus group (P < 0.01); 12 h after operation 2.7 (1.8) in the i.v. group and 0.6 (0.9) in the brachial plexus group (P < 0.01); 18 h after operation 1.7 (1.0) in the i.v. group and 0.7 (1.0) in the brachial plexus group (P < 0.05); and 24 h after operation 3.2 (2.4) in the i.v. group and 0.7 (1.2) in the brachial plexus group (P < 0.01). We conclude that continuous injection of butorphanol into the brachial plexus sheath provided superior analgesia compared with continuous i.v. injection.

Molecular characterization of the family of the N-methyl-D-aspartate receptor subunits

cDNA clones for four different N-methyl-D-aspartate (NMDA) receptor subunits (NMDAR2A-NMDAR2D) were isolated through polymerase chain reactions followed by molecular screening of a rat brain cDNA library. These subunits are only about 15% identical with the key subunit of the NMDA receptor (NMDAR1) but are highly homologous (approximately 50% homology) with one another. They also commonly possess large hydrophilic domains at both amino- and carboxyl-terminal sides of the four putative transmembrane segments. NMDAR2A and NMDAR2C expressed individually in Xenopus oocytes showed no electrophysiological response to agonists. However, these subunits in combined expression with NMDAR1 markedly potentiated the NMDAR1 activity and produced functional variability in the affinity of agonists, the effectiveness of antagonists, and the sensitivity to Mg2+ blockade. Thus, NMDAR1 is essential for the function of the NMDA receptor, and multiple NMDAR2 subunits potentiate and differentiate the function of the NMDA receptor by forming different heteromeric configurations with NMDAR1. Northern blotting and in situ hybridization analyses revealed that the expressions of individual mRNAs for the NMDAR2 subunits overlap in some brain regions but are also specialized in many other regions. This investigation demonstrates the anatomical and functional differences of the NMDAR2 subunits, which provide the molecular basis for the functional diversity of the NMDA receptor.