Activity-dependent, stress-responsive BDNF signaling and the quest for optimal brain health and resilience throughout the lifespan.

During development of the nervous system, the formation of connections (synapses) between neurons is dependent upon electrical activity in those neurons, and neurotrophic factors produced by target cells play a pivotal role in such activity-dependent sculpting of the neural networks. A similar interplay between neurotransmitter and neurotrophic factor signaling pathways mediates adaptive responses of neural networks to environmental demands in adult mammals, with the excitatory neurotransmitter glutamate and brain-derived neurotrophic factor (BDNF) being particularly prominent regulators of synaptic plasticity throughout the central nervous system. Optimal brain health throughout the lifespan is promoted by intermittent challenges such as exercise, cognitive stimulation and dietary energy restriction, that subject neurons to activity-related metabolic stress. At the molecular level, such challenges to neurons result in the production of proteins involved in neurogenesis, learning and memory and neuronal survival; examples include proteins that regulate mitochondrial biogenesis, protein quality control, and resistance of cells to oxidative, metabolic and proteotoxic stress. BDNF signaling mediates up-regulation of several such proteins including the protein chaperone GRP-78, antioxidant enzymes, the cell survival protein Bcl-2, and the DNA repair enzyme APE1. Insufficient exposure to such challenges, genetic factors may conspire to impair BDNF production and/or signaling resulting in the vulnerability of the brain to injury and neurodegenerative disorders including Alzheimer's, Parkinson's and Huntington's diseases. Further, BDNF signaling is negatively regulated by glucocorticoids. Glucocorticoids impair synaptic plasticity in the brain by negatively regulating spine density, neurogenesis and long-term potentiation, effects that are potentially linked to glucocorticoid regulation of BDNF. Findings suggest that BDNF signaling in specific brain regions mediates some of the beneficial effects of exercise and energy restriction on peripheral energy metabolism and the cardiovascular system. Collectively, the findings described in this article suggest the possibility of developing prescriptions for optimal brain health based on activity-dependent BDNF signaling.

The hidden cost of organ sale.

The idea of establishing a market for organs is now the subject of unusual controversy. Proponents emphasize the concept of autonomy; opponents invoke fairness and justice. The controversy, however, has given sparse attention to what it would mean to society and medicine to establish a market in organs and to the intended and unintended consequences of such a practice. This article addresses these issues by exploring the tensions between 'extrinsic' and 'intrinsic' incentives, suggesting that donation might well decline were financial incentives introduced. It also contends that social relationship and social welfare policy would be transformed in negative ways and that a regulated market in organs would be extraordinarily difficult to achieve. Finally, it argues that organ sale would have a highly detrimental affect on medicine as a profession.

Focal cooling rapidly terminates experimental neocortical seizures.

The efficacy of surgical resection for epilepsy is considerably lower for neocortical epilepsy than for temporal lobe epilepsy. We have explored focal cooling with a thermoelectric (Peltier) device as a potential therapy for neocortical epilepsy. After creating a cranial window in anesthetized rats, we induced seizures by injecting artificial cerebrospinal fluid containing 4-aminopyridine (4-AP), a potassium channel blocker. Within 30 minutes of 4-AP injection, animals developed recurrent seizures (duration 85.7 +/- 26.2 seconds; n = 10 rats) that persisted for 2 hours. When a small Peltier device cooled the exposed cortical surface to 20-25 degrees C at seizure onset, the seizure duration was reduced to 8.4 +/- 5.0 seconds (n = 10 rats; p < 0.001). When the Peltier device was placed close to the cortical surface, but not allowed to make physical contact, there was no effect on seizure duration (104.3 +/- 20.7 seconds; p > 0.05 compared to control). Interestingly, the duration of uncooled seizures was reduced after we allowed the cortex to rewarm from prior cooling. Histological examination of the cortex after cooling has shown no evidence of acute or delayed neuronal injury, and blood pressure and temperature remained stable. It may be possible to use Peltier devices for cortical mapping or, when seizure detection algorithms improve, for chronic seizure control.

Rapid cooling aborts seizure-like activity in rodent hippocampal-entorhinal slices.

PURPOSE: As a preliminary step in the development of an implantable Peltier device to abort focal neocortical seizures in vivo, we have examined the effect of rapid cooling on seizures in rodent hippocampal-entorhinal slices. METHODS: Seizure-like discharges were induced by exposing the slices to extracellular saline containing 4-aminopyridine (50 micromol/L). RESULTS: When we manually activated a Peltier device that was in direct contact with the slice, seizures terminated within seconds of the onset of cooling, sometimes preceding a detectable decrease in temperature measured near the top of the slice. However, activation of the Peltier device did not stop seizures when slices were no longer in direct physical contact with the device, indicating that this was not a field effect. When cooling was shut off and temperature returned to 33 degrees C, bursting sometimes returned, but a longer-term suppressive effect on seizure activity could be observed. In two of our experiments, a custom computer program automatically detected seizure discharges and triggered a transistor-transistor logic pulse to activate the Peltier device. In these experiments, the Peltier device automatically terminated the slice bursting in less than 4 seconds. When the Peltier device was placed in contact with the normal, exposed cortex of a newborn pig, we found that the cortical temperature decreased rapidly from 36 degrees C to as low as 26 degrees C at a depth of 1.7 mm below the cooling unit. CONCLUSIONS: These experiments show that local cooling may rapidly terminate focal paroxysmal discharges and might be adapted for clinical practice.

Anti-aging medicine. 2. Efficacy and safety of hormones and antioxidants.

Little is known about the efficacy and safety of substances that are being promoted to consumers as "anti-aging" therapies. Hormones such as DHEA, human growth hormone, and testosterone tend to decline with aging, but the therapeutic value of replacing them to "normal" physiologic levels has not been substantiated by controlled clinical trials. The best source of antioxidants is a balanced diet, although older patients may benefit from vitamin E supplementation. Providing anti-aging medicine in the primary care setting means practicing good medicine. It means talking to patients who request these therapies and understanding why they want them and how much risk they're willing to take.

Anti-aging medicine. What makes it different from geriatrics?

The growth in popularity of so-called "anti-aging" medicine challenges physicians to examine their attitudes about aging. Does one define aging as a predisposition to pathology or as part of the life cycle? Is longevity without the chronic diseases associated with aging a realistic goal? Anti-aging modalities being prescribed by some practitioners include hormone replacement therapies, vitamin and mineral supplements, diet, and exercise. Although diet, exercise, and some vitamin and mineral supplements are well-recognized as preventive measures, unproven hormone, mega-vitamin, and herbal therapies are controversial. Both the patient and the physician bring biases and values to the discussion of anti-aging medicine, and that combination will influence the treatment decisions.

Reversible physiological alterations in sympathetic neurons deprived of NGF but protected from apoptosis by caspase inhibition or Bax deletion.

Cell death in nervous system development and in many neurodegenerative diseases appears to be apoptotic or programmed. Withdrawal of nerve growth factor (NGF) from cultures of superior cervical ganglia neurons (SCG) is an excellent model of programmed cell death (PCD), producing apoptosis within 24-48 h. This death can be prevented by treatment with caspase inhibitors or deletion of the proapoptotic Bax gene. Since inhibition of apoptosis is an attractive strategy for the therapy of many neurological diseases and little is known about the function of neurons when apoptosis has been aborted, we examined the electrophysiological properties of NGF-deprived SCG neurons from rats and mice, saved by the caspase inhibitor boc-aspartyl(OMe)fluoromethyl ketone (BAF) or by Bax deletion. Compared to NGF-maintained controls, the resting membrane potentials of BAF-saved neurons were depolarized by 9 mV and the action potentials were prolonged by over 50%. Nicotinic cholinergic current density was depressed by about 50%. Electrophysiological parameters returned to normal within 4 days after NGF restoration. Neurons from Bax-deficient mice were altered differently by NGF withdrawal. There were no detectable changes in resting or action potentials. However, nicotinic current density was reduced just as in BAF-saved rat neurons. There were no observable changes in the processes of individual neurons after 6 days of NGF deprivation in the presence of BAF. Our results indicate that neurons are physiologically altered during pharmacological inhibition of PCD, but fully recover after trophic support is returned.

Effects of anticonvulsant lactams on in vitro seizures in the hippocampal slice preparation.

Some 3,3-disubstituted 2-pyrrolidinones and 2-piperidinones (five- and six-membered ring lactams, respectively) possess potent in vivo anticonvulsant activity. In vitro these lactams potentiate GABA(A) receptor-mediated chloride currents, which is thought to be the mechanism by which they exert their therapeutic effects. However, the apparent affinity for these GABA(A) interactions is low: EC50s range from hundreds of micromolar to low millimolar values. In order to more completely characterize the activities of these compounds, it was necessary to know the concentrations required to curtail epileptiform activity in an intact neural network, and the mechanism by which this occurs. To address these questions, we used two methods of inducing ictal activity in hippocampal-entorhinal cortical slices: 4-aminopyridine (4-AP) and low Mg2+. We found that 3,3-diethyl-2-pyrrolidinone (diethyl-lactam) prevents seizure-like discharges with IC50s of 1.1 and 2.1 mM in the two models, respectively. These values are nearly identical to the EC50 value obtained in whole-cell studies of diethyl-lactam's GABA(A) receptor modulation. The addition of the GABA(A) antagonist picrotoxin to the low Mg2+ ACSF produced seizures which persisted during diethyl-lactam application. Neither 3-benzyl-3-ethyl-2-piperidinone (3-BEP) nor alpha-ethyl-alpha-methyl-gamma-thiobutyrolactone (alpha-EMTBL), two compounds which are similar to diethyl-lactam, but demonstrate picrotoxin-insensitive inhibition of voltage-dependent currents, diminished low Mg2+/picrotoxin seizure activity. Our results support the hypothesis that diethyllactam and related compounds exert their anticonvulsant activity primarily, if not exclusively, by modulating the GABA(A) receptor.

Mutations of the mitochondrial genome: clinical overview and possible pathophysiology of cell damage.

Mitochondria possess their own DNA and transcription and translation machinery for the synthesis of 13 protein subunits for the oxidative phosphorylation system, two rRNAs and 22 tRNAs. In 1988 the first human neurodegenerative diseases associated with mutations in the mitochondrial genome were described. The most recent biochemical and genetic research suggests that mitochondrial disorders are best categorized as: (i) primary mutations of the mitochondrial DNA, either sporadic or maternally inherited; (ii) nuclear mutations that result in alterations in mitochondrial DNA or intergenomic signalling defects; or (iii) Mendelian defects that affect the respiratory chain in the absence of mitochondrial DNA mutations. There is still little information about the pathophysiology of these different disorders. In order to obtain some insight into the cellular mechanisms of neurodegeneration, we examined cultured fibroblasts from patients with the MELAS (mitochondrial encephalopathy, lactic acidosis and stroke-like episodes) syndrome, which is most frequently caused by a mutation in the mitochondrial tRNA for leucine. We found that their basal level of ionized calcium was elevated and that they could not normally sequester calcium influxes induced by depolarization. In addition, they were unable to maintain normal mitochondrial membrane potentials, as determined using a voltage-sensitive fluorescent indicator. Despite these physiological perturbations, the MELAS fibroblasts had normal concentrations of ATP. If neurons in MELAS patients have similar physiological abnormalities, their functional properties and long-term viability may be compromised.

Contribution of subsaturating GABA concentrations to IPSCs in cultured hippocampal neurons.

The time course of EPSCs and IPSCs is at least partly determined by the concentration profile of neurotransmitter acting on postsynaptic receptors. Several recent reports have suggested that the peak synaptic cleft concentration of the inhibitory neurotransmitter GABA likely reaches at least 500 microM, a level that saturates the GABAA receptor. In the course of investigating the experimental anticonvulsant 3,3-diethyl-2-pyrrolidinone (diethyl-lactam), we have observed an important contribution to IPSC decay by subsaturating concentrations of GABA. Diethyl-lactam augments currents elicited by the exogenous application of subsaturating concentrations of GABA in voltage-clamped, cultured hippocampal neurons and significantly prolongs the decay of autaptic IPSCs and miniature IPSCs in our cultures. In addition, diethyl-lactam potentiates currents in excised outside-out membrane patches elicited by the prolonged application of low concentrations of GABA. However, when patches are exposed to 1-2 msec pulses of 1 mM GABA, diethyl-lactam does not alter current decay. Tiagabine, which blocks GABA reuptake, does not prolong IPSCs, so it is unlikely that uptake inhibition accounts for the enhancement of IPSCs. EPSCs and miniature IPSC frequency are unaffected by diethyl-lactam, again consistent with a postsynaptic site of action. We propose that during an IPSC, a substantial number of postsynaptic receptors must be exposed to subsaturating concentrations of GABA. A simplified model of GABAA receptor kinetics can account for the effects of diethyl-lactam on exogenous GABA and IPSCs if diethyl-lactam has its main effect on the monoliganded states of the GABAA receptor.

Inhibition of voltage-dependent sodium channels by the anticonvulsant gamma-aminobutyric acid type A receptor modulator, 3-benzyl-3-ethyl-2-piperidinone.

3-Benzyl-3-ethyl-2-piperidinone (3-BEP) belongs to a family of compounds that includes alpha- substituted gamma-butyrolactones, gamma-thiobutyrolactones, 2-pyrrolidinones and hexahydro-2H-azepin-2-ones. Many of these drugs exhibit potent in vivo anticonvulsant activity in mice. Previous electrophysiological studies demonstrated that they potentiate gamma-aminobutyric acid- (GABA) mediated chloride currents. This GABAA receptor modulation was thought to be the main mechanism of anticonvulsant activity. We report that 3-BEP also modulates sodium channels. It decreased sodium currents in cultured rat hippocampal neurons in a voltage- and concentration-dependent manner. The drug's apparent affinity increased as neurons were depolarized. At a holding potential of -60 mV, the apparent IC50 was 487 microM. This concentration is comparable to its EC50 for GABAA modulation (575 microM). Current blockade occurred over all activation voltages tested. The steady state inactivation curve was shifted by 600 microM 3-BEP from V50 = -65.3 mV to -72.0 mV, and recovery from inactivation was slowed from tau = 4.9 to 12.8 msec. Sodium current inhibition was not observed for three related compounds, suggesting a degree of chemical specificity for this activity. We conclude that in addition to its known effects on GABAA receptors, 3-BEP modulates sodium channels. Therefore this compound may prevent seizures by both enhancing inhibition and diminishing neuronal excitability.

Structure-activity studies of fluoroalkyl-substituted gamma-butyrolactone and gamma-thiobutyrolactone modulators of GABA(A) receptor function.

Dihydro-2(3H)-furanones (gamma-butyrolactones) and dihydro-2(3H)-thiophenones (gamma-thiobutyrolactones) containing fluoroalkyl groups at positions C-3, C-4, and C-5 of the heterocyclic rings were prepared. The anticonvulsant/convulsant activities of the compounds were evaluated in mice. Brain concentrations of the compounds were determined and the effects of the compounds on [35S]-tert-butylbicyclophosphorothionate ([35S]TBPS) binding to the picrotoxin site on GABAA receptors were investigated. The effects of the compounds on GABAA receptor function were studied using electrophysiological methods and cultured rat hippocampal neurons. Fluorination at C-3 results in either subtle or pronounced effects on the pharmacological activity of the compounds. When hydrogens are replaced with fluorines at the methylene carbon of an ethyl group, as in 3-(1,1-difluoroethyl)dihydro-3-methyl-2(3H)-furanone (1), the anticonvulsant actions of the compound are not much changed from those found for the corresponding alkyl-substituted analogue. In marked contrast, fluorination at the methyl carbon of the ethyl group, as in dihydro-3-methyl-3-(2,2,2-trifluoroethyl)-2(3H)-furanone (3), produces a compound having convulsant activity. This convulsant activity seems to be due to an increased affinity of the compound for the picrotoxin site on GABAA receptors caused by an interaction that involves the trifluoromethyl group. Results obtained with gamma-butyrolactones containing either a 3-(1-trifluoromethyl)ethyl or a 3-(1-methyl-1-trifluoromethyl)ethyl substituent indicate that the interactions of the trifluoromethyl group with the picrotoxin binding site are subject to both stereochemical and steric constraints. Sulfur for oxygen heteroatom substitution, as in the corresponding gamma-thiobutyrolactones, affects the type (competitive, non-competitive, etc.) of binding interactions that these compounds have with the picrotoxin site in a complex manner. Fluorination of alkyl groups at the C-4 and C-5 positions of gamma-butyrolactones having convulsant activity increases convulsant potency.

Excitotoxic swelling occurs in oxygen and glucose deprived human cortical slices.

The experimental evidence linking glutamate to ischemic neuronal injury is derived from in vitro or in vivo animal stroke models. We, therefore, developed an in vitro preparation to determine whether glutamate contributes to early neuronal swelling in oxygen and glucose deprived (OGD) human neocortical slices. In order to monitor neuronal swelling, we measured extracellular tissue resistance in brain slices by passing constant current pulses through two electrodes and recording the voltage drop between them. We verified that NMDA (30 microM) or OGD induced a rise in tissue resistance in rat neocortical slices. We then examined human neocortical slices from 11 patients undergoing resections for intractable epilepsy. Both the rodent and human neocortical slices swelled within 10 min of OGD. In both, the glutamate antagonist dizocilpine (MK-801) reduced the swelling. In the rats, MK-801 (5 microM) prolonged the latency to onset of neuronal swelling following OGD from 7.6 +/- 0.6 min (mean +/- S.E.M., n = 16) to 17.4 +/- 2.6 min (n = 6; p < 0.01). Other putative neuroprotective agents were much less effective in this paradigm. In the human slices, MK-801 again prolonged the latency to resistance increase from 8.6 +/- 0.4 min (n = 8) to 17.2 +/- 1.7 min (n = 9, p < 0.01). This is the direct demonstration that glutamate receptor activation leads to neuronal swelling in substrate deficient human brain. These results, which are similar to those obtained in the rodent brain slices, help validate the animal slices as appropriate models for the study of OGD in human brain.

A community-based clinical selective in end-of-life care.

There is a widespread recognition among medical educators and accreditation organizations that medical students and young physicians lack the competency necessary to care for persons near the end of life. This article describes the institutional and attitudinal barriers to innovation in curriculum design. It then presents and evaluates a 1-month selective for fourth year students that focuses on providing end-of-life care to immigrant populations in community-based home hospice. The selective joined biomedical training in pain management and palliative care, a clinical rotation in home hospice care with an analysis of the way that social and ethnic factors inform and influence end-of-life care.

Ionized intracellular calcium concentration predicts excitotoxic neuronal death: observations with low-affinity fluorescent calcium indicators.

Cytosolic calcium ([Ca2+]i) is an important mediator of neuronal signal transduction, participating in diverse biochemical reactions that elicit changes in synaptic efficacy, metabolic rate, and gene transcription. Excessive [Ca2+]i also has been implicated as a cause of acute neuronal injury, although measurement of [Ca2+]i in living neurons by fluorescent calcium indicators has not consistently demonstrated a correlation between [Ca2+]i and the likelihood of neuronal death after a variety of potentially lethal insults. Using fluorescence videomicroscopy and microinjected calcium indicators, we measured [Ca2+]i in cultured cortical neurons during intense activation with either NMDA (300 microM) or AMPA (450 microM). At these concentrations NMDA killed >80% of the cultured neurons by the next day, whereas neuronal death from AMPA was <20%. Using the conventional calcium indicator, fura-2/AM, we estimated [Ca2+]i elevations to be approximately 300-400 nM during exposure to either glutamate agonist. In contrast, indicators with lower affinity for calcium, benzothiazole coumarin (BTC), and fura-2/dextran reported [Ca2+]i levels >5 microM during lethal NMDA exposure, but [Ca2+]i levels were <1.5 microM during nonlethal activation of AMPA receptors or voltage-gated calcium channels. Fura-2 reported [Ca2+]i responses during brief exposure to glutamate, NMDA, AMPA, kainate, and elevated extracellular K+ between 0.5 and 1 microM. With the use of BTC, only NMDA and glutamate exposures resulted in micromolar [Ca2+]i levels. Neurotoxic glutamate receptor activation is associated with sustained, micromolar [Ca2+]i elevation. The widely used calcium indicator fura-2 selectively underestimates [Ca2+]i, depending on the route of entry, even at levels that appear to be within its range of detection.

Lactone modulation of the gamma-aminobutyric acid A receptor: evidence for a positive modulatory site.

The gamma-aminobutyric acid-A (GABA(A)) receptor complex is allosterically modulated by a variety of substances, some of clinical importance. Barbiturates and neurosteroids augment GABA-currents and also directly gate the channel. A variety of gamma-butyrolactone analogues also modulate GABA-induced currents, with some potentiating and others inhibiting. Because several gamma-thiobutyrolactone analogues have biphasic effects on GABA currents, experiments with wild-type and picrotoxinin-insensitive GABA(A) receptors were performed to analyze whether some gamma-thiobutyrolactones interact with two distinguishable sites on the GABA(A) receptor. beta-Ethyl-beta-methyl-gamma-thiobutyrolactone inhibited GABA-induced currents at low concentrations (0.001-1 mM), but potentiated GABA-induced currents at higher concentrations (3-10 mM) in wild-type alpha1beta2gamma2-subunit containing ionophores. The related alpha-ethyl-alpha-methyl-gamma-thiobutyrolactone potentiated submaximal GABA currents in wild-type receptors at both low and high concentrations (0.1-10 mM). Mutations in the second transmembrane domain of alpha1, beta2, or gamma2 conferred picrotoxinin-insensitivity onto GABA(A) receptor complexes. When these mutated alpha1, beta2, or gamma2 subunits were incorporated into the receptor complex, beta-ethyl-beta-methyl-gamma-thiobutyrolactone potentiated GABA currents over the entire concentration range (0.1-10 mM). Neither the potentiating activity nor the EC50 of alpha-ethyl-alpha-methyl-gamma-thiobutyrolactone changed in the mutant receptors. Further studies demonstrated that the mutations did not affect the EC50 of chlordiazepoxide or phenobarbital. These and our earlier results identify a modulatory site on the GABA(A) receptor distinct from that interacting with barbiturates, benzodiazepines, and steroids. Additionally, they show that the gamma-butyrolactones probably interact at two different sites on the ionophore to produce opposite effects on GABA-mediated current.

Mitochondrial morphology and intracellular calcium homeostasis in cytochrome oxidase-deficient human fibroblasts.

Mitochondrial encephalomyopathies arise from mutations in the mitochondrial or nuclear genome and result in defective energy metabolism. Investigation of cellular pathophysiology in these disorders has been limited to nonneuronal explant cultures such as fibroblasts and myoblasts. While investigating mitochondrial structure and function in fibroblasts obtained from control and cytochrome oxidase-deficient (COX) patients, we observed possible abnormalities by vital dye confocal microscopy. Most notable were swelling, reticulation (e.g., intricate fusion of mitochondria), and proliferation of mitochondria. However, a detailed quantitative comparison of mitochondrial morphology in age-, sex-, and passage-matched cultures revealed no significant differences between control and cytochrome oxidase-deficient fibroblasts, nor any differences with passage. In addition, COX fibroblasts exhibited no obvious impairment of intracellular calcium handling, measured by fura-2. These results indicate that cytochrome oxidase deficiency, at the level in these cultures, does not produce structural or ionic concentration alterations in fibroblasts. Future investigation of the pathophysiology of this respiratory chain disorder may require excitable tissue.

Synthesis and anticonvulsant activities of 3,3-dialkyl- and 3-alkyl-3-benzyl-2-piperidinones (delta-valerolactams) and hexahydro-2H-azepin-2-ones (epsilon-caprolactams).

A series of 3-substituted 2-piperidinone (delta-valerolactam) and hexahydro-2H-azepin-2-one (epsilon-caprolactam) derivatives were prepared and evaluated as anticonvulsants in mice. In the 2-piperidinone series, 3,3-diethyl compound 7b is the most effective anticonvulsant against pentylenetetrazole-induced seizures (ED50, 37 mg/kg; PI (TD50/ED50), 4.46), and 3-benzyl compound 4c (ED50, 41 mg/kg; PI, 7.05) is the most effective anticonvulsant against seizures induced by maximal electroshock. By contrast, none of the epsilon-caprolactams tested had anticonvulsant effects below doses causing rotorod toxicity. log P values were correlated with neurotoxicity and [35S]TBPS displacement, but not with anticonvulsant activity. Electrophysiological evaluations of selected compounds from each series indicated that both the delta-valero-lactams and epsilon-caprolactams potentiated GABA-mediated chloride currents in rat hippocampal neurons.