Activation of serotonergic neurons in the medullary caudal raphe shortens the laryngeal chemoreflex in anaesthetized neonatal rats.

NEW FINDINGS: What is the central question of this study? Does activation of serotonergic neurons in the caudal medullary raphe, some of which project to the nucleus of the solitary tract, shorten the laryngeal chemoreflex? What is the main finding and its importance? We found that serotonin originating from neurons in the caudal raphe acts through a 5-HT3 receptor located in the nucleus of the solitary tract to terminate reflex apnoea. Failure or deficiency of this arousal-related process is likely to be relevant to the pathogenesis of sudden infant death syndrome. Failure to terminate apnoea and arouse is likely to contribute to sudden infant death syndrome (SIDS). Serotonin is deficient in the brainstems of babies who have died of SIDS. We tested the hypothesis that activation of serotoninergic neurons in the caudal medullary raphe, some of which project to the nucleus of the solitary tract (NTS), would shorten the laryngeal chemoreflex (LCR). We studied anaesthetized neonatal rat pups between postnatal days 9 and 17. We injected 5-40 µl of water into the larynx to elicit the LCR and measured the duration of respiratory disruption. Microinjection of 50 nl of 100 µm AMPA into the caudal medullary raphe shortened the apnoeas (P < 0.001) and respiratory inhibition (P < 0.005) associated with the LCR. When 50 nl of 30 mm ondansetron, a 5-HT3 antagonist, was microinjected bilaterally into the NTS, AMPA microinjected into the caudal raphe no longer shortened the LCR. After bilateral microinjection of vehicle into the NTS, AMPA microinjection into the caudal raphe significantly shortened the LCR. AMPA, a glutamate receptor agonist, may activate many neurons within the caudal raphe, but blocking the 5-HT3 receptor-dependent responses in the NTS prevented the shortening of the LCR associated with AMPA microinjections into the caudal raphe. Thus, serotonin originating from neurons in the caudal raphe acts through a 5-HT3 receptor located in the NTS to terminate or shorten the LCR. Serotonin is deficient in the brainstems of babies who have died of SIDS, and deficient serotonergic termination of apnoea is likely to be relevant to the pathogenesis of SIDS.

Interleukin-1ß and interleukin-6 enhance thermal prolongation of the LCR in decerebrate piglets.

Thermal stress and prior upper respiratory tract infection are risk factors for the Sudden Infant Death Syndrome. The adverse effects of prior infection are likely mediated by interleukin-1ß (IL-1ß). Therefore, we examined the single and combined effects of IL-1ß and elevated body temperature on the duration of the Laryngeal Chemoreflex (LCR) in decerebrate neonatal piglets ranging in age from post-natal day (P) 3 to P7. We examined the effects of intraperitoneal (I.P.) injections of 0.3mg/Kg IL-1ß with or without I.P. 10mg/Kg indomethacin pretreatment on the duration of the LCR, and in the same animals we also examined the duration of the LCR when body temperature was elevated approximately 2°C. We found that IL-1ß significantly increased the duration of the LCR even when body temperature was held constant. There was a significant multiplicative effect when elevated body temperature was combined with IL-1ß treatment: prolongation of the LCR was significantly greater than the sum of independent thermal and IL-1ß-induced prolongations of the LCR. The effects of IL-1ß, but not elevated body temperature, were blocked by pretreatment with indomethacin alone. We also tested the interaction between IL-6 given directly into the nucleus of the solitary tract (NTS) bilaterally in 100ngm microinjections of 50µL and pretreatment with indomethacin. Here again, there was a multiplicative effect of IL-6 treatment and elevated body temperature, which significantly prolonged the LCR. The effect of IL-6 on the LCR, but not elevated body temperature, was blocked by pretreatment with indomethacin. We conclude that cytokines interact with elevated body temperature, probably through direct thermal effects on TRPV1 receptors expressed pre-synaptically in the NTS and through cytokine-dependent sensitization of the TRPV1 receptor. This sensitization is likely initiated by cyclo-oxygenase-2 dependent synthesis of prostaglandin E2, which is stimulated by elevated levels of IL-1ß or IL-6. Inflammatory sensitization of the LCR coupled with thermal prolongation of the LCR may increase the propensity for apnea and Sudden Infant Death Syndrome.

Serotonin in the solitary tract nucleus shortens the laryngeal chemoreflex in anaesthetized neonatal rats.

What is the central question of this study? Failure to terminate apnoea and arouse is likely to contribute to sudden infant death syndrome (SIDS). Serotonin is deficient in the brainstems of babies who died of SIDS. Therefore, we tested the hypothesis that serotonin in the nucleus of the solitary tract (NTS) would shorten reflex apnoea. What is the main finding and its importance? Serotonin microinjected into the NTS shortened the apnoea and respiratory inhibition associated with the laryngeal chemoreflex. Moreover, this effect was achieved through a 5-HT3 receptor. This is a new insight that is likely to be relevant to the pathogenesis of SIDS. The laryngeal chemoreflex (LCR), an airway-protective reflex that causes apnoea and bradycardia, has long been suspected as an initiating event in the sudden infant death syndrome. Serotonin (5-HT) and 5-HT receptors may be deficient in the brainstems of babies who die of sudden infant death syndrome, and 5-HT seems to be important in terminating apnoeas directly or in causing arousals or as part of the process of autoresuscitation. We hypothesized that 5-HT in the brainstem would limit the duration of the LCR. We studied anaesthetized rat pups between 7 and 21 days of age and made microinjections into the cisterna magna or into the nucleus of the solitary tract (NTS). Focal, bilateral microinjections of 5-HT into the caudal NTS significantly shortened the LCR. The 5-HT1a receptor antagonist, WAY 100635, did not affect the LCR consistently, nor did a 5-HT2 receptor antagonist, ketanserin, alter the duration of the LCR. The 5-HT3 specific agonist, 1-(3-chlorophenyl)-biguanide, microinjected bilaterally into the caudal NTS significantly shortened the LCR. Thus, endogenous 5-HT released within the NTS may curtail the respiratory depression that is part of the LCR, and serotonergic shortening of the LCR may be attributed to activation of 5-HT3 receptors within the NTS. 5-HT3 receptors are expressed presynaptically on C fibre afferents of the superior laryngeal nerve, and serotonergic shortening of the LCR may be mediated presynaptically by enhanced activation of inhibitory interneurons within the NTS.

Influence of age, body temperature, GABAA receptor inhibition and caffeine on the Hering-Breuer inflation reflex in unanesthetized rat pups.

We measured the duration of apnea induced by sustained end-inspiratory lung inflation (the Hering Breuer Reflex, HBR) in unanesthetized infant rat pups aged 4 days (P4) to P20 at body temperatures of 32°C and 36°C. The expiratory prolongation elicited by the HBR lasted longer in the younger pups and lasted longer at the higher body temperature. Blockade of adenosine receptors by caffeine following injection into the cisterna magna (ICM) significantly blunted the thermal prolongation of the HBR. Blockade of gama-amino-butyric acid A (GABAA) receptors by pre-treatment with ICM bicuculline had no effect on the HBR duration at either body temperature. To test the hypothesis that developmental maturation of GABAergic inhibition of breathing was modifying the response to bicuculline, we pretreated rat pups with systemically administered bumetanide to lower the intracellular chloride concentration, and repeated the bicuculline studies. Bicuculline still did not alter the HBR at either temperature after bumetanide treatment. We administered PSB-36, a selective adenosine A1 receptor antagonist, and this drug treatment did not modify the HBR. We conclude that caffeine blunts the thermal prolongation of the HBR, probably by blocking adenosine A2a receptors. The thermally sensitive adenosinergic prolongation of the HBR in these intact animals does not seem to depend on GABAA receptors.

A community-academic partnership to adapt a curriculum for people with serious mental illnesses and diabetes.

BACKGROUND: Individuals with serious mental illnesses (SMI) represent a high-risk health disparities population disproportionately affected by diabetes and obesity. OBJECTIVES: This paper describes a community-based participatory research (CBPR) approach to adapting a well-known evidence-based behavioral change protocol, the Diabetes Prevention Program (DPP) lifestyle intervention, for individuals with diabetes and SMI in the community setting. METHODS: A committee composed of university researchers and representatives from the recovery community modified the DPP following three criteria: Person centeredness, practicality, and empowerment. LESSONS LEARNED: Major modifications to the DPP were made in light of barriers and challenges faced by individuals with diabetes and SMI. CONCLUSIONS: The adaptations made to the DPP, and the process through which the modifications were made, may be used by physicians, mental health practitioners, and health educators to engage individuals confronting self-management of diabetes and mental illness.

Coordination of breathing with nonrespiratory activities.

Many articles in this section of Comprehensive Physiology are concerned with the development and function of a central pattern generator (CPG) for the control of breathing in vertebrate animals. The action of the respiratory CPG is extensively modified by cortical and other descending influences as well as by feedback from peripheral sensory systems. The central nervous system also incorporates other CPGs, which orchestrate a wide variety of discrete and repetitive, voluntary and involuntary movements. The coordination of breathing with these other activities requires interaction and coordination between the respiratory CPG and those governing the nonrespiratory activities. Most of these interactions are complex and poorly understood. They seem to involve both conventional synaptic crosstalk between groups of neurons and fluid identity of neurons as belonging to one CPG or another: neurons that normally participate in breathing may be temporarily borrowed or hijacked by a competing or interrupting activity. This review explores the control of breathing as it is influenced by many activities that are generally considered to be nonrespiratory. The mechanistic detail varies greatly among topics, reflecting the wide variety of pertinent experiments.

TRPV1 channels in the nucleus of the solitary tract mediate thermal prolongation of the LCR in decerebrate piglets.

Elevating body temperature or just the temperature of the dorsal medulla by approximately 2°C prolongs the laryngeal chemoreflex (LCR) in decerebrate neonatal piglets. We tested the hypothesis that transient receptor potential vanilloid 1 (TRPV1) receptors in the nucleus of the solitary tract (NTS) mediate thermal prolongation of the LCR. We studied the effect of a selective TRPV1 receptor antagonist on thermal prolongation of the LCR, and we tested the effect of a TRPV1 agonist on the duration of the LCR under normothermic conditions. We studied 37 decerebrate neonatal piglets between the ages of post-natal days 4 and 7. The TRPV1 receptor antagonist, 5'-iodoresiniferatoxin (65µM/L in 100nL), blocked thermal prolongation of the LCR when injected bilaterally into the region of the NTS. The TRPV1 agonist, resiniferatoxin (0.65-1.0mM/L in 100nL), prolonged the LCR after bilateral injection into the NTS even when the body temperature of each piglet was normal. The effect of the TRPV1 agonists could be blocked by treatment with the GABA(A) receptor antagonist, bicuculline, whether given intravenously (0.3mg/kg) or focally injected bilaterally into the NTS (10mM in 100nL). We conclude that TRPV1 receptors in the NTS mediate thermal prolongation of the LCR.

An adenosine A(2A) agonist injected in the nucleus of the solitary tract prolongs the laryngeal chemoreflex by a GABAergic mechanism in decerebrate piglets.

Hyperthermic prolongation of the laryngeal chemoreflex (LCR) in decerebrate piglets is prevented or reversed by GABA(A) receptor antagonists and adenosine A(2A) (Ad-A(2A)) receptor antagonists administered in the nucleus of the solitary tract (NTS). Therefore, we tested the hypothesis that enhanced GABA(A) activity and administration of the Ad-A(2A) agonist, CGS-21680, would prolong the LCR in normothermic conditions. We studied 46 decerebrate piglets ranging from 3 to 8 postnatal days of age. Focal injection into the NTS of 100 nl of 0.5 m nipecotic acid, a GABA reuptake inhibitor, significantly (P < 0.05) prolonged the LCR in normothermic conditions in 10 of 11 animals tested. Injecting 100 nl of 5-12.5 microm CGS-21680 unilaterally or bilaterally into the NTS also prolonged the LCR in normothermic conditions (n = 15), but the effect was smaller than that of unilateral injection of nipecotic acid. Systemic administration of the GABA(A) receptor antagonist, bicuculline, prevented the CGS-21680-dependent prolongation of the LCR in normothermic animals (n = 11). We conclude that thermal prolongation of the LCR depends on a thermally sensitive process or set of neurons in the NTS, which, when activated by elevated brain temperature, enhances adenosinergic and GABAergic function in the region of the NTS. These results emphasize the importance of a thermally sensitive integrative site in the dorsal medulla that, along with sites in the ventral medulla, determine the response to laryngeal chemoreflex stimulation.

Telephonic nurse case management for patients with diabetes and mental illnesses: a qualitative perspective.

OBJECTIVES: Gold Choice, a partially capitated Medicaid managed care programme for individuals with a behavioural health diagnosis, implemented a telephonic nurse case management (TNCM) programme to improve diabetes self-management. We sought to identify issues faced by patients with co-morbid behavioural health diagnoses and diabetes as documented in the telephonic nurse case manager's progress notes. We also explored the role of the TNCM in addressing members' needs. METHODS: We undertook a qualitative analysis of 853 de-identified progress notes from 539 Gold Choice members and conducted a semi-structured interview with the TNCM. RESULTS: Seven major themes emerged reflecting the nurse's perspectives on challenges faced by Gold Choice members and addressed by the TNCM: (1) Transience of the population. (2) Complex needs, involving not only medical and psychiatric conditions but also housing, transportation and survival. (3) Confusion regarding diabetes diagnosis. (4) Mistrust and suspicion. (5) Difficulties with medical care. (6) Need for diabetes self-management education/skills. (7) Marked appreciation that the TNCM would initiate contact and care about the patient. DISCUSSION: Members with co-morbid behavioural health diagnoses and diabetes constitute a complex population with extensive needs. The TNCM's role extends beyond diabetes care and entails social support as well as navigation of the healthcare and social service systems.

Gestational cigarette smoke exposure and hyperthermic enhancement of laryngeal chemoreflex in rat pups.

Laryngeal chemoreflex (LCR) apnea occurs in infant mammals of many species in response to water or other liquids in the laryngeal lumen. The apnea can last for many seconds, sometimes leading to dangerous hypoxemia, and has therefore been considered as a possible mechanism in the Sudden Infant Death Syndrome (SIDS). We have found recently that this reflex is markedly prolonged in decerebrate piglets and anesthetized rat pups that are warmed 1-3 degrees C above their normal body temperatures. We intermittently exposed pregnant rats to cigarette smoke and examined the LCR in their four- to fifteen-day-old offspring under general anesthesia, with and without whole body warming. During warming, pups of gestationally smoke-exposed dams had significantly longer LCR-induced respiratory disruption than similarly warmed control pups. The results may be significant for the pathogenesis and/or prevention of SIDS as maternal cigarette smoking during human pregnancy and heat stress in infants are known risk factors for SIDS.

An adenosine A(2A) antagonist injected in the NTS reverses thermal prolongation of the LCR in decerebrate piglets.

Hyperthermia prolongs the laryngeal chemoreflex (LCR). Under normothermic conditions, adenosine antagonists shorten and adenosine A(2A) (Ad-A(2A)) agonists prolong the LCR. Therefore, we tested the hypothesis that SCH-58261, an Ad-A(2A) receptor antagonist, would prevent thermal prolongation of the LCR when injected unilaterally within the nucleus of the solitary tract (NTS). We studied decerebrate piglets aged 4-13 days. We elicited the LCR by injecting 0.1ml of water into the larynx and recorded integrated phrenic nerve activity. The laryngeal chemoreflex was prolonged when the body temperature of each piglet was raised approximately 2.5 degrees C, and SCH-58261 reversed the thermal prolongation of the LCR when injected into the NTS (n=13), but not when injected in the nucleus ambiguus (n=9). Injections of vehicle alone into the NTS did not alter the thermal prolongation of the LCR (n=9). We conclude that activation of adenosine receptors, perhaps located on GABAergic neurons in the NTS, contributes to thermal prolongation of the LCR.

Laryngeal apnea in rat pups: effects of age and body temperature.

In neonatal mammals of many species, including human infants, apnea and other reflex responses frequently arise from stimulation of laryngeal receptors by ingested or regurgitated liquids. These reflexes, mediated by afferents in the superior laryngeal nerves (SLNs), are collectively known as the laryngeal chemoreflex (LCR) and are suspected to be responsible for some cases of the sudden infant death syndrome (SIDS). The LCR is strongly enhanced by mild increases in body temperature in decerebrate piglets, a finding that is of interest because SIDS victims are often found in overheated environments. Because of the experimental advantages of studying reflex development and mechanisms in neonatal rodents, we have developed methods for eliciting laryngeal apnea in anesthetized rat pups and have examined the influence of mild hyperthermia in animals ranging in age from 3 to 21 days. We found that apnea and respiratory disruption, elicited either by intralaryngeal water or by electrical stimulation of the SLN, occurred at all ages studied. Raising body temperature by 2-3 degrees C prolonged the respiratory disturbance in response to either stimulus. This effect of hyperthermia was prominent in the youngest animals and diminished with age. We conclude that many studies of the LCR restricted to larger neonatal animals in the past can be performed in infant rodents using appropriate methods. Moreover, the developmental changes in the LCR and in the thermal modulation of the LCR seem to follow different temporal profiles, implying that distinct neurophysiological processes may mediate the LCR and thermal prolongation of the LCR.

Elevated body temperature exaggerates laryngeal chemoreflex apnea in decerebrate piglets.

We investigated the interaction between body temperature and the duration of the laryngeal chemoreflex (LCR) in decerebrate piglets. Elevating body temperature by approximately 2 degrees C prolongs the duration of the LCR and the length of apnea associated with the reflex. This thermal prolongation seems to arise within the nucleus of the solitary tract in the brainstem, and we believe the thermal effect is mediated by enhanced GABAergic neurotransmission.

Unilateral microdialysis of gabazine in the dorsal medulla reverses thermal prolongation of the laryngeal chemoreflex in decerebrate piglets.

The laryngeal chemoreflex (LCR) is elicited by water in the larynx and leads to apnea and respiratory disruption in immature animals. The LCR is exaggerated by the elevation of brain temperature within or near the nucleus of the solitary tract (NTS) in decerebrate piglets. Thermal prolongation of reflex apnea elicited by superior laryngeal nerve stimulation is reduced by systemic administration of GABA(A) receptor antagonists. Therefore, we tested the hypothesis that microdialysis within or near the NTS of gabazine, a GABA(A) receptor antagonist, would reverse thermal prolongation of the LCR. We examined this hypothesis in 21 decerebrate piglets (age 3-13 days). We elicited the LCR by injecting 0.1 ml of water into the larynx before and after each piglet's body temperature was elevated by approximately 2.5 degrees C and before and after 2-5 mM gabazine was dialyzed unilaterally and focally in the medulla. Elevated body temperature failed to prolong the LCR in one piglet, which was excluded from analysis. Elevated body temperature prolonged the LCR in all the remaining animals, and dialysis of gabazine into the region near the NTS (n = 10) reversed the thermal prolongation of the LCR even though body temperature remained elevated. Dialysis of gabazine in other medullary sites (n = 10) did not reverse thermal prolongation of the LCR. Gabazine had no consistent effect on baseline respiratory activity during hyperthermia. These findings are consistent with the hypothesis that hyperthermia activates GABAergic mechanisms in or near the NTS that are necessary for the thermal prolongation of the LCR.

An adaptation of the diabetes prevention program for use with high-risk, minority patients with type 2 diabetes.

PURPOSE: The purpose of this pilot study was to determine the effectiveness of an edited Diabetes Prevention Program (DPP) Lifestyle Resources Core Teaching Plan for managing patients with type 2 diabetes in an urban underserved setting. Modifications were made to attempt to cut to the bare essentials to work within the constrained budgets of safety net providers. The primary aim was to achieve a mean absolute reduction in HbA1c level of 1 percentage point. METHODS: The authors conducted a randomized controlled trial of 9 months' duration for patients with type 2 diabetes with an HbA1c>or=8.0%. A total of 67 patients randomized into usual-care and case management groups were evaluated with an intention-to-treat analysis. A modified DPP workbook was used during 7 monthly visits with a nurse case manager. RESULTS: As compared with the usual-care group, those in the case management group experienced a greater reduction in HbA1c level (-1.87 vs -0.54; P=.011) and weight (-2.47 kg vs +0.88 kg; P=.011). CONCLUSION: Use of an edited version of the DPP workbook in an urban, low-income, minority population with type 2 diabetesproduced a significant absolute reduction in HbA1c percentage and weight.

GABAergic processes mediate thermal prolongation of the laryngeal reflex apnea in decerebrate piglets.

We tested the hypotheses that elevated body temperature would prolong reflex apnea following electrical stimulation of the superior laryngeal nerve (SLN) in decerebrate neonatal piglets and that thermal prolongation of reflex apnea after stimulation of the SLN depended on GABAergic mechanisms. These studies were conducted in 13 decerebrate piglets (age 3-15 days). The SLN was stimulated at approximately 1.5 times the threshold stimulus level for 10 s starting at the beginning of inspiration. We measured the duration of the apnea and respiratory disruption that followed SLN stimulation. Elevating body temperature prolonged the duration of the apnea and respiratory disruption that followed SLN stimulation, and treatment with antagonists of gama-aminobutyric acid A-type (GABAA) receptors reversed the thermal prolongation of reflex apnea and the period of respiratory disruption even though body temperature remained elevated. We conclude that elevated body temperature enhances or amplifies GABAergic mechanisms that prolong the respiratory inhibition following electrical stimulation of the SLN.

Facilitating treatment adherence with lifestyle changes in diabetes.

Healthy eating and increased physical activity can prevent or delay diabetes and its complications. Techniques that facilitate adherence to these lifestyle changes can be adapted to primary care. Often, the patient's readiness to work toward change must be developed gradually. To prepare patients who are reluctant to change, it is effective to assess and address their conviction and confidence. Patients facing the long-term task of making lifestyle changes benefit from assistance in setting highly specific behavior-outcome goals and short-term behavior targets. Individualization is achieved by tailoring these goals and targets to the patient's preferences and progress, building the patient's confidence in small steps, and implementing more intensive interventions according to a stepped-care model. At each office visit, physician follow-up of the patient's self-monitored goals and targets enhances motivation and allows further customization of the plan. A coaching approach can be used to encourage positive choices, develop self-sufficiency, and assist the patient in identifying and overcoming barriers. More intensive intervention using a team approach maximizes adherence.

Prolongation of the laryngeal chemoreflex after inhibition of the rostral ventral medulla in piglets: a role in SIDS?

We tested the hypothesis that inhibition of neurons within the rostral ventral medulla (RVM) would prolong the laryngeal chemoreflex (LCR), a putative stimulus in the sudden infant death syndrome (SIDS). We studied the LCR in 19 piglets, age 3-16 days, by injecting 0.05 ml of saline or water into the larynx during wakefulness, non-rapid eye movement (NREM) sleep, and REM sleep, before and after 1 or 10 mM muscimol dialysis in the RVM. Muscimol prolonged the LCR (P < 0.05), and the prolongation was greater when the LCR was stimulated with water compared with saline (P < 0.02). The LCR was longer during NREM sleep than during wakefulness and longest during REM sleep (REM compared with wakefulness). Muscimol had no effect on the likelihood of arousal from sleep after LCR stimulation. We conclude that the RVM provides a tonic facilitatory drive to ventilation that limits the duration of the LCR, and loss of this drive may contribute to the SIDS when combined with stimuli that inhibit respiration.