Development of Novel, Value-Based, Digital Endpoints for Clinical Trials: A Structured Approach Toward Fit-for-Purpose Validation.

Novel digital endpoints gathered via wearables, small devices, or algorithms hold great promise for clinical trials. However, implementation has been slow because of a lack of guidelines regarding the validation process of these new measurements. In this paper, we propose a pragmatic approach toward selection and fit-for-purpose validation of digital endpoints. Measurements should be value-based, meaning the measurements should directly measure or be associated with meaningful outcomes for patients. Devices should be assessed regarding technological validity. Most importantly, a rigorous clinical validation process should appraise the tolerability, difference between patients and controls, repeatability, detection of clinical events, and correlation with traditional endpoints. When technically and clinically fit-for-purpose, case building in interventional clinical trials starts to generate evidence regarding the response to new or existing health-care interventions. This process may lead to the digital endpoint replacing traditional endpoints, such as clinical rating scales or questionnaires in clinical trials. We recommend initiating more data-sharing collaborations to prevent unnecessary duplication of research and integration of value-based measurements in clinical care to enhance acceptance by health-care professionals. Finally, we invite researchers and regulators to adopt this approach to ensure a timely implementation of digital measurements and value-based thinking in clinical trial design and health care. SIGNIFICANCE STATEMENT: Novel digital endpoints are often cited as promising for the clinical trial of the future. However, clear validation guidelines are lacking in the literature. This paper contains pragmatic criteria for the selection, technical validation, and clinical validation of novel digital endpoints and provides recommendations for future work and collaboration.

Cellular and subcellular localization of PDE10A, a striatum-enriched phosphodiesterase.

PDE10A is a recently identified phosphodiesterase that is highly expressed by the GABAergic medium spiny projection neurons of the mammalian striatum. Inhibition of PDE10A results in striatal activation and behavioral suppression, suggesting that PDE10A inhibitors represent a novel class of antipsychotic agents. In the present studies we further elucidate the localization of this enzyme in striatum of rat and cynomolgus monkey. We find by confocal microscopy that PDE10A-like immunoreactivity is excluded from each class of striatal interneuron. Thus, the enzyme is restricted to the medium spiny neurons. Subcellular fractionation indicates that PDE10A is primarily membrane bound. The protein is present in the synaptosomal fraction but is separated from the postsynaptic density upon solubilization with 0.4% Triton X-100. Immuno-electron microscopy of striatum confirms that PDE10A is most often associated with membranes in dendrites and spines. Immuno-gold particles are observed on the edge of the postsynaptic density but not within this structure. Our studies indicate that PDE10A is associated with post-synaptic membranes of the medium spiny neurons, suggesting that the specialized compartmentation of PDE10A enables the regulation of intracellular signaling from glutamatergic and dopaminergic inputs to these neurons.

Medically unexplained physical symptoms in emergency medicine.

Medically unexplained physical symptoms (MUPS) are physical symptoms for which no relevant organic pathology can be found. Patients with MUPS commonly present to the emergency department (ED) but are rarely considered in emergency medicine teaching or literature. Management of these patients is frequently more challenging than where there is an obvious organic pathology. This review provides the emergency physician with background knowledge regarding the classification and aetiology of MUPS. It then provides strategies for more effective management, such as exploring the contribution of psychosocial factors with patients, explaining negative test results, and providing reassurance and avoiding creating iatrogenic anxiety. Early recognition of the fact that symptoms may not result from organic disease and an appreciation of the role of psychosocial factors may improve outcomes by reducing unnecessary investigation and admission, and avoiding reinforcement that encourages further similar presentations and unhelpful coping mechanisms.

Reactive astrogliosis is widespread in the subcortical white matter of amyotrophic lateral sclerosis brain.

Widespread astrogliosis exists in the subcortical white matter in amyotrophic lateral sclerosis (ALS). As revealed by glial fibrillary acidic protein (GFAP) immunostaining, the gliosis has the morphological properties of an active process. It is present in the midfrontal, inferior parietal, temporal, cingulate, and occipital cortices, as well as in the motor cortex. Compared to matched regions from other neurological diseases, the gliosis in ALS does not appear to be the nonspecific result of a progressive, degenerative disease. In cell number and apparent cell size, the gliosis is comparable to that present in neurological diseases known to have white matter gliosis. Cytologically, the gliosis most closely resembles that present in cases of cerebral infarction. The basis for this similarity is unknown.

Monoclonal antibody Tor 23 binds a subset of neural cells in the human cortex and displays an altered binding distribution in Alzheimer's disease.

Recent evidence suggests that alterations in molecules of the external neuronal surface may be pivotal factors in Alzheimer's disease (AD) either as primary or secondary lesions. We are studying neuronal surface components with a library of monoclonal antibodies (MAbs) made to highly purified, exclusively cholinergic nerve terminals of the Torpedo ray. The most extensively characterized of the Tor MAbs. Tor 23, binds the external membrane of some human neuronal cells in culture. Our present findings demonstrate that Tor 23, in situ, binds the apparent limiting membrane of rare neurons of the human isocortex. Tor 23 binds, in addition, internally within a subpopulation of subcortical white matter astrocytes, as identified by colocalization with glial fibrillary acidic protein. Neuronal surface binding of Tor 23 parallels our findings in other species: astrocyte staining was not observed in other species and may be unique to human. Immunoblot analysis of white matter reveals one polypeptide band with a relative mobility of 115,000 +/- 15,000 daltons. In the mid-frontal cortex from cases of AD. Tor 23 immunopositive neurons are greatly reduced in number and immunopositive astrocytes are completely absent. The reduction of the neuronal surface epitope defined by Tor 23 supports the recent hypothesis that surface molecules are altered in AD. The absence of Tor 23 positive astrocytes opens an area for specific investigation: namely, the role subcortical astrocytes may play in the pathogenesis of AD.

Increase in insulin-like growth factor II receptor within ischemic neurons following focal cerebral infarction.

The mechanisms underlying the response of the brain to ischemia are not fully understood. Biochemical and morphological changes following neocortical infarction can be investigated in rats using a model of focal cerebral ischemia induced by unilateral occlusion of the middle cerebral artery (MCA). Evaluation of ischemic damage often employs conventional histologic stains. Immunocytochemistry can be used as a valuable tool in this model to define changes in specific proteins of interest. In this study, an antiserum raised against insulin-like growth factor II (IGF-II) receptor was used to evaluate changes of IGF-II receptor immunoreactivity in the cerebral cortex of rats 4 and 7 days following permanent MCA occlusion. IGF-II receptor immunoreactivity was found to be associated with neocortical pyramidal neurons within the core of the ischemic infarct itself. The staining intensity was markedly elevated above that observed in nonischemic neurons. Immunopositive neurons exhibited a punctate staining pattern. These neurons appeared to correspond to argentophilic neurons, as defined by modified Bielschowsky silver staining. Evaluation of other neuronal markers revealed the absence of immunoreactivity for neuron-specific enolase and for tyrosine hydroxylase within the ischemic area. These observations show an increase in a specific growth factor receptor within neurons in the ischemic core of a focal infarct several days following permanent focal infarction, a time when neurons are presumed to be dead. The significance and the potential role of IGF-II receptor in lesion-induced plasticity are discussed.

Implants containing beta-amyloid protein are not neurotoxic to young and old rat brain.

Because the cellular effects of beta-amyloid protein (beta-AP) are currently unclear, we evaluated the in vivo effects of beta-AP implants in a lipid matrix to prolong tissue exposure in the brains of rats. Young 3-month-old rats and aged 18-month-old rats received implants of beta-AP prepared in a cocoa butter matrix in the dorsal hippocampus and corpus striatum on one side of the brain and implants of either prolactin or scrambled beta-AP peptide in cocoa butter on the contralateral side. The old rats also received implants of beta-AP embedded in a cholesterol matrix or cholesterol alone in the frontal cortex. The young rats were sacrificed 3-4 days after implantation, while the old rats were sacrificed 6-8 weeks after implantation. Lesion size on the beta-AP implanted side did not differ significantly from lesion size observed with control peptides. Bielschowsky silver staining revealed few argyrophilic neurites and axonal spheroids associated with either beta-AP or control implants. Alz 50 and ubiquitin immunoreactivity were not observed. None of the implant sites demonstrated cytopathology characteristic of Alzheimer's disease. The results of this study indicate that beta-AP implantation into the brains of rats produced no consistent effect beyond that seen with control peptide implants.

Synthetic amyloid beta-protein fails to produce specific neurotoxicity in monkey cerebral cortex.

Because progressive amyloid beta-protein (A beta P) deposition and surrounding neuritic dystrophy occur spontaneously in primates, we evaluated the in vivo effects of synthetic A beta P in monkey cortex. Experimental and control A beta P were stereotactically injected into multiple neocortical sites of adult rhesus monkeys in a vehicle of either artificial cerebrospinal fluid or acetonitrile. After 2 weeks or 3 months, injection sites were identified and characterized histologically and immunocytochemically. A beta P antibodies specifically detected the injected A beta P1-40 peptide. Serial sections stained with silver and antineurofilament protein demonstrated comparable degrees of degenerating neurons, dystrophic neurites, and axonal spheroids associated with both experimental and control peptide injections. Alz 50 staining was sparse or absent in all sites. We conclude that specific cellular changes closely resembling AD pathology were not detected in these experiments, and that control and experimental A beta P peptides produced indistinguishable effects. Methodological concerns regarding the in vivo modeling of A beta P bioactivity are discussed.

Global cerebral ischemia activates nuclear factor-kappa B prior to evidence of DNA fragmentation.

The oxidative stress responsive transcription factor nuclear factor-kappa B (NF-kappa B) consists of a p50 (50 kDa) and p65/RelA (65 kDa) component and can be activated in vitro by TNF alpha, IL1 beta, hydrogen peroxide and oxygen radicals. All of the above factors are also known to be elevated at certain times after transient global ischemia. The present study was performed to determine if NF-kappa B was activated in vivo by transient global forebrain ischemia. Adult male rats were subjected to 30 min of 4-vessel occlusion (4-VO) and sacrificed at selected post-ischemic time points. Levels of NF-kappa B p50 and p65 subunits were determined by immunocytochemistry, Western blot and electrophoretic mobility-shift analysis. The enhancer complex was also confirmed by immuno-gel-shift analysis. Specific labeling of DNA strand breaks and DNA fragmentation was examined in situ by means of the terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) method. Western blot analysis of hippocampus showed induction of p50 and p65. A time course of NF-kappa B induction in hippocampus showed a p50-specific band at 6 h that increased in intensity over 12, 48 h and then decreased by 96 h post-ischemia. Immunocytochemistry revealed at 24 h post-ischemia that p65 and p50 immunoreactivity was present in neuronal nuclei of hippocampal CA1 neurons as well as all other hippocampal regions and several other forebrain regions which were not vulnerable to transient forebrain ischemia. At 72 h post-ischemia, nuclear NF-kappa B immunoreactivity had disappeared in all brain areas except in hippocampal CA1 neurons which were degenerating. No evidence for DNA fragmentation as revealed by TUNEL staining could be observed at 24 h. However, at 72 h, hippocampal CA1 neurons were heavily labeled. The results of this study demonstrate that global forebrain ischemia causes a transient activation of NF-kappa B in many forebrain regions. NF-kappa B remains persistently activated in the vulnerable hippocampal CA1 sector. Because of the persistent activation of NF-kappa B in these neurons, the possibility exists that NF-kappa B has a role in programmed cell death in hippocampal CA1 neurons.

Metabotropic glutamate receptor activation in vivo induces intraneuronal amyloid immunoreactivity in guinea pig hippocampus.

Stimulation of metabotropic glutamate receptors in vitro has been shown to accelerate the breakdown of amyloid precursor protein (APP) to form increased production of non-amyloidogenic secreted APP (sAPP). The mechanism whereby this occurs is not entirely clear but it is presumed to be linked to generation of diacylglycerol and activation of protein kinase C because other neurotransmitter receptors such as m1 and m3 muscarinic receptors, known to be coupled to this second messenger cascade, likewise increase sAPP production. Although it is presumed that a reciprocal relationship exists between the formation of amyloid beta protein (Abeta) and the production of sAPP, recent evidence suggests alternative processing can occur. Given the fact that much of the observations on APP metabolism have been made in vitro we sought to investigate the effect of metabotropic receptor activation on Abeta in vivo in a species known to contain the same amino acid sequence of Abeta as found in humans. Intrahippocampal injection of the mGluR agonist 1S,3R-ACPD in guinea pigs produced neurodegeneration of CA1 hippocampal pyramidal neurons at 12 h postinjection. Immunocytochemistry of sections from ACPD injected animals using selective antibodies to Abeta revealed the presence of punctate intraneuronal granules in pyramidal neurons of the hippocampus. These structures appeared to be localized within the nucleus and were particularly prominent in neurons within the region of neurodegeneration. Immunoreactivity was not observed in vehicle injected controls nor in sections from ACPD injected animals stained with preadsorbed antiserum. Abeta immunodetection was correlated with the onset of neurodegeneration since animals evaluated at 1 h and 4 h postinjection lacked both Abeta immunoreactivity as well as neurodegeneration. Evaluation of animals injected with NMDA revealed neurodegeneration but no Abeta immunoreactivity suggesting Abeta formation did not appear to be due to non-selective excitotoxicity. Staining of sections with antibodies directed to various regions of APP demonstrated increased C-terminal APP immunoreactivity in pyramidal neurons in the vicinity of degeneration. These data support recent in vitro studies illustrating that Abeta can be found intracellularly within neurons.

Increased expression of peripheral benzodiazepine receptors in the facial nucleus following motor neuron axotomy.

Peripheral benzodiazepine receptors (PBRs) are expressed in a variety of tissues but are normally found at low levels in the brain. Following various types of nerve injury, a reactive gliosis results that exhibits a high expression of this receptor. To further characterize the expression of PBRs following neuronal injury, we evaluated PBR expression in the facial nucleus following facial nerve axotomy (FNA). Injury to a peripheral nerve results in a complex series of metabolic and morphological changes around the injured neuron. Transections of the facial nerve results in a rapid activation of both astrocytes and microglia around axotomized motor neurons. FNA resulted in an increase in the staining for both astrocytes (glial fibrillary acidic protein) and activated microglia (OX42). There was also a reduction in synaptic contacts with the motor nucleus as evidenced by reduced staining for the synaptic marker, synaptophysin. In sections labeled with [3H]-PK11195, the subsequent autoradiograms displayed marked increases in the labeling for PBRs. This increase was observed at 5, 7 and 10 days after nerve transection. The increase was primarily in the level of expression (Bmax), with no change in the affinity of the ligand (Kd). The increase in PBR expression after FNA supports the hypothesis that PBRs can be used as a sensitive marker for CNS injury.

In vivo effects of beta-amyloid implants in rodents: lack of potentiation of damage associated with transient global forebrain ischemia.

Recent studies have shown that the principal component of the senile plaque in Alzheimer's disease (AD), beta-amyloid protein (beta AP) can exert direct and indirect neurotoxicity in vitro. Because of the studies that demonstrated potentiation of excitatory amino acid toxicity by beta AP, we decided to test whether beta AP was able to potentiate damage in an in vivo model where excitotoxic damage is thought to be important. The present study evaluated the in vivo effects of beta AP implants in the brain of rats before and after being subjected to 10 min of transient global forebrain ischemia by 4-vessel occlusion (4-VO). Implants of either synthetic beta AP or prolactin (PRL), which was used as a control protein, were made into the striatum and the hippocampus of either the left (beta AP) or the right (PRL) cerebral hemisphere. The implants were made in a lipophilic, non-toxic vehicle so as to try and achieve sustained beta AP exposure. One group of animals was evaluated for direct in vivo effects within 1 week following implantation; the other group was subjected to 4-VO 3-4 days post-implantation for evaluation of potential indirect effects. This latter group was compared to the histopathology of animals subjected to 4-VO without prior implantation. In the group of animals evaluated for direct effects, no evidence of neurotoxicity was observed. Bielschowsky silver staining and immunostaining for ubiquitin were unremarkable in all lesions. beta AP was detected by immunocytochemistry in the parenchymal tissue that received beta AP implants. Marked glial activation was observed to be associated with experimental and control implants. Under the experimental conditions employed in this study, significant protection from ischemia rather than potentiation of damage was observed. These results suggest that beta AP may not be neurotoxic in rodents in vivo and that the lesions and/or trauma produced by the implantation procedure 3-4 days prior to 4-VO may have induced factors that were protective against ischemia-induced damage.

Amyloid precursor protein accumulates in regions of neurodegeneration following focal cerebral ischemia in the rat.

The distribution of beta-amyloid precursor protein (APP) was examined immunocytochemically in rats subjected to focal cerebral ischemia by permanent occlusion of the middle cerebral artery. At 4 and 7 days post-occlusion, APP immunoreactivity was preferentially localized within axonal swellings, dystrophic neurites and neuronal perikarya all along the periphery of the infarct. Immunolabeling was observed with antibodies generated against N-terminal, midregion, and C-terminal domains of APP. No immunoreactivity was observed with antisera directed against beta-amyloid protein (beta A4) itself. This pathological accumulation of APP is consistent with alterations of APP recently described in other models of neurodegeneration and implies a role for this protein in the response to CNS injury.

Bcl-Xshort is elevated following severe global ischemia in rat brains.

Hippocampal CA1 neurons are highly susceptible to short periods of transient global ischemia. We have previously reported in a rat model of transient forebrain global ischemia that activation and nuclear localization of NF-kB occurs in the CA1 neurons at 24 and 72 h post reperfusion. Events following NF-kB activation would ultimately determine whether damaged cells will undergo programmed cell death. We have selected bcl-x gene expression for study because there is increasing evidence that proteins encoded by the bcl-2 gene family (bcl-2, bcl-x, bax etc) play a role in the regulation of programmed cell death. We have observed that the bcl-x gene promoter contains a putative consensus sequence for NF-kB/CS4 responsive activation. We also can show that other members of the bcl-2 multigene family contain the NF-kB/CS4 sequence in their five prime regulatory regions. In this study, we show that NF-kB p50 and NF-kB p65 act in synergy to transactivate the bcl-x promoter in co-transfected 293 cells. We also report that following ischemia and NF-kB activation, bcl-x messenger RNA levels increase in the CA1 hippocampal region. As a result of this transcriptional increase, surprisingly, it is bcl-xs, the apoptotic form of bcl-x, that is elevated. These results suggest that activation of NF-kB can lead to increased expression of bcl-x as manifested by the increase in the short form of bcl-x.

Calcium-sensitive cytosolic phospholipase A2 (cPLA2) is expressed in human brain astrocytes.

Calcium-sensitive cytosolic phospholipase A2 (cPLA2) is responsible for receptor-mediated liberation of arachidonic acid, and thus plays an important role in the initiation of the inflammatory lipid-mediator cascade generating eicosanoids and platelet-activating factor. In this study we have investigated the cellular distribution of cPLA2 in brain using a monoclonal antibody raised against cPLA2 to immunostain tissue sections of human cerebral cortex. We have localized cPLA2 in astrocytes of the gray matter. Colocalization with glial fibrillary acidic protein (GFAP) confirmed that cPLA2 is associated predominantly with protoplasmic astrocytes. Astrocytes of the white matter, on the other hand, were not immunoreactive. In experiments using different human astrocytoma cell lines we found that cPLA2 can be immunochemically localized in UC-11 MG cells, but cannot be detected in U-373 MG cells. This finding is consistent with the observation that cPLA2 mRNA as well as cPLA2 enzymatic activity can be readily measured in UC-11 MG astrocytoma cells, yet cannot be detected in U-373 MG cells. Our data suggest that the astrocyte is a primary source of cPLA2 in the brain and provide further evidence for the importance of this cell type in inflammatory processes in the brain.

The distribution of phosphodiesterase 2A in the rat brain.

The phosphodiesterases (PDEs) are a superfamily of enzymes that regulate spatio-temporal signaling by the intracellular second messengers cAMP and cGMP. PDE2A is expressed at high levels in the mammalian brain. To advance our understanding of the role of this enzyme in regulation of neuronal signaling, we here describe the distribution of PDE2A in the rat brain. PDE2A mRNA was prominently expressed in glutamatergic pyramidal cells in cortex, and in pyramidal and dentate granule cells in the hippocampus. Protein concentrated in the axons and nerve terminals of these neurons; staining was markedly weaker in the cell bodies and proximal dendrites. In addition, in both hippocampus and cortex, small populations of non-pyramidal cells, presumed to be interneurons, were strongly immunoreactive. PDE2A mRNA was expressed in medium spiny neurons in neostriatum. Little immunoreactivity was observed in cell bodies, whereas dense immunoreactivity was found in the axon tracts of these neurons and their terminal regions in globus pallidus and substantia nigra pars reticulata. Immunostaining was dense in the medial habenula, but weak in other diencephalic regions. In midbrain and hindbrain, immunostaining was restricted to discrete regions of the neuropil or clusters of cell bodies. These results suggest that PDE2A may modulate cortical, hippocampal and striatal networks at several levels. Preferential distribution of PDE2A into axons and terminals of the principal neurons suggests roles in regulation of axonal excitability or transmitter release. The enzyme is also in forebrain interneurons, and in mid- and hindbrain neurons that may modulate forebrain networks and circuits.

An atlas of a rare neuronal surface antigen in the rat central nervous system.

The mature nervous system contains functional synaptic networks composed of neuronal sets and subsets whose identity and maintenance may rely on external surface molecules specific for these neuronal subdivisions. Such molecules may reside permanently on specific neurons, serving to identify those neurons within a complex population. From a collection of monoclonal antibodies made to the Torpedo cholinergic synaptosome preparation, we have identified several antibodies that bind the surface of some, but not all, neurons of the mature rat brain (Kushner and Stephenson, 1983; Kushner, 1984). In the present study we catalog which neurons of the entire rat brain and spinal cord are immunopositive for one of these antibodies, Tor 23. The atlas we have compiled can be used (1) on a practical level to guide affinity purifications and neuronal cell sorting, and (2) more esoterically to address whether surface antigenic sets of neurons share or define a common functional property. In the forebrain, Tor 23-positive neurons predominate as a rare cell type of the inner cortical laminae. In the midbrain, few cells stain. In the hindbrain, labeled neurons are dispersed among several nuclei. The exceptions to these observations, areas that almost exclusively contain Tor 23-immunopositive neurons, are the spinal cord ventral horn, the deep cerebellar nuclei, some cerebellar-related nuclei, selected auditory nuclei, the supraoptic and paraventricular nuclei of the hypothalamus, and the CA2 pyramidal neurons of the hippocampus. The neurons that bind Tor 23 are related biochemically by virtue of that shared epitope alone. Whether they are related in a functional manner is a separate issue. Tor 23 demarks many motor-related structures, specifically, the ventral horn motor lamina, the orofacial motor nuclei 5 and 7, the ambiguus nucleus, the deep cerebellar nuclei, the pontine reticulotegmental nucleus, the lateral reticular nucleus, the gigantocellular reticular nucleus, the red nucleus, and neurons within the motor and somatosensory cortices. The overlap of Tor 23 with motor structures suggests that Tor 23 is a motor system marker.

Torpedo monoclonal antibodies react with components of the human peripheral nervous system.

A panel of 141 monoclonal antibodies, generated to the Torpedo ray cholinergic nerve terminal preparation, were tested for binding to components of human nerve and muscle. Tested by immunofluorescence, 13 of the antibodies reacted with components of the human intercostal nerve, and 9 bound either muscle or blood vessels in a diversity of staining patterns. Results indicate that the antibodies identify a spectrum of different antigens. Some of the antibodies that cross react with the human nervous system have been studied in the ray and rat. In the human peripheral nerve and muscle, their cytochemical distribution is consistent with what has been observed in these other species. These antibodies, therefore, are likely to identify components of the neuromuscular junction that have been conserved in evolution from elasmobranchs to humans. The antibodies identified here are potentially useful tools for a molecular examination of human nerves and muscles in pathological conditions.

Is prehospital thrombolysis for acute myocardial infarction warranted in the urban setting? The case against.

This paper forms the second part of the debate on prehospital thrombolysis (PHT). It is argued that large scale studies have failed to show a benefit for PHT, even when the time saved over conventional treatment was considerably greater than would be the case in the UK urban setting. In practice, a relatively small proportion of the total population receiving thrombolysis would receive PHT. Other strategies to reduce time to thrombolysis can benefit all patients and are likely to be more cost effective and safer.

Family of human neuronal external surface epitopes defined by Torpedo monoclonal antibodies.

We are employing a library of monoclonal antibodies (MAbs) that were made to Torpedo cholinergic synaptosomes to identify conserved, physiologically vital epitopes of the neuronal surface. Our particular interest is in those epitopes that are present on some but not all neurons. In the present study we screened this library on different cell lines, the neuronal cell lines PC12, NG108, MC-IXC, and SY5Y, and the endocrine cell lines GH-3 and HIT. Of these cell lines, only SY5Y cells bind MAbs that define neuronal surface subsets. Utilizing its parent cell line, SK-N-SH, we verified that six MAbs, Tor 25, Tor 103, Tor 190, Tor 201, Tor 219, and Tor 233, bind the external neuronal surface. The cytolocalization of all six MAbs is very similar: the membrane of the cell body and its processes are finely outlined in a punctate distribution. Western blot analyses of Torpedo electric organ homogenates, a highly enriched source of antigenic material, revealed that each MAb identifies multiple polypeptides, two of which have the relative mobilities of 180 kD and 67 kD. In a screen of peripheral nerves from cases of amyotrophic lateral sclerosis (ALS), we found that all these MAbs revealed surface alterations; some displayed a decrease in binding, while others displayed an increase. The combined data provide evidence that these epitopes belong to an important, complex family of polypeptides of the external neuronal surface.