Process evaluation of five tailored programs to improve the implementation of evidence-based recommendations for chronic conditions in primary care.

BACKGROUND: Although there is evidence that tailored implementation strategies can be effective, there is little evidence on which methods of tailoring improve the effect. We designed and evaluated five tailored programs (TPs) each consisting of various strategies. The aim of this study was to examine (a) how determinants of practice prioritized in the design phase of the TPs were perceived by health care professionals who had been exposed to the TPs and whether they suggested other important determinants of practice and (b) how professionals used the offered strategies and whether they suggested other strategies that might have been more effective. METHODS: We conducted a mixed-method process evaluation linked to five cluster-randomized trials carried out in five European countries to implement recommendations for five chronic conditions in primary care settings. The five TPs used a total of 28 strategies which aimed to address 38 determinants of practice. Interviews of professionals in the intervention groups and a survey of professionals in the intervention and control groups were performed. Data collection was conducted by each research team in the respective national language. The interview data were first analyzed inductively by each research team, and subsequently, a meta-synthesis was conducted. The survey was analyzed descriptively. RESULTS: We conducted 71 interviews; 125 professionals completed the survey. The survey showed that 76 % (n = 29) of targeted determinants of practice were perceived as relevant and 95 % (n = 36) as being modified by the implementation interventions by 66 to 100 % of professionals. On average, 47 % of professionals reported using the strategies and 51 % considered them helpful, albeit with substantial variance between countries and strategies. In the interviews, 89 determinants of practice were identified, of which 70 % (n = 62) had been identified and 45 % (n = 40) had been prioritized in the design phase. The interviewees suggested 65 additional strategies, of which 54 % (n = 35) had been identified and 20 % (n = 13) had been prioritized, but not selected in the final programs. CONCLUSIONS: This study largely confirmed the perceived relevance of the targeted determinants of practice. This contrasts with the fact that no impact of the trials on the implementation of the recommendations could be observed. The findings suggest that better methods for prioritization of determinants and strategies are needed. TRIAL REGISTRATION: Each of the five trials was registered separately in recognized trial registries. Details are given in the respective trial outcome papers.

Synaptic and cellular changes induced by the schizophrenia susceptibility gene G72 are rescued by N-acetylcysteine treatment.

Genetic studies have linked the primate-specific gene locus G72 to the development of schizophrenia and bipolar disorder. Transgenic mice carrying the entire gene locus express G72 mRNA in dentate gyrus (DG) and entorhinal cortex, causing altered electrophysiological properties of their connections. These transgenic mice exhibit behavioral alterations related to psychiatric diseases, including cognitive deficits that can be reversed by treatment with N-acetylcysteine, which was also found to be effective in human patients. Here, we show that G72 transgenic mice have larger excitatory synapses with an increased amount of N-methyl-d-aspartate (NMDA) receptors in the molecular layer of DG, compared with wild-type littermates. Furthermore, transgenic animals have lower number of dentate granule cells with a parallel, but an even stronger decrease in the number of excitatory synapses in the molecular layer. Importantly, we also show that treatment with N-acetylcysteine can effectively normalize all these changes in transgenic animals, resulting in a state similar to wild-type mice. Our results show that G72 transcripts induce robust alterations in the glutamatergic system at the synaptic level that can be rescued with N-acetylcysteine treatment.

Properties and dynamics of inhibitory synaptic communication within the CA3 microcircuits of pyramidal cells and interneurons expressing parvalbumin or cholecystokinin.

KEY POINTS: To understand how a network operates, its elements must be identified and characterized, and the interactions of the elements need to be studied in detail. In the present study, we describe quantitatively the connectivity of two classes of inhibitory neurons in the hippocampal CA3 area (parvalbumin-positive and cholecystokinin-positive interneurons), a key region for the generation of behaviourally relevant synchronous activity patterns. We describe how interactions among these inhibitory cells and their local excitatory target neurons evolve over the course of physiological and pathological activity patterns. The results of the present study enable the construction of precise neuronal network models that may help us understand how network dynamics is generated and how it can underlie information processing and pathological conditions in the brain. We show how inhibitory dynamics between parvalbumin-positive basket cells and pyramidal cells could contribute to sharp wave-ripple generation. ABSTRACT: Different hippocampal activity patterns are determined primarily by the interaction of excitatory cells and different types of interneurons. To understand the mechanisms underlying the generation of different network dynamics, the properties of synaptic transmission need to be uncovered. Perisomatic inhibition is critical for the generation of sharp wave-ripples, gamma oscillations and pathological epileptic activities. Therefore, we aimed to quantitatively and systematically characterize the temporal properties of the synaptic transmission between perisomatic inhibitory neurons and pyramidal cells in the CA3 area of mouse hippocampal slices, using action potential patterns recorded during physiological and pathological network states. Parvalbumin-positive (PV+) and cholecystokinin-positive (CCK+) interneurons showed distinct intrinsic physiological features. Interneurons of the same type formed reciprocally connected subnetworks, whereas the connectivity between interneuron classes was sparse. The characteristics of unitary interactions depended on the identity of both synaptic partners, whereas the short-term plasticity of synaptic transmission depended mainly on the presynaptic cell type. PV+ interneurons showed frequency-dependent depression, whereas more complex dynamics characterized the output of CCK+ interneurons. We quantitatively captured the dynamics of transmission at these different types of connection with simple mathematical models, and describe in detail the response to physiological and pathological discharge patterns. Our data suggest that the temporal propeties of PV+ interneuron transmission may contribute to sharp wave-ripple generation. These findings support the view that intrinsic and synaptic features of PV+ cells make them ideally suited for the generation of physiological network oscillations, whereas CCK+ cells implement a more subtle, graded control in the hippocampus.

Determinants of heart failure self-care behaviour in community-based patients: a cross-sectional study.

BACKGROUND: Self-care behaviour in patients with heart failure (HF) represents a series of specific actions that patients should take, as an important treatment component. AIMS: The aim of this study was to identify potential determinants of HF self-care in ambulatory patients with stable systolic HF. METHODS: In a cross-sectional study of 318 patients with chronic systolic HF recruited in 48 German primary care practices, we evaluated the patient-reported European HF Self-care Behaviour scale (EHFScBs) assessments (range 12-60, where lower scores indicate better self-care). Potential determinants included socio-demographic (e.g. age, living status), clinical (e.g. NYHA class, LVEF, NT-proBNP levels, co-morbidities), behavioural (e.g. smoking and alcohol intake), psychosocial (SF-36 scales and KCCQ domains, e.g. quality of life and self-efficacy) and depression status (PHQ-D), plus previous health care utilisation. Mixed regression modelling was applied. RESULTS: Patients had a mean (SD) age of 69.0 (10.4) years and were 71% male. They had a good overall EHFScBs score of 24.7 (7.8) (n=274). In the final regression model (n=271), six determinants were retained (ß; descriptive p-value): self-efficacy (-0.24; <.001), age (-0.22; <.001), prosthetic heart valve (-0.14; .01), referrals to cardiologists (-0.14; .02), peripheral arterial disease (0.13; .03) and quality of life (0.16; .02). CONCLUSION: In this exploratory cross-sectional study, the potential non-modifiable and modifiable risk factors and resources involved in patients' HF self-care were at the individual and organisational level. Self-efficacy and quality of life are potentially modifiable, so these could be targeted for improvement by enhancing patient motivation, HF education and further supporting a collaborative care approach.

Identifying factors associated with experiences of coronary heart disease patients receiving structured chronic care and counselling in European primary care.

BACKGROUND: Primary care for chronic illness varies across European healthcare systems. In patients suffering from coronary heart disease (CHD), factors associated with patients' experiences of receiving structured chronic care and counselling at the patient and practice level were investigated. METHODS: In an observational study comprising 140 general practices from five European countries (Austria, Germany, the Netherlands, Switzerland and the United Kingdom), 30 patients with Coronary Heart Disease (CHD) per practice were chosen at random to partake in this research. Patients were provided with a questionnaire and the Patient Assessment of Chronic Illness Care (PACIC-5A) - instrument. Practice characteristics were assessed through a practice questionnaire and face to face interviews. Data were aggregated to obtain two practice scores representing quality management and CHD care, respectively. A hierarchical multilevel analysis was performed to examine the impact of patient and practice characteristics on PACIC scores. RESULTS: The final sample included 1745 CHD-patients from 131 general practices with a mean age of 67.8 (SD 9.9) years. The overall PACIC score was 2.84 (95%CI: 2.79; 2.89) and the 5A score reflecting structured lifestyle counselling was 2.75 (95% CI: 2.69; 2.79). At the patient level, male gender, more frequent practice contact and fewer related or unrelated conditions were associated with higher PACIC scores. At the practice level, performance scores reflecting quality management (p = 0.013) and CHD care (p = 0.009) were associated with improved assessment of the structured chronic care and counselling received. CONCLUSIONS: Patients' perceived quality of care varies. However, good practice management and organisation of care were positively reflected in patients' assessments of receiving structured chronic illness care. This highlights the importance of integrating patient experiences into quality measurements to provide feedback to health care professionals.

[Challenges and potentials of primary care in a multicultural society]. / Herausforderungen und Potenziale hausärztlicher Versorgung in einer multikulturellen Gesellschaft.

The greatest proportion of basic health care for patients with a migrational background living in Germany is provided by general practitioners. There is evidence that patients with a migrational background see a general practitioner as a gate keeper in case of physical or mental complaints even more frequently than the native German population. In contrast, the impact of migration-specific tasks in general practice appears to be relatively low in the medical and public discourse. This article analyzes the current situation of medical care for migrant patients in general practice and shows its potential to offer low-threshold high quality health care services to migrant patients and the whole population. In addition, an overview on migration-specific issues in research, teaching, and continuous medical education of general practitioners is provided. Finally, the implications of these findings for future research questions on migration-sensitive interventions are discussed.

Complementary synaptic distribution of enzymes responsible for synthesis and inactivation of the endocannabinoid 2-arachidonoylglycerol in the human hippocampus.

Clinical and experimental evidence demonstrates that endocannabinoids play either beneficial or adverse roles in many neurological and psychiatric disorders. Their medical significance may be best explained by the emerging concept that endocannabinoids are essential modulators of synaptic transmission throughout the central nervous system. However, the precise molecular architecture of the endocannabinoid signaling machinery in the human brain remains elusive. To address this issue, we investigated the synaptic distribution of metabolic enzymes for the most abundant endocannabinoid molecule, 2-arachidonoylglycerol (2-AG), in the postmortem human hippocampus. Immunostaining for diacylglycerol lipase-α (DGL-α), the main synthesizing enzyme of 2-AG, resulted in a laminar pattern corresponding to the termination zones of glutamatergic pathways. The highest density of DGL-α-immunostaining was observed in strata radiatum and oriens of the cornu ammonis and in the inner third of stratum moleculare of the dentate gyrus. At higher magnification, DGL-α-immunopositive puncta were distributed throughout the neuropil outlining the immunonegative main dendrites of pyramidal and granule cells. Electron microscopic analysis revealed that this pattern was due to the accumulation of DGL-α in dendritic spine heads. Similar DGL-α-immunostaining pattern was also found in hippocampi of wild-type, but not of DGL-α knockout mice. Using two independent antibodies developed against monoacylglycerol lipase (MGL), the predominant enzyme inactivating 2-AG, immunostaining also revealed a laminar and punctate staining pattern. However, as observed previously in rodent hippocampus, MGL was enriched in axon terminals instead of postsynaptic structures at the ultrastructural level. Taken together, these findings demonstrate the post- and presynaptic segregation of primary enzymes responsible for synthesis and elimination of 2-AG, respectively, in the human hippocampus. Thus, molecular architecture of the endocannabinoid signaling machinery supports retrograde regulation of synaptic activity, and its similar blueprint in rodents and humans further indicates that 2-AG's physiological role as a negative feed-back signal is an evolutionarily conserved feature of excitatory synapses.

The effect of Echinacea preparations in three laboratory tests of anxiety: comparison with chlordiazepoxide.

Echinacea preparations are traditionally used to treat upper respiratory infections and inflammations. No psychotropic effects of Echinacea have been reported so far, although some recently reported active constituents are behaviorally active. Prompted by these findings, the anxiolytic potential of five different Echinacea preparations was evaluated. Three of these decreased anxiety but two of them had a very narrow effective dose range. Only one extract decreased anxiety within a wide dose-range (3-8 mg/kg). Anxiolytic effects were consistently seen in three different tests of anxiety, the elevated plus-maze, social interaction and shock-induced social avoidance tests. No locomotor suppressant effects were seen at any dose. Noteworthy, the doses that showed anxiolytic effects in the present study were much lower than those used in the laboratory models of the traditional indications. Chlordiazepoxide robustly decreased anxiety-like behavior in all tests but suppressed locomotion at higher doses. Perceived and real risks of conventional medications increase the demand for alternative therapies, provided that these are safe and efficient. Earlier evidence shows that Echinacea preparations have an excellent safety profile, while our findings suggest for the first time that certain preparations have a considerable anxiolytic potential. Further research is required to identify factors that differentiate efficient and inefficient preparations.

[Health screening and vaccination status--results from a patient survey in German general practices]. / Gesundheitsuntersuchung und Impfstatus--Ergebnisse einer Patientenbefragung in deutschen Hausarztpraxen.

The vaccination status of German adults needs improvement. Low participation is also known in health screening programmes like the "Check up 35" which is offered every two years for adults aged 35 or above. However, the number of participants in health screening increases with age whereas vaccination status decreases. Within a study about patients' attitudes towards prevention in primary care, we investigated the knowledge about the vaccination status. Therefore, an anonymous survey was conducted among 333 patients from five general practices in 2007. 76% of the potential participants in health screening declared that they utilise it at least infrequently. In contrast to those who participate frequently in health screening (67%), those who participate infrequently (38%) or never (33%) but declare that their vaccination status is complete are significantly rare. Due to the results of our study it has to be discussed whether the health screening "Check up 35" should be regularly accompanied with vaccination counselling.

BCG priming of dendritic cells enhances T regulatory and Th1 function and suppresses allergen-induced Th2 function in vitro and in vivo.

BACKGROUND: The inverse correlation of mycobacterial infection with asthma prevalence and the inhibitory effects of vaccination with Bacille Calmette-Guérin (BCG) on airway hyperreactivity in asthma models suggest modulation of dendritic cell (DC) and T cell functions by mycobacterial compounds. METHODS: To delineate these immunological effects, the immunogenicity of BCG Copenhagen, BCG Chicago and BCG Pasteur was compared in a mouse model. Bone marrow-derived dendritic cells (BMDCs) from BALB/c mice were stimulated with ovalbumin (OVA) with or without BCG. BMDCs were phenotypically characterized by flow cytometry, and we used ELISA to measure the cytokine production of BMDCs as well as of co-cultivated allergen-specific T cells in response to OVA-pulsed. Immunomodulatory effects of BCG were studied in a model of allergic airway inflammation by adoptive transfer of allergen-pulsed BMDCs. RESULTS: Immunomodulation with BCG induced production of IL-10 and IL-12 by BMDCs. Co-cultured allergen-specific T cells produced less IL-5, IL-13 and IFN-gamma but more IL-10. Also the number of FoxP3(+) regulatory T cells was enhanced. Strongest effects were seen with BCG Chicago and BCG Pasteur. In vivo, administration of BCG modulated OVA-pulsed BMDCs then reduced eosinophilic airway inflammation but enhanced infiltration with granulocytes. Airway hyperreactivity and mucus production were reduced and more FoxP3(+) T cells were observed. CONCLUSION: BCG-induced suppression of Th2-type allergic airway inflammation was associated with enhancement of regulatory T cell function but also of Th1-associated neutrophilic airway inflammation. These findings raise concerns regarding the safety profile of BCG as a potential tool for prevention and therapy of allergic airway disease.

Quantitative proton magnetic resonance spectroscopy of the normal liver and malignant hepatic lesions at 3.0 Tesla.

This comparative study of tumour patients and volunteers aimed at differentiating liver parenchyma from neoplastic lesions by using localised (1)H MRS at 3.0 T as an adjunct to MRI. In total 186 single-voxel proton spectra of the liver were acquired at 3.0 T using the body transmit receive coil. Consecutive stacks of breath-hold spectra were acquired in the PRESS technique at a short echo time of 35 ms and a repetition time of 2,000 ms. Processing of the spectra included spectral alignment with the software package SAGE and quantitative processing with LCModel. The resulting metabolite concentrations were presented in arbitrary units relative to the internal water. In general, the spectra showed four main groups of resonances originating from the methyl protons (0.8-1.1 ppm) and methylene protons of the lipids (1.1-1.5 ppm; 2.0-2.2 ppm) as well as the methyl protons of choline-containing compounds (CCC) at 3.2 ppm. Overall, the CCC and lipid values in malignant liver tumours showed no significant differences to liver parenchyma. On average, total lipid measurements in normal liver parenchyma increased with age, while those of the CCC did not show pertinent changes. Significant differences between the contents of CCC in malignant liver tumours and normal liver parenchyma were not observed, because in patients and volunteers normal liver tissue showed a large variability in the content of CCC.

Relationship between neuronal vulnerability and potassium-chloride cotransporter 2 immunoreactivity in hippocampus following transient forebrain ischemia.

Cation chloride cotransporters have been reported to be expressed in neurons in the hippocampus and to regulate intracellular Cl(-) concentration. The neuron-specific K-Cl cotransporter 2 (KCC2) is necessary for maintaining the low intracellular chloride concentration required for the hyperpolarizing actions of GABA. In this study we examined the vulnerability of KCC2-containing neurons as well as the changes in the pattern of KCC2 distribution in the rat hippocampus following 15 min ischemia induced by four-vessel occlusion. Immunostaining for the 72 kDa heat shock protein (HSP-72) was used to investigate the extent of damage in neuronal populations previously shown to be vulnerable to ischemia. At 6-24 h after ischemia, when the pyramidal cells in the CA1 (subfield of cornu Ammonis) region showed no morphological signs of damage, a small rise of KCC2 immunoreactivity was already observed. After 2 days, when the CA1 pyramidal cells started to degenerate, a progressive downregulation of the KCC2 protein was visible. Interestingly, in the same areas, the parvalbumin containing interneurons showed no signs of ischemic damage, and KCC2 immunoreactivity was retained on their membrane surface. In CA1 pyramidal cells, the reduction in KCC2 expression may lead to an elevation of intracellular Cl(-) concentration, which causes a shift in equilibrium potential toward more positive levels. Consequently, the reduction of the inhibitory action of GABA through downregulation of KCC2 function may be involved in the pathomechanisms of delayed neuronal death in the CA1 subfield.

Quantitative ultrastructural differences between local and medial septal GABAergic axon terminals in the rat hippocampus.

Functionally distinct subsets of hippocampal inhibitory neurons exhibit large differences in the frequency, pattern and short-term plasticity of GABA release from their terminals. Heterogeneity is also evident in the ultrastructural features of GABAergic axon terminals examined in the electron microscope, but it is not known if or how this corresponds to interneuron subtypes. We investigated the feasibility of separating morphologically distinct clusters of terminal types, using the approach of measuring several ultrastructural parameters of GABAergic terminals in the CA1 area of the rat hippocampus. Septo-hippocampal axon terminals were anterogradely labeled by biotinylated dextran amine and visualized by pre-embedding immunogold staining to delineate one homogeneous terminal population. Long series (100-150) of ultrathin sections were cut from stratum oriens and stratum radiatum of the CA1 area, and GABAergic terminals were identified by post-embedding immunogold staining. Stereologically unbiased samples of the total GABAergic axon terminal population and a random sample of the septal axon terminals were reconstructed in 3D, and several of their parameters were measured (e.g. bouton volume, synapse surface, volume occupied by vesicles, mitochondria volume). Septal terminals demonstrated significantly larger mean values for most parameters than the total population of local GABAergic terminals. There was no significant difference between terminals reconstructed in the basal and apical dendritic regions of pyramidal cells, neither for the septal nor for the local population. Importantly, almost all parameters were highly correlated, precluding the possibility of clustering the local terminals into non-overlapping subsets. Factor and cluster analysis confirmed these findings. Our results suggest that similarly to excitatory terminals, inhibitory terminals follow an "ultrastructural size principle," and that the terminals of different interneuron subtypes cannot be distinguished by ultrastructure alone.

MR-guided interstitial laser thermotherapy of colorectal liver metastases: efficiency, safety and patient survival.

PURPOSE: Evaluation of MR-guided interstitial laser thermotherapy (ILT) of colorectal liver metastases under consideration of efficacy, safety and patient survival. MATERIALS AND METHODS: Sixty-six inoperable patients with a total of 117 colorectal liver metastases were treated with MR-guided laser therapy in 96 sessions. 40.9% of patients presented metastases from rectum carcinoma, 30.3% from sigmoid carcinoma and 28.8% from colon carcinoma. Inclusion criteria were < or =5 metastases < or =5 cm in greatest diameter and no extrahepatic tumor spread. Internally water-cooled 9F power-laser-applicators were placed under CT-fluoroscopy. For MR-guided ILT, a 1064 nm Nd-YAG-lasers with a beam divider with multi applicator technique was used. The energy applied was 10 watt per centimeter diffusor length, with the diffusor length ranging from 20 to 40 mm. The mean duration of the energy application was 23 minutes (range: 15 - 37 minutes). The endpoint of the laser ablation was defined as the absence of hyperintense tumor tissue in the continuously monitored T2-w fat saturated gradient-echo sequences. Follow-up included contrast-enhanced MRI using T1- and T2-weighted spin-echo and gradient-echo sequences every three months after treatment. Survival times were calculated using the Kaplan-Meier method. RESULTS: The median follow-up was 8.7 months (mean 11.8; standard deviation 9.9; range 1 to 36). The overall median progression free survival was 6.1 months (range, 0.3 to 27+ months). Median survival was 23 months (95% CI, 17-29 months). The rate of major complications was 2.1% (n = 2) and peri-procedural mortality (30 days) was 3% (n = 2). After 3, 6, 9, and 12 months, local tumor control was 98.3%, 91.4%, 76.1%, and 69.4%, respectively. In no patient metastatic deposits along the catheter access route were found. CONCLUSIONS: In patients with colorectal liver metastases, interstitial laser thermotherapy is an effective and safe therapeutic option and therefore suitable not only in palliative situations.

Correlated species differences in the effects of cannabinoid ligands on anxiety and on GABAergic and glutamatergic synaptic transmission.

Cannabinoid ligands show therapeutic potential in a variety of disorders including anxiety. However, the anxiety-related effects of cannabinoids remain controversial as agonists show opposite effects in mice and rats. Here we compared the effects of the cannabinoid agonist WIN-55,212 and the CB1 antagonist AM-251 in CD1 mice and Wistar rats. Special attention was paid to antagonist-agonist interactions, which had not yet been studied in rats. In mice, WIN-55,212 decreased whereas AM-251 increased anxiety. The antagonist abolished the effects of the agonist. In contrast, WIN-55,212 increased anxiety in rats. Surprisingly, the antagonist potentiated this effect. Cannabinoids affect both GABAergic and glutamatergic functions, which play opposite roles in anxiety. We hypothesized that discrepant findings resulted from species differences in the relative responsiveness of the two transmitter systems to cannabinoids. We investigated this hypothesis by studying the effects of WIN-55,212 on evoked hippocampal inhibitory and excitatory postsynaptic currents (IPSCs and EPSCs). IPSCs were one order of magnitude more sensitive to WIN-55,212 in mice than in rats. In mice, IPSCs were more sensitive than EPSCs to WIN-55,212. This is the first study showing that the relative cannabinoid sensitivity of GABA and glutamate neurotransmission is species-dependent. Based on behavioural and electrophysiological findings, we hypothesize that WIN-55,212 reduced anxiety in mice by affecting GABA neurotransmission whereas it increased anxiety in rats via glutamatergic mechanisms. In rats, AM-251 potentiated this anxiogenic effect by inhibiting the anxiolytic GABAergic mechanism. We suggest that the anxiety-related effects of cannabinoids depend on the relative cannabinoid responsiveness of GABAergic and glutamatergic neurotransmission.

Morphology and synaptic input of substance P receptor-immunoreactive interneurons in control and epileptic human hippocampus.

Substance P (SP) is known to be a peptide that facilitates epileptic activity of principal cells in the hippocampus. Paradoxically, in other models, it was found to be protective against seizures by activating substance P receptor (SPR)-expressing interneurons. Thus, these cells appear to play an important role in the generation and regulation of epileptic seizures. The number, distribution, morphological features and input characteristics of SPR-immunoreactive cells were analyzed in surgically removed hippocampi of 28 temporal lobe epileptic patients and eight control hippocampi in order to examine their changes in epileptic tissues. SPR is expressed in a subset of inhibitory cells in the control human hippocampus, they are multipolar interneurons with smooth dendrites, present in all hippocampal subfields. This cell population is considerably different from SPR-positive cells of the rat hippocampus. The CA1 (cornu Ammonis subfield 1) region was chosen for the detailed morphological analysis of the SPR-immunoreactive cells because of its extreme vulnerability in epilepsy. The presence of various neurochemical markers identifies functionally distinct interneuron types, such as those responsible for perisomatic, dendritic or interneuron-selective inhibition. We found considerable colocalization of SPR with calbindin but not with parvalbumin, calretinin, cholecystokinin and somatostatin, therefore we suppose that SPR-positive cells participate mainly in dendritic inhibition. In the non-sclerotic CA1 region they are mainly preserved, whereas their number is decreased in the sclerotic cases. In the epileptic samples their morphology is considerably altered, they possessed more dendritic branches, which often became beaded. Analyses of synaptic coverage revealed that the ratio of symmetric synaptic input of SPR-immunoreactive cells has increased in epileptic samples. Our results suggest that SPR-positive cells are preserved while principal cells are present in the CA1 region, but show reactive changes in epilepsy including intense branching and growth of their dendritic arborization.

Subcellular localization of type 1 cannabinoid receptors in the rat basal ganglia.

Endocannabinoids, acting via type 1 cannabinoid receptors (CB1), are known to be involved in short-term synaptic plasticity via retrograde signaling. Strong depolarization of the postsynaptic neurons is followed by the endocannabinoid-mediated activation of presynaptic CB1 receptors, which suppresses GABA and/or glutamate release. This phenomenon is termed depolarization-induced suppression of inhibition (DSI) or excitation (DSE), respectively. Although both phenomena have been reported to be present in the basal ganglia, the anatomical substrate for these actions has not been clearly identified. Here we investigate the high-resolution subcellular localization of CB1 receptors in the nucleus accumbens, striatum, globus pallidus and substantia nigra, as well as in the internal capsule, where the striato-nigral and pallido-nigral pathways are located. In all examined nuclei of the basal ganglia, we found that CB1 receptors were located on the membrane of axon terminals and preterminal axons. Electron microscopic examination revealed that the majority of these axon terminals were GABAergic, giving rise to mostly symmetrical synapses. Interestingly, preterminal axons showed far more intense staining for CB1, especially in the globus pallidus and substantia nigra, whereas their terminals were only faintly stained. Non-varicose, thin unmyelinated fibers in the internal capsule also showed strong CB1-labeling, and were embedded in bundles of myelinated CB1-negative axons. The majority of CB1 receptors labeled by immunogold particles were located in the axonal plasma membrane (92.3%), apparently capable of signaling cannabinoid actions. CB1 receptors in this location cannot directly modulate transmitter release, because the release sites are several hundred micrometers away. Interestingly, both the CB1 agonist, WIN55,212-2, as well as its antagonist, AM251, were able to block action potential generation, but via a CB1 independent mechanism, since the effects remained intact in CB1 knockout animals. Thus, our electrophysiological data suggest that these receptors are unable to influence action potential propagation, thus they may not be functional at these sites, but are likely being transported to the terminal fields. The present data are consistent with a role of endocannabinoids in the control of GABA, but not glutamate, release in the basal ganglia via presynaptic CB1 receptors, but also call the attention to possible non-CB1-mediated effects of widely used cannabinoid ligands on action potential generation.

CB1 cannabinoid receptors are enriched in the perisynaptic annulus and on preterminal segments of hippocampal GABAergic axons.

Cannabinoids have been shown to modulate the inhibitory effect of cholecystokinin-containing GABAergic interneurons in the hippocampus via type 1 cannabinoid receptors (CB1 receptor). Although immunohistochemical studies, using pre-embedding techniques, have demonstrated that these receptors are abundant on GABAergic axon terminals, little is known about their exact location relative to the synapse. Here we used two recently developed antibodies against the CB1 receptor to study this question with the postembedding immunogold method, which allows the quantitative examination of receptor distribution along the axonal membrane, even within the synaptic active zone. CB1 receptor positive terminals target both the dendritic and somatic surface of neurons in the CA1 area of the rat hippocampus. We found no difference between these two populations of terminals either in their CB1 receptor density or in the distribution of receptors on their membrane. Recent studies suggest that endocannabinoids play a role in retrograde signaling at these synapses, i.e. signaling molecules diffuse from the postsynaptic membrane to nearby presynaptic terminals. Therefore, we examined the distribution of CB1 receptors on the terminal membranes. We found that they are rare in the synaptic active zone, but are enriched in the perisynaptic annulus, where they can directly influence synaptic calcium channels. Perisynaptic CB1 receptors represent about one tenth of all CB1 receptors in a terminal. In contrast, CB1 receptors have a lower density on the extrasynaptic membrane of terminals far from the postsynaptic cell. We estimated that these terminals contain exceptionally large numbers of CB1 receptors, i.e. a single axon terminal was usually labeled with more than 450 particles. An unexpected finding was that the density of CB1 receptors was significantly higher on preterminal axons than on synaptic terminals. These observations suggest that endocannabinoid signaling may subserve roles other than simply reducing transmitter release from axon terminals.

Cannabinoid CB1 receptor dependent effects of the NMDA antagonist phencyclidine in the social withdrawal model of schizophrenia.

Clinical and laboratory findings suggest that cannabinoid signalling is implicated in schizophrenia. However, the interaction remains poorly understood, as data are often contradictory. Here we investigated wild-type (WT) and cannabinoid CB1 receptor-knockout (CB1-KO) mice in the phencyclidine-induced social withdrawal model of schizophrenia. N-methyl-D-aspartate (NMDA) antagonists (including phencyclidine) induce psychotic symptoms in humans, and are used to model schizophrenia in a variety of experimental conditions. In WTs, 5 mg/kg phencyclidine increased locomotion and stereotyped behaviours, and decreased social interactions. These changes are consistent with a schizophrenia-like effect. In CB1-KOs, phencyclidine decreased locomotion, enhanced ataxia and stereotypy more markedly than in WTs, but did not affect social interactions. Locomotion showed a significant negative correlation with both ataxia and stereotypy, suggesting that in CB1-KOs, the locomotor suppressive effect of phencyclidine was secondary to changes in these variables. Our findings demonstrate that CB1 gene disruption dramatically alters the behavioural effects of the NMDA antagonist phencyclidine, suggesting that the CB1 receptor is involved in schizophrenia. As social disruption and stereotypy respectively are believed to model negative and positive symptoms of schizophrenia, our findings tentatively suggest that cannabinoids are differentially involved in these two symptom categories. These findings require verification by experiments involving CB1 receptor blockers, as the genetic and pharmacological blockade of receptors may not always provide similar results.

Colon dissection: a new three-dimensional reconstruction tool for computed tomography colonography.

PURPOSE: To improve the sensitivity of computed tomography (CT) colonography in the detection of polyps by comparing the 3D reconstruction tool "colon dissection" and endoluminal view (virtual colonoscopy) with axial 2D reconstructions. MATERIAL AND METHODS: Forty-eight patients (22 M, 26 F, mean age 57 +/- 21) were studied after intra-anal air insufflation in the supine and prone positions using a 16-slice helical CT (16 x 0.625 mm, pitch 1.7; detector rotation time 0.5 s; 160 mAs und 120 kV) and conventional colonoscopy. Two radiologists blinded to the results of the conventional colonoscopy analyzed the 3D reconstruction in virtual-endoscopy mode, in colon-dissection mode, and axial 2D slices. RESULTS: Conventional colonoscopy revealed a total of 35 polyps in 15 patients; 33 polyps were disclosed by CT methods. Sensitivity and specificity for detecting colon polyps were 94% and 94%, respectively, when using the "colon dissection", 89% and 94% when using "virtual endoscopy", and 62% and 100% when using axial 2D reconstruction. Sensitivity in relation to the diameter of colon polyps with "colon dissection", "virtual colonoscopy", and axial 2D-slices was: polyps with a diameter >5.0 mm, 100%, 100%, and 71%, respectively; polyps with a diameter of between 3 and 4.9 mm, 92%, 85%, and 46%; and polyps with a diameter < 3 mm, 89%, 78%, and 56%. The difference between "virtual endoscopy" and "colon dissection" in diagnosing polyps up to 4.9 mm in diameter was statistically significant. CONCLUSION: 3D reconstruction software "colon dissection" improves sensitivity of CT colonography compared with the endoluminal view.