By A. Kapotth. Marian College.
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MALENKA The most fascinating and important property of the mam- SHORT-TERM SYNAPTIC PLASTICITY malian brain is its remarkable plasticity, which can be thought of as the ability of experience to modify neural Virtually every synapse that has been examined in organisms circuitry and thereby to modify future thought, behavior, ranging from simple invertebrates to mammals exhibits nu- and feeling. Thinking simplistically, neural activity can merous different forms of short-term synaptic plasticity that modify the behavior of neural circuits by one of three mech- last on the order of milliseconds to a few minutes (for de- anisms: (a) by modifying the strength or efficacy of synaptic tailed reviews, see 1 and 2). In general, these result from a transmission at preexisting synapses, (b) by eliciting the short-lasting modulation of transmitter release that can growth of new synaptic connections or the pruning away occur by one of two general types of mechanisms. One of existing ones, or (c) by modulating the excitability prop- involves a change in the amplitude of the transient rise in erties of individual neurons. Synaptic plasticity refers to the intracellular calcium concentration that occurs when an ac- first of these mechanisms, and for almost 100 years, activity- tion potential invades a presynaptic terminal. This occurs dependent changes in the efficacy of synaptic communica- because of some modification in the calcium influx before tion have been proposed to play an important role in the transmitter release or because the basal level of calcium in remarkable capacity of the brain to translate transient expe- the presynaptic terminal has been elevated because of prior riences into seemingly infinite numbers of memories that activity at the terminal. A second mechanism occurs down- can last for decades. Because of its fundamental importance, stream of calcium elevation in the presynaptic terminal and there has been an enormous amount of work describing involves some modulation of the biochemical processes in- the many forms of synaptic plasticity and their underlying volved in synaptic vesicle exocytosis. Synaptic transmission can either be enhanced or de- Paired-Pulse Facilitation and Depression pressed by activity, and these alterations span temporal do- mains ranging from milliseconds to enduring modifications When two presynaptic stimuli are delivered within a short that may persist for days or weeks and perhaps even longer. More lasting changes are thought to play impor- vals. Given these diverse functions, it is not sur- presynaptic plasma membrane, waiting to be released. Many prising that many forms and mechanisms of synaptic plastic- synapses at longer interstimulus intervals (20to 500milli- seconds) exhibit paired-pulse facilitation that is thought to ity have been described. In this chapter, I provide a brief result from the influx of calcium that occurs in response to overview of some of the forms of synaptic plasticity found the first action potential. Malenka: Department of Psychiatry and Behavioral Sciences, tial facilitation. However, with a single action potential, the Stanford University School of Medicine, Palo Alto, California. Furthermore, given that presynaptic pro- there is much interest in the possibility that transient modu- teins that may be involved in short-term plasticity may be lation, by activation of protein kinases, of some of the pre- abnormal in neuropsychiatric disorders (11), it is not unrea- synaptic phosphoproteins that are known to be involved in sonable to speculate that abnormal short-term synaptic dy- the control of transmitter release may play an important namics in specific neural circuits may contribute to the path- role in very short-term synaptic plasticity. For example, ophysiology of any number of mental illnesses. Whether a specific synapse displays paired-pulse facilita- During the last decade, there was enormous interest in eluci- tion or depression depends on the initial state of the synapse dating the mechanisms responsible for activity-dependent and its recent history of activation. Because these forms of long-lasting modifications in synaptic strength.
However discount 100 mg caverta with mastercard erectile dysfunction and diabetes treatment, 1 month treatment of piroxicam or sulindac was associated with a significant decrease in creatinine clearance purchase caverta without prescription erectile dysfunction treatment gurgaon. Users of pyrazolones had NS risk of ESRD compared with nonusers buy caverta overnight delivery erectile dysfunction doctor memphis. Users of non-aspirin NSAIDs had NS risk of ESRD compared with nonusers. Sub-analysis showed regular use of aspirin compared with non-use of aspirin was significantly associated with increased risk of chronic renal failure in people with diabetic nephropathy, glomerulonephritis, nephrosclerosis, or hereditary renal disease. The GDG also accepted that nephrotoxic drugs may affect progression. Of particular concern are the possible acute and chronic effects of NSAIDs which are available without prescription. Acute use of NSAIDs can lead to an acute and usually reversible fall in GFR but chronic use at therapeutic doses could be associated with progression of CKD. It was recommended that if chronic use of NSAIDs was considered clinically necessary the effect on GFR should be monitored and the drugs should be stopped if there is evidence of progressive CKD. The evidence about possible adverse effects of aspirin was felt to be confounded by the use of aspirin in patients with cardiovascular disease which is a known risk factor for progression of CKD. The evidence on the effects of smoking and ethnicity on the risk of progression was not conclusive but was sufficiently suggestive to merit highlighting within a recommendation. The evidence on the effects of obesity on the risk of progression was unconvincing and did not require highlighting within a recommendation. Despite the lack of evidence for urinary outflow tract obstruction for progression of CKD, the GDG consensus was that obstruction to outflow would lead to progression of CKD. Therefore it was agreed that urinary outflow tract obstruction should be considered as a risk factor. These risk factors are: q cardiovascular disease q proteinuria q hypertension q diabetes q smoking q black or Asian ethnicity q chronic use of non-steroidal anti-inflammatory drugs (NSAIDs) q urinary outflow tract obstruction. R29 In people with CKD the chronic use of NSAIDs may be associated with progression and acute use is associated with a reversible fall in glomerular filtration rate (GFR). Exercise caution when treating people with CKD with NSAIDs over prolonged periods of time. Monitor the effects on GFR, particularly in people with a low baseline GFR and/or in the presence of other risks for progression. The answer to this predominantly lies in 3 main areas: diagnosis and treatment of treatable kidney disease, identification and control of risk factors for progression of CKD and planning for renal replacement therapy in patients progressing to end stage renal disease. The area that has deservedly received the most attention is planning for renal replacement therapy. There is abundant literature detailing the negative effect of late referral of patients with advanced CKD. Late referral leads to increased morbidity and mortality, increased length of hospital stay, and increased costs. The dominant factor though is insufficient time to prepare the patient for dialysis, particularly the establishment of permanent vascular access for haemodialysis. A CKD management programme encompasses blood pressure control and reduction of proteinuria, treatment of hyperlipidaemia, smoking cessation and dietary advice, treatment of anaemia, treatment of acidosis and metabolic bone disease, and just as importantly, the provision of timely and understandable information and education. The converse question though is how much of what nephrologists do could be done just as safely and effectively in primary care, and how much of an overlap is there between nephrology, diabetes, cardiology and the care of older people? Seven papers were identified and all were excluded as they were narrative reviews or guidelines. The GDG considered the recommendations in other guidelines on who should be referred and also considered the aims and benefits of referral from their own professional standpoint. The GDG noted that section 5 and section 6 of the guideline had reviewed evidence relating to level of eGFR, proteinuria and risk factors for CKD and progression of CKD. From this evidence a consensus was reached regarding appropriate referral criteria in these areas. The GDG agreed that all people with a rapidly declining GFR and those with stage 4 and 5 CKD (with or without diabetes) should be referred, as well as those with heavy proteinuria unless this was already known to be due to diabetes and was being appropriately treated. The GDG agreed that specialist care can be provided by GPs, specialist nurses, renal nurses, geriatricians, diabetologists, cardiologists and nephrologists and that referral did not necessarily mean that the individual had to attend an out-patient clinic. In some situations advice could be obtained by correspondence. Furthermore, once an individual had been seen in a specialist clinic and a management plan agreed, it may be possible for their future care to be carried out by the referring clinician rather than the specialist. The GDG recommended that if people with lower urinary tract symptoms required referral, this should initially be to urological services. R31 Consider discussing management issues with a specialist by letter, email or telephone in cases where it may not be necessary for the person with CKD to be seen by the specialist. If this is the case, criteria for future referral or re-referral should be specified. R34 People with CKD and renal outflow obstruction should be referred to urological services, unless urgent medical intervention is required, e. In rat models of CKD, exercise training has been shown to be renoprotective. Equally, there may be insufficient adjustment of potential confounders. Obesity leads to CKD through diabetes and hypertension but is it an independent risk factor for CKD? Similarly, although it is suggested that smoking and physical inactivity contribute to progression of CKD, is this a direct or indirect effect, and is there a relationship to gender? There were no smoking cessation studies in a CKD population. All of these studies were limited by small sample sizes. Observational studies that assessed the association of smoking, obesity, alcohol consumption, or exercise with progression of CKD were therefore included. One RCT examined changes in GFR, muscle strength, and total body potassium over 3 months in people aged over 50 years old with CKD on a low protein diet randomised to resistance training (N=14) or sham training (N=12). One RCT190 and two before-and-after observational studies191,192 investigated the effect of weight loss on renal disease progression in obese, mostly diabetic populations. RCT compared a low-calorie diet (N=20, 5-months follow-up, reduction of 500 kcal, consisting 89 Chronic kidney disease of 25–30% fat and 55–65% carbohydrate, and protein content adjusted to 1. The effect of smoking on renal functional decline was examined in two diabetic cohort studies and two case-control studies. A German diabetic cohort of smokers (N=44, mean age 47 years, 86% had baseline proteinuria >0. Progression to ESRD was compared between males who smoked for 0–5 pack-years (N=73), for 5–15 pack years (N=28), and for >15 pack years (N=43). One person in the control group died, and 1 person in the control group withdrew after 10 months for personal reasons.
Lithium treatment also decreases responsive to a multitude of signals and is unlikely to define phosphorylation of MAP-1 generic caverta 100 mg amex erectile dysfunction remedies natural, a microtubule-associated pro- the specific action underlying the therapeutic effect of lith- tein involved in microtubule dynamics within the growth ium in BPD discount caverta 50 mg with mastercard erectile dysfunction doctor pune. Future studies may fruitfully examine a poten- cone and axonal outgrowth (141) cheap caverta 50 mg without prescription erectile dysfunction treatment natural remedies. Lithium-induced de- tial role for lithium in the regulation of newly discovered phosphorylation of MAP-1 reduces its ability to bind to candidate genes linked to BPD (128), in addition to those microtubules; in cerebellar granule neurons, this effect was implicated in its pathophysiology (129). Thus, it is possible account for recent findings of a neuroprotective effect in under the appropriate conditions that inhibition of GSK- some cell systems. A number of groups have demonstrated 3 by lithium can induce significant changes in microtubule a neuroprotective effect of lithium in systems both in vivo assembly that result in changes in the association dynamics and in vitro against a variety of insults, including glutamate- among cytoskeletal proteins mediating neuroplastic changes induced excitatory apoptosis (130–132). The B-cell lymphoma/ lates the expression of the PKC substrate MARCKS in leukemia 2 gene (bcl2), abundantly present in mammalian brain, as noted previously. MARCKS is a complex protein Chapter 79: Mechanism of Action of Antidepressants and Mood Stabilizers 1147 that binds calmodulin in a calcium-dependent manner; it ANTIDEPRESSANTS also binds and cross-links filamentous actin, thereby confer- Neurotransmitter Signaling ring focal rigidity to the plasma membrane. Following phos- phorylation of its phosphorylation site domain in the pres- Antidepressants are usually classified according to structure ence of activated PKC, MARCKS translocates from the [e. Thus, this protein is in a key position to trans- reuptake inhibitors (SSRIs)]. However, it may be more use- duce extracellular signals to alterations in the conformation ful to classify them according to the acute pharmacologic of the actin cytoskeleton, which are critical to cellular pro- effects that are presumed to trigger behavioral improvement. First are the drugs that selectively ronal growth cones, developmentally regulated, and neces- blockthe reuptake of norepinephrine (NE). These include sary for normal brain development (144–146). MARCKS certain TCAs and TCA-like compounds (maprotiline). An- expression remains elevated in specific regions of the hippo- other drug that falls into this category is reboxetine, al- campus and limbic-related structures, which retain the po- though it is distinct structurally from the TCAs and TCA- tential for plasticity in the adult rat (147,148) and human like compounds (152). It is currently available as an antide- brain (149), and its expression is induced in the mature pressant in European and South American countries but is central nervous system during axonal regeneration (150). Second are the SSRIs, Recent studies support a role for MARCKS in plastic events which, as their class name implies, selectively blockthe reup- associated with learning and memory. Induction of long- take of serotonin [5-hydroxytryptimine (5-HT)] in vivo. Moreover, adult mutant mice ment of synaptic transmission. Some TCAs are in this cate- expressing MARCKS at 50% exhibit significant spatial gory, as are the MAOIs. Some novel drugs are also in this learning deficits that are reversed in the presence of a category. One of these is venlafaxine, discussed in more MARCKS transgene (144). Mirtazapine is not a MARCKS plays an important role in the mediation of neu- potent inhibitor of the reuptake of either NE or 5-HT roplastic processes in the developing and mature central (153). It is a relatively potent antagonist, though, of inhibi- nervous system. Thus, by virtue of its action in signaling tory 2 autoreceptors on noradrenergic nerves. By blocking pathways utilizing PI/PKC and GSK-3 cascades (Fig. Thus, even though it synaptic and postsynaptic membrane structure to stabilize is not a reuptake inhibitor, mirtazapine can directly enhance aberrant neuronal activity in critical regions of the brain NE-mediated transmission (154–156). In this respect, then, involved in the regulation of mood (92). MECHANISM-BASED CLASSIFICATION FOR ANTIDEPRESSANTS Current Category Mechanism Examples Classification (If Any) I Selective blockade of NE DMI, NT amoxapine, TCAs reuptake (SNRIs) maprotiline reboxetine TCA-like — II Selective blockade of 5-HT Citalopram, fluoxetine, SSRIs reuptake (SSRIs) paroxetine, sertraline III Nonselective enhancement IMI, AMI phenelzine, TCAs of NE and 5-HT tranylcypromine MAOIs transmission venlafaxine mirtazapine (sometimes with SSRIs) — IV Unknown potent trimipramine bupropion TCA stimulatory effects on NE nefazodone, trazodone — or 5-HT — 5-HT, 5-hydroxytryptamine (serotonin); AMI, amitriptyline; DMI, desipramine; IMI, imipramine; MAOI, monoamine oxidase inhibitor; NE, norepinephrine; NT, nortriptyline; SNRI, selective norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant. However, mirtazapine may also enhance seroto- norepinephrine transporter (NET) or serotonin transporter ninergic transmission, albeit indirectly (157–159). These studies were also carried hancement is caused in part by NE activation of 1 nora- out in brain tissue, usually from rats. The potencies of drugs drenergic receptors located on serotoninergic soma and to produce such effects were thought to be reflective of their dendrites to increase cell firing and the release of 5-HT potencies at blocking NE or 5-HT uptake clinically. Mirtazapine may also blockinhibitory 2adreno- cloning of the SERT and NET in the early 1990s enabled ceptors located on serotoninergic terminals (i. However,somerecentdatacallintoquestion these are studies in which the human NET (hNET) or the likelihood that mirtazapine enhances serotoninergic human SERT (hSERT) is transfected, often stably, into cells transmission (163). Whether mirtazapine increases seroto- that normally do not have any NET or SERT. These cells ninergic transmission may depend on the state of activation can be maintained in cell culture systems and used to mea- of the centralnoradrenergic system when the drugis adminis- sure the uptake of 3H-NE and 3H-5-HT by the hNET and tered. At this hSERT, respectively, and the binding of radioligands to the time, we have placed mirtazapine in the third category. Further, such cells can be used to mea- In the fourth and final heterogeneous group are drugs sure the potencies of antidepressants to blocksuch effects. In other words, their mechanisms of action tages of such systems are equally obvious—namely, they are unknown. Drugs in this category include the TCA trimi- are artificial, and a variety of factors can influence results pramine and also bupropion, nefazodone, and trazodone. As Kenakin (173) has written, 'Transfecting the It has been speculated that bupropion acts through dopami- cDNA of a receptor protein into a foreign cell and expecting nergic mechanisms because it is the only antidepressant that a physiologic system can be likened to placing the Danish more potently blocks the reuptake of dopamine than that King Hamlet on the moon and expecting Shakespeare to of either NE or 5-HT (164). Irrespective whether bupropion inhibits dopamine reuptake in patients of the noradrenergic parameter chosen (Table 79. Also, citalo- (164), but the efficacy of bupropion cannot at this time be pram is the least potent drug on all measures. Perhaps the attributed to effects on noradrenergic transmission. In general, these values done on serotoninergic or noradrenergic systems is their tend to be sixfold to 10-fold higher (i. They are very weak than those found to inhibit such uptake into rat brain synap- inhibitors of NE reuptake and relatively weak inhibitors tosomes. An interesting specific difference is seen with ven- of 5-HT reuptake (167). If enhancement of serotoninergic lafaxine; its potency to inhibit 3H-NE uptake by rat brain transmission is a mechanism that ultimately leads to clinical is five to eight times greater than its potency on the other efficacy, it is not clear how antagonism of the 5-HT2Arecep- noradrenergic parameters. For serotoninergic parameters tor produces such enhancement. Some data indicate that also, the rankorder of potencies appears reasonably similar 5-HT2-receptor antagonism enhances 5-HT1A-receptor re- irrespective of the specific parameter—namely, paroxetine sponsivity (168,169), or that 5-HT2-receptor antagonists sertraline citalopram fluoxetine imipramine share discriminative stimulus properties with 5-HT1A- venlafaxine amitriptyline nortriptyline desipramine receptor antagonists (170). However, the potencies found for most of such effects (171), and whether such an effect would en- the drugs to inhibit hSERT binding are greater than those hance endogenous serotoninergic transmission is uncertain. Subsequently, radioligand binding increases the likelihood that an effect will occur clinically, techniques were developed such that the potencies of antide- and low potency (e.
Side effects reduce overall patient satisfaction cheap caverta 50 mg amex erectile dysfunction medicine in homeopathy, and techniques that reduce opioid requirements may be of benefit buy caverta with mastercard erectile dysfunction treatment home remedies. Some authors state that IIB or TAPB may offer no benefit on pain control compared to neuraxial morphine (Costello 2009 buy 100mg caverta visa erectile dysfunction drugs herbal, Kanazi 2010, McMorrow 2011). The addition of morphine to the local anesthetic is easier to perform, is less time-consuming and does not require extra equipment or skills to be performed (Kanazi 2010). In a study, patients receiving both subarachnoid anesthesia with 0,1 mg morphine and a TAPB had a higher incidence of pruritus and anti-emetic use. Less pain on movement and later postoperative morphine request were shown by patients receiving subarachnoid morphine compared to saline (McMorrow 2011). Gynecologic Surgery Few trials have evaluated abdominal blocks for gynecologic surgery. Bilateral IIB for total abdominal hysterectomy or prolapse repair through a Pfannenstiel incision under general anesthesia has shown to reduce prevalently dynamic pain and morphine need. In a study the reduction of morphine was 51% (21 +/- 9 mg vs. Bilateral TAPB in total abdominal hysterectomy significantly reduced morphine requirements at all time points for 48 hours. A longer time to first morphine request and reduced postoperative pain scores at rest and on movement were shown compared to the placebo (Carney 2008 (2)). The reduction in pain scores is often not significant, suggesting the existence of additional pain from deep pelvic dissection and suturing of the vaginal vault during hysterectomy 78 | Ultrasound Blocks for the Anterior Abdominal Wall (Kelly 1996). Recently, a trial on women undergoing pubic to umbilical midline incision for heterogeneous gynecologic malignancy, showed no benefit of ultrasound-guided TAPB on analgesic requirement, pain scores, adverse effects and satisfaction over multimodal analgesia (Griffiths 2010). Other Abdominal Surgery Procedures Andrea Pradella, Tommaso Mauri Lower Abdominal Surgery Lower abdominal surgery includes varicocelectomy, appen- dicectomy, open prostatectomy, lumbectomy and intra-aortic procedures with femoral artery cannulation. Surgical reports on awake varicocelectomy show the efficacy of local anesthetic infiltration beneath the aponeurosis of the EOM into the inguinal canal to block the ilioinguinal and genitofemoral nerves (Hsu 2005). Recently, an effective ultrasound-guided spermatic cord block was reported (Wipfli 2011). In the only randomized study in adults undergoing varicocelectomy under general anesthesia and an IIB before surgery, patients experienced significantly reduced postoperative pain scores at rest and during mobilization, less analgesic consumption, less nausea and vomiting and were all discharged at 6 hours (Yazigi 2002). The IIB and the TAPB have also been evaluated in the performance of appendicectomy. The IIB performed before surgery in children undergoing appendicectomy showed better 80 | Ultrasound Blocks for the Anterior Abdominal Wall pain scores and less analgesic consumption for 6 hours (Courrèges 1996). The reduced pain and postoperative morphine consumption effects of ultrasound-guided TAPB in appendicectomy may last for 24 hours (Niraj 2009 (2)). TAPB for laparoscopic appendicectomy in children has been shown to offer no important clinical benefit over local anesthetic port-site infiltration (Sandeman 2011). Ultrasound-guided TAPB has also been evaluated in patients scheduled for major orthopedic surgery and anterior iliac crest harvest for autologous bone graft, with pain abolished for the first 48 hours (Chiono 2010). Upper Abdominal Surgery TAPB is an effective method of blocking the sensory afferents supplying the anterior abdominal wall. However, the classical TAPB may not reliably produce analgesia above the umbilicus (Shibata 2007). The subcostal TAPB involves injection immediately inferior to the costal margin. It has been reported to provide analgesia for incisions extending above the umbilicus (Hebbard 2008). A further development of the subcostal TAPB is the possibility to place a catheter along the oblique subcostal line in the TAM plane for continuous infusion of local anesthetic (Niraj 2011, Hebbard 2010). An ultrasound-guided technique with a Tuohy epidural needle and catheter may be used in this case. Bowel surgery TAPB in adults undergoing large bowel resection via a midline abdominal incision resulted in a significant reduction of pain scores and morphine requirements for the first 24 postoperative hours (21. Other Abdominal Surgery Procedures | 81 TAPB employed for laparoscopic colonic-rectal resections reduces overall postoperative morphine (31. In a retrospective analysis of patients undergoing laparoscopic colonic-rectal resection, an ultrasound-guided TAPB significantly reduced time to the resumption of diet and postoperative hospital stay (Zafar 2010). Ultrasound-guided TAPB in patients undergoing laparoscopic cholecystectomy was associated with a significant reduction in the administration of intraoperative sufentanyl and postoperative morphine (10. Kidney surgery TAPB may reduce pain scores and morphine requirements in patients undergoing renal transplant (Jankovic 2009 (2)). Pain scores and intraoperative opioid need may be reduced for 12 hours (Mukhtar 2010). Kidney transplant recipients receiving IIB and block of T11 to 12 intercostal nerves show reduced postoperative pain and total morphine consumption (12. Subcostal bilateral TAPB with catheters compared to epidural analgesia in adult patients undergoing elective open hepatic-biliary or kidney surgery, provided no significant differences in pain scores at rest and during coughing at 8, 24, 48 and 72 h after surgery. Tramadol consumption was significantly greater in the TAP group (Niraj 2011). After the flap resection, the fibers of the EOM and IOM are separated until the TAM is visualized and local anesthetic is injected bilaterally. Similarly, patients receiving a combination of intercostal, iliohypogastric, ilioinguinal and pararectus blocks for abdominoplasty, showed successful long-term relief of pain and a significantly reduced recovery time, allowing the patient to return to normal activities and work much sooner (Feng 2010). Abdominal Midline Surgery Savino Spadaro, Tommaso Mauri The rectus sheath block (RSB) is safe, easy to learn and perform, and provides the anesthesiologist with another method for effective and long-lasting analgesia for common day-case procedures. The RSB has been described both in adults and in children. Although regional anesthesia techniques are commonly used for postoperative pain control in children, there have been few studies investigating the efficacy of RSB. The technique is recommended for midline laparoscopy where it provides effective analgesia. The onset of analgesia is usually evident within five to ten minutes and provides excellent operative conditions with muscular relaxation (Smith 1988). In children, RSB is a simple block that provides intra- and postoperative analgesia for umbilical, paraumbelical and epigastric hernia repair. Another potential use of RSB is for analgesia after pyloromyotomy. In adults, the RSB may be an alternative to epidural anesthesia for some surgical procedures (Azemati 2005). The RSB has also been described as particularly useful to improve postoperative analgesia after midline laparotomy for umbilical or epigastric hernia repair in high risk patients. However, a pilot study failed to demonstrate the advantage of RSB over infiltration for umbilical hernia repair (Isaac 2006). Local Anesthetics, Pharmacokinetics and Adjuvants Amedeo Costantini The action of local anesthetics is elicited through a specific block of the sodium channels in the peripheral and central nervous system.