Methadone and ketamine have been used in neuropathic pain management, but the benefits of the association of both drugs are uncertain. Aiming to enhance the analgesic efficacy and to reduce the occurrence of adverse-effects, an oral solutionof methadone plus ketamine was tested in patients suffering of neuropathic pain of different etiologies and resistant to other analgesics. All patients were treated in the Clinical Care & Pain Management of Santa Maria University Hospital (HUSM) between October 2006 and March 2008. Pain (primary aim) was analyzed before and several times after starting the treatment, through the visual analogical scale (VAS), allodynia and burning or shooting pain evaluation. The development of adverse-effects (secondary aim), such as somnolence, nausea, vomit, dizziness, hallucination, constipation and headache, was also investigated. The first part of this thesis presented the case report of 18 neuropathic pain patients treated with the oral solution of methadone plus ketamine during 6 months.Except for one patient that discontinued the treatment due to intolerable adverse effect, all patients reported pain relief and lowprevalence of adverse effects throughout the treatment. The second part of this thesis presents arandomized, double-blind study conducted with 37 neuropathic patients. Patients were randomly assigned in three treatment groups: methadone group (n=13), ketamine group (n=11) and methadone plus ketaminegroup (n=13). All patients received the designated treatment by oral route, during 3 months. Methadone, ketamine or methadone plus ketamine treatmentgradually (better effect in 30 than in 7 days) and largely (inhibition of about 70% at the end of treatment) reduced the level of neuropathic pain (VAS) with nodifference between the treatment groups.The proportion of patients presenting burning or shooting pain was similarly reduced in all treatmentgroups, but the prevalence of allodynia was significantly reduced only in ketamine group. Excepted for the somnolence that was more prevalent in methadone and methadone plus ketamine groups, the prevalence of the adverse effects was very similar in all treatment groups. All together, the present data show that the combination of methadone plus ketamine was effective to reliefneuropathic pain resistant to other analgesics, though the combination of the two drugs did not show superior efficacy than those reached by methadone or ketamine alone. This study strengthens the use of methadone or ketamine as alternatives to treat neuropathic pain. The drug of choice, however, should be based on the patient background. / Metadona e cetamina têm sido usados no tratamento da dor neuropática, mas os benefícios da associação das duas drogas são desconhecidos. Com o objetivo de melhorar a eficácia analgésica e reduzir a ocorrência de efeitos adversos, uma solução oral de metadona mais cetamina foi testada em pacientes que sofrem de dor neuropática de diferentes etiologias e resistentes a outros tipos de tratamento. Todos os pacientes foram tratados no ambulatório da dor do Hospital Universitário de Santa Maria (HUSM) entre outubro de 2006 e março de 2008. A dor foi analisada antes e várias vezes depois de iniciar o tratamento, através da escala visual analógica (EVA), bem como alodinia, dor em queimação e/ou em choque. Efeitos adversos, como sonolência, náuseas, vômitos, tontura, alucinação, constipação e dor de cabeça, também foram investigados. A primeira parte desta tese apresenta um relato de caso de 18 pacientes com dor neuropática, submetidos ao tratamento com a solução oral de metadona mais cetamina durante seis meses. Exceto para um paciente que descontinuou o tratamento devido a efeitos adversos intoleráveis, todos os pacientes relataram alívio da dor e de baixa prevalência de efeitos adversos ao longo do tratamento. A segunda parte desta tese apresenta um estudo duplo-cego randomizado, realizado com 37 pacientes apresentando dor neuropática de diferentes etiologias. Os pacientes foram divididos aleatoriamente em três grupos de tratamento: grupo metadona (n = 13), grupo cetamina (n = 11) e grupo metadona mais cetamina (n = 13). Todos os pacientes receberam o tratamento designado por via oral, durante 3 meses. O tratamento com metadona, cetamina ou metadona mais cetamina, gradualmente (melhor efeito em 30 do que em 7 dias) e em grande parte (inibição de cerca de 70% no final do tratamento) reduziu o nível de dor neuropática sem apresentar diferença significativa entre os grupos. A dor em queimação ou em choque apresentada pelos pacientes foi igualmente reduzida em todos os grupos de tratamento, mas a prevalência de alodinia foi significativamente reduzida apenas no grupo cetamina. A sonolência foi mais prevalente nos grupos da metadona e metadona mais cetamina, a manifestação dos demais efeitos adversos foi muito semelhante em todos os grupos de tratamento.

Les encéphalites à anticorps (Ac) anti-récepteur NMDA (NMDAR) sont des pathologies auto-immunes nouvellement décrites ciblant un récepteur majeur du système nerveux central, le NMDAR. Les synapses glutamatergiques assurent la majeure partie de la transmission excitatrice du cerveau et les récepteurs ionotropiques au glutamate de type NMDA ont un rôle clé dans la plasticité synaptique, c'est-à-dire les modifications de la force de transmission synaptique constituant le corrélat cellulaire des processus d'apprentissage et de mémoire. Les études in vitro et in vivo de l'effet des Ac anti-NMDAR tendent à montrer une altération de la dynamique des NDMAR et une internalisation. Les Ac auraient un effet pathogénique pouvant expliquer des symptômes. Au cours de ma thèse, j'ai souhaité approfondir la compréhension de cette pathologie sur le plan clinique et mécanistique. Pour cela j'ai étudié les caractéristiques cliniques et histologiques des patients présentant une tumeur maligne associée, me permettant d'établir des recommandations de prise en charge au vu du taux de mortalité plus élevé chez ces patients et d'une fréquence plus importante de tératomes ovariens immatures que dans la population générale. En parallèle j'ai étudié l'effet des Ac anti-NMDAR sur la transmission et la plasticité synaptique dans un modèle murin d'administration chronique des anticorps. Ces études menées en électrophysiologie sur tranches aigües m'ont permis de mettre en évidence un effet des anticorps du LCR sur la plasticité synaptique significatif mais d'amplitude moindre que les études in vitro l'avaient suggéré. Nous avons également montré l'importance de la durée d'exposition aux anticorps / Anti-NMDAR autoimmune encephalitis is a newly described pathology, characterized by the presence of IgG antibodies (Abs) directed against NMDA receptor (NMDAR). Glutamatergic synapses are the main component of excitatory transmission in the adult brain and the ionotropic glutamate receptor NMDAR has a key role in synaptic plasticity. Synaptic plasticity is defined by the synapses property to modify their transmission strength and seems to be the cellular correlate of learning and memory. In vitro and in vivo studies on anti-NMDAR Abs effects showed an altered dynamic at the membrane followed by an internalization of NMDAR. Thus, Abs seem to have a pathogenic effect, able to explain clinical symptoms. During my thesis, I wanted to deepen the understanding of this pathology on the clinical and mechanistic level. To this end, I studied the clinical and histological features of patients with an associated tumor. Results obtained allow me to establish management recommendations considering the high mortality rate in these patients and a higher frequency of immature ovarian teratomas than in the general population. Simultaneously, I studied the effect of anti-NMDAR Abs on synaptic transmission and plasticity in a murine model allowing chronic Abs infusion. These results obtained by electrophysiology on acute slices allowed me to demonstrate an effect of CSF Abs on synaptic plasticity but of less amplitude that the in vitro studies had suggested. Results also highlighted the importance of the duration to antibodies exposure

The polyamines, putrescine, spermidine and spermine, are present in high concentrations in the central nervous system and, because of their policationic nature, they can interact with diverse cellular anionic targets (nucleic acids and proteins) and modulate the learning and memory by interacting with the polyamine binding site at N-methyl-D-aspartate receptor. In this study we investigated the effects of the systemic administration of spermidine and arcaine on the memory of the inhibitory avoidance task in rats. It was also determined whether the effects of the spermidine and arcaine involve state dependence. The animals were trained in an inhibitory avoidance apparatus (0.4 mA, 3s) and tested in the same apparatus 24 hours later. Immediate post-training administration of spermidine (50 mg/kg, i.p.) improved, while arcaine (10 and 30 mg/kg, i.p.) impaired step-down latencies in the inhibitory avoidance test. Administration of spermidine (50 mg/kg, i.p.) 15 minutes before testing did not alter the performance of rats which were injected with spermidine (50 mg/kg, i.p.) or vehicle immediately after training. However, administration of arcaine (30 mg/kg, i.p.) 15 minutes before testing reverted the impairment of memory caused by the administration of arcaine (30 mg/kg, i.p.) immediately after training. Administration of arcaine (30 mg/kg, i.p.) or MK-801 (0.03 mg/kg, i.p.) before testing partially reverted the impairment of memory caused by the administration of arcaine (30 mg/kg, i.p.) or MK-801 (0.03 mg/kg, i.p.) immediately after training, characterizing a crossed state dependence. The results suggest that memory improvement caused by the administration of spermidine immediately after training is not due to state dependence. In contrast, the impairment of memory induced by arcaine is due to state dependence. The crossed state dependence between arcaine and MK-801 supports that state dependence induced by arcaine is related to NMDA receptor hypofunction. / As poliaminas, putrescina, espermidina e espermina estão presentes em altas concentrações no sistema nervoso central e, por sua natureza policatiônica, podem interagir com sítios aniônicos de macromoléculas (ácidos nucléicos e proteínas) e modulam o aprendizado e a memória interagindo com o sítio de ligação das poliaminas no receptor N-metil-D-apartato. Neste estudo nós investigamos os efeitos da administração sistêmica de espermidina e arcaína sobre a memória da tarefa de esquiva inibitória em ratos. Também foi determinado se os efeitos da espermidina e arcaína envolvem dependência de estado. Os animais foram treinados em um aparelho de esquiva inibitória (0,4 mA, 3 seg) e testados no mesmo aparelho, 24 horas depois. A administração imediatamente após o treino de espermidina (50 mg/kg, i.p.) melhorou, enquanto que arcaína (10 e 30 mg/kg, i.p.) prejudicou a latência de descida da plataforma no teste da esquiva inibitória. A administração de espermidina (50 mg/kg, i.p.) 15 minutos antes do teste não afetou a performance dos ratos que foram injetados com espermidina (50 mg/kg, i.p.) ou veículo imediatamente após o treino. Entretanto, a administração de arcaína (30 mg/kg, i.p.) 15 minutos antes do teste reverteu o prejuízo da memória causado pela administração de arcaína (30 mg/kg, i.p.) imediatamente após o treino. A administração de arcaína (30 mg/kg, i.p.) ou MK-801 (0,03 mg/kg, i.p.) antes do teste reverteu parcialmente o prejuízo da memória causado pela administração de arcaína (30 mg/kg) ou MK-801 (0,03 mg/kg) imediatamente após o treino, caracterizando dependência de estado cruzada. Estes resultados sugerem que a melhora da memória causada pela administração de espermidina imediatamente após o treino não é devido à dependência de estado. Em contraste, o prejuízo da memória induzido pela arcaína é devido a uma dependência de estado. A dependência de estado cruzada entre arcaína e MK-801. sugere que a dependência de estado induzida pela arcaína envolve a hipofunção do receptor NMDA.

Acid-sensing ion channels (ASIC) are a class of ligand gated plasma membrane ion channels that are activated by low extracellular pH. During ischemia, ASIC1a are activated and contribute to the demise of neurons. Pharmacological block of ASIC1a provides neuroprotection at delayed time points. However, no endogenous receptors have been implicated in the modulation of ASIC1a activity. The hypothesis presented is that sigma receptor activation inhibits ASIC1a function and ASIC1a-induced [Ca²?]i elevations during acidosis and ischemia, which may be a mechanism by which sigma ligands provide neuroprotection following stroke. This hypothesis is based on the following observations: First, sigma receptors regulate multiple ion channels that become activated during ischemia. Second, ASIC1a remain functionally active hours beyond the ischemic insult and sigma receptors have been shown to be neuroprotective at delayed time points following stroke. Ratiometric Ca²+ fluorometry and whole-cell patch clamp experiments showed that sigma-1 receptor activation depresses elevations in [Ca²+]i and membrane currents mediated by ASIC1a channels in cortical neurons. Furthermore, most of the elevations in [Ca²+]i triggered by acidosis are the result of Ca²+ channels opening downstream of ASIC1a activation. Stimulation of sigma-1 receptors effectively suppressed these secondary Ca²+ fluxes both by inhibiting ASIC1a and the other channels directly. The signaling cascade linking sigma-1 receptors and ASIC1a was determined to involve a pertussis toxin-sensitive G protein and A-Kinase Anchoring Protein 150/calcineurin complex, which resulted in a decrease of acid-induced [Ca²+]i elevations and ASIC1a-mediated currents. Furthermore, immunohistochemical studies confirmed that sigma-1 receptors, ASIC1a and AKAP150 colocalize in the plasma membrane of cortical neuron cell bodies and in the dendritic processes of these cells. Additionally, concurrent exposure to acidosis and ischemia resulted in synergistic potentiation of [Ca²+]i dysregulation. Although ASIC1a activation does not induce long-lived priming of synaptic vesicles for release, channel activation does have a temporal effect on ischemia-mediated [Ca²+]i increases after ischemia onset. Moreover, presynaptic ASIC1a channels promote synaptic transmission during ischemia by overcoming block of neurotransmission and thus enhance postsynaptic [Ca²+]i elevations. Sigma-1 receptor activation decreased ischemia-mediated Ca²+ dysregulation at pH values of 7.4 - 6.0 and prevented the synergistic interaction between ischemia and acidosis.

Selon l'OMS, les troubles dépressifs majeurs (TDM) seront la 2ème cause d'incapacité dans le monde en 2020 et deviendront la 1ère en 2030. Les antidépresseurs classiques ont des effets thérapeutiques retardés et de nombreux patients sont résistants. La kétamine, antagoniste du récepteur N-methyl-D-aspartate (R-NMDA) du L-glutamate, possède un effet antidépresseur rapide chez les patients résistants à un traitement classique. Le mécanisme de cette activité étonnante n'est pas bien compris. En couplant la microdialyse intracérébrale à un test comportemental prédictif d'une activité antidépressive dans un modèle de souris BALB/cJ de phénotype anxieux, nous montrons que cette activité de la kétamine dépend de la balance excitation-inhibition entre les systèmes glutamate/R-NMDA et R-AMPA, GABA/R-GABAA, sérotonine du circuit cortex préfrontal/noyau du raphé. Nos résultats suggèrent également que ce serait la combinaison [kétamine-(2R,6R)-hydroxynorkétamine, son principal métabolite cérébral] qui porterait l'effet antidépresseur. Mes travaux de thèse contribuent à une meilleure compréhension de l'effet rapide antidépresseur de la kétamine. / According to the WHO, major depressive disorder (MDD) will be the second leading cause of disability in the world in 2020 and will become the first in 2030. Conventional antidepressant drugs have delayed therapeutic effects and many patients are resistant. Ketamine, an N-methyl-D-aspartate (NMDA-R) receptor antagonist of L-glutamate, exerts a rapid antidepressant effect in patients who are resistant to standard therapy. The mechanism of this amazing activity is not well understood. By coupling intracerebral microdialysis to a predictive behavioral test of antidepressant activity in a BALB/cJ mouse model with an anxious phenotype, we show that this ketamine activity is dependent on the excitation-inhibition balance between glutamate/NMDA-R and AMPA-R, GABA/GABAA-R, serotonin systems in the prefrontal cortex/raphe nucleus circuit. Our results also suggest that it would be the combination [ketamine-(2R,6R)-hydroxynorketamine, its main brain metabolite] that would carry the antidepressant effect. My thesis work pave the way for the development of new fast-acting antidepressant drugs.

L'hypertension artérielle pulmonaire (HTAP) est une maladie rare caractérisée par une augmentation de la pression artérielle pulmonaire moyenne liée à un important remodelage de la paroi vasculaire obstruant progressivement les petites artères pulmonaires. Le récepteur NMDA (NMDAR) est un récepteur au glutamate jouant un rôle crucial dans la transmission synaptique neuronale. Il est aussi présent dans des cellules périphériques, notamment les cellules vasculaires aortiques et cérébrales, et participe à leur prolifération. De plus, le NMDAR contribue à la prolifération des cellules cancéreuses. Puisque dans l'HTAP, les cellules vasculaires pulmonaires présentent un phénotype cancer-like, hyperprolifératif et résistant à l'apoptose, nous avons émis l'hypothèse selon laquelle les NMDARs vasculaires pulmonaires pourraient contribuer au remodelage vasculaire et conduire à l'HTAP. Nous avons montré que les cellules vasculaires pulmonaires expriment physiologiquement les principaux éléments d'une communication glutamatergique fonctionnelle via le NMDAR. Dans l'HTAP, le glutamate s'accumule dans les vaisseaux remodelés et l'endothéline-1, un acteur majeur du remodelage vasculaire, induit la libération du glutamate par les cellules musculaires lisses. Le NMDAR est mobilisé dans les cellules vasculaires et sa fonction pourrait être altérée en raison d'un déséquilibre dans le ratio d'expression de ses sous-unités. L'activation du NMDAR contribue à la prolifération des cellules vasculaires pulmonaires et à l'angiogenèse, éléments clés de la physiopathologie de l'HTAP. Des études réalisées sur des souris n'exprimant pas les NMDARs vasculaires ou utilisant des antagonistes du NMDAR mettent en évidence le rôle du NMDAR dans l'hypertension pulmonaire expérimentale. Ces résultats suggèrent que le NMDAR est un nouvel acteur du remodelage vasculaire et qu'il représente une nouvelle cible thérapeutique de l'HTAP. Ils apportent également de nouveaux éléments alimentant l'analogie entre le système vasculaire et le système nerveux. / Pulmonary arterial hypertension (PAH) is a rare disease characterized by an increase in the mean pulmonary arterial pressure, due to a deep vascular remodeling leading to the progressive obstruction of the small pulmonary arteries. The NMDA receptor (NMDAR) is a glutamate receptor playing a crucial role in the neuronal synaptic communication. It is also present in peripheral cells, including aortic and cerebral vascular cells, and promotes their proliferation. Moreover, NMDAR contributes to proliferation of cancer cells. As pulmonary vascular cells exhibit a cancer-like hyperproliferative and apoptotic-resistant phenotype in PAH, we hypothesized that the activation of pulmonary vascular NMDARs may contribute to the vascular remodeling leading to PAH. We found that pulmonary vascular cells express the main features of a functional synaptic-like glutamatergic communication through NMDARs. In PAH, glutamate accumulates in pulmonary arteries, and endothelin-1, a major actor of the PAH-associated vascular remodeling, triggers glutamate release from smooth muscle cells. Furthermore, the NMDAR is mobilized and its function may be altered due to an unbalanced expression ratio of the NMDAR subunits. Moreover, NMDAR activation contributes to vascular cell proliferation and angiogenesis, key features of PAH pathophysiology. Finally, studies with NMDAR antagonists and vascular NMDAR-knockout mice showed that vascular NMDARs are involved in pulmonary hypertension. These results suggest that NMDAR is a new actor of the vascular remodeling and could represent a new therapeutic target in PAH. They also bring new pieces to the vascular/nervous parallels.

Migrän är en av de vanligaste sjukdomarna i världen och förekommer hos både barn och vuxna. Den uppskattade prevalensen i Sverige är 15 % och prevalensen världen över är drygt 10 %. Det är idag känt att både gener och miljöfaktorer är inblandade i uppkomsten av migrän men det är dock oklart exakt hur migrän uppstår. Migrän är en kostnadskrävande sjukdom dels i form av behandlingskostnader men även på grund av inkomstbortfall då sjukdomen utgör ett stort funktionshinder. Behandlingsmetoder vid migrän indelas i tre kategorier: icke-farmakologisk, anfallskuperande farmakologisk, respektive profylaktisk farmakologisk behandling. Det finns ett behov av att hitta substanser som ger mildare biverkningar vid migrän, jämfört med de behandlingar som används idag, framförallt eftersom många barn är drabbade. Syftet med examensarbetet var att undersöka om magnesiumtillskott är ett effektivt behandlingsalternativ vid migrän, dels för behandling vid migränanfall och dels som förebyggande behandling av migrän. Då magnesium har en rad viktiga funktioner i kroppen leder låga magnesiumnivåer till ökade risker för sjukdomar och komplikationer. Studier visar att det finns samband mellan brist på magnesium och en ökad sjuklighet med kopplingar till bland annat typ 2 diabetes, högt blodtryck, kardiovaskulär sjukdom, migränhuvudvärk och spänningshuvudvärk. För att undersöka om magnesium kan användas för att behandla migränanfall analyserades fyra olika studier där magnesium har använts som anfallskuperande behandling. För att undersöka om magnesium kan användas i profylaktisk behandling av migrän analyserades även fyra olika studier där magnesium har getts i förebyggande syfte. För sökning efter studier användes databasen PubMed. Magnesiums smärtlindrande verkan i anfallskuperande behandling av migrän var inte övertygande vid jämförelse mot placebo. Av de studier där magnesium användes som förebyggande behandling visade dock samtliga av dessa fyra studier fördelaktiga resultat gällande bland annat migränanfallens intensitet vid jämförelse mot placebo. I två studier där man dagligen använde magnesiumcitrat som förebyggande behandling sågs även signifikanta sänkningar i migränanfallens frekvens jämfört med placebo. De analyserade studierna i detta examensarbete visar att magnesium verkar fungera som förebyggande behandling av migrän. Fler studier behövs för att undersöka om magnesium kan användas som smärtlindrande behandling vid migränanfall. Då det finns ett behov av alternativa metoder för behandling av migrän som ger milda biverkningar motiverar detta till att göra fortsatta studier inom området.

N-methyl-D-aspartate (NMDA) receptors are glutamatergic ionotropic receptors involved in excitatory synaptic transmission, synaptic plasticity and excitotoxicity. They are heteromeric complexes of GluN1 combined with GluN2A-D and/or GluN3A-B subunits that are activated by glutamate and glycine. Many allosteric modulators can influence the activity of these receptors including neurosteroids. Pregnanolone sulfáte (3α5βS) is an endogenous neurosteroid that inhibits NMDA receptors in a use-dependent manner and has neuroprotective effect. Binding site for 3α5βS on the NMDA receptor molecule is still not indentified. The aim of my work was to contribute to the identification of the biding site by kinetic analysis of rate of response return from 3α5βS inhibition. Using the point mutation we also attempted to identify the amino acids residues that could be involved in the neurosteroid binding. In order to study the effect of 3α5βS on NMDA receptors the electropfysiological recordings on human embryonic kidney 293T cells expressing recombinant GluN1/GluN2B receptors was performed. We confirm that the effect of 3α5βS on GluN1/GluN2B receptors is voltage-independent. The results of my work indicate that steroids can reach the binding site on the NMDA receptors through the membrane rather than directly from the aqueous...

NMDA receptor is necessary for excitatory transmission in the central nervous system. Altered funtion of the NMDA receptors is associated with many neurodegenerative and neuropsychiatric diseases. All available crystal structures of the NMDAR meant great shift towards our understanding of details of the receptor and its function. Unfortunately, these up- to-date available structures present only certain functional states of receptors and also a few structural data are still missing. For complete comprehension of the process of activation and deactivation of NMDA receptors, we need to supplement the current information with more data. The aim of this thesis was to employ a combination of different approaches (computational modelling, cloning, biochemistry, protein expression and purification and mass spectrometry) to obtain new structural data, by which we would be able to fill in the gaps in current receptor models, especially at various functional states of the receptor. Key words: NMDA receptor, glutamate receptor, computational modelling, structure, cloning, protein expression

Compelling evidence suggests that major depression is associated with dysfunction of the brain glutamatergic transmission, and that the glutamatergic N-methyl-d-aspartate (NMDA) receptor plays a role in antidepressant activity. Recent post-mortem studies demonstrate that depression is associated with altered concentrations of proteins associated with NMDA receptor signalling in the brain. The present study investigated glutamate signalling proteins in the amygdala from depressed subjects, given strong evidence for amygdala pathology in depression. Lateral amygdala samples were obtained from 1314 pairs of age- sex-, and post-mortem-interval-matched depressed and psychiatrically healthy control subjects. Concentrations of NR1 and NR2A subunits of the NMDA receptor, as well as NMDA receptor-associated proteins such as post-synaptic density protein-95 (PSD-95) and neuronal nitric oxide synthase (nNOS) were measured by Western immunoblotting. Additionally, levels of enzymes involved in glutamate metabolism, including glutamine synthetase and glutamic acid decarboxylase (GAD-67), were measured in the same amygdala samples. NR2A protein levels were markedly and significantly elevated (+115%, p=0.03) in depressed subjects compared to controls. Interestingly, PSD-95 levels were also highly elevated (+128%, p=0.01) in the same depressed subjects relative to controls. Amounts of NR1, nNOS, glutamine synthetase, and GAD-67 were unchanged. Increased levels of NR2A and PSD-95 suggest that glutamate signalling at the NMDA receptor in the amygdala is disrupted in depression.