Developing a community-led rare disease ELSI research agenda

BACKGROUND

Research priorities are best defined through engagement with communities who will be impacted by the research and have lived experience of the topics to be studied. We aimed to establish a pediatric rare disease community stakeholder group and empower them in (1) eliciting perspectives from affected families in the wider region and (2) synthesizing collective ideas into a research agenda focused on shared ethical, legal, and social implications (ELSI) across rare disease.

METHODS

This two-year project utilized a community-centered approach to engage rare disease community members as equal partners in developing a research agenda for ELSI in rare disease. We established "Rare Voices" (RV), a 22-member stakeholder group of patients, parents, clinicians and researchers. Following capacity-building trainings, RV designed and conducted listening sessions with teen patients and parents of children with rare diseases to explore challenges, positive experiences, and ethical concerns. Listening session findings were synthesized and contextualized into research topics, which RV members further refined and prioritized. We used established measures to assess RV member engagement and satisfaction.

RESULTS

From 14 listening sessions with parents (n = 52) and teen patients (n = 13), RV identified eight core research topics as most important for future rare disease research: coordinating care, communication, accessing resources and care, impact on family unit, community and support in society, mental health and identity, ethical aspects of care, and uncertainty. RV members were highly engaged throughout the two-year project and reported high levels of satisfaction with the experience and research agenda.

CONCLUSIONS

Through capacity-building and authentic engagement, this project resulted in a community-led rare disease research agenda to guide future rare disease ELSI research that aligns with patients' and families' priorities. An environment of equal partnership and respect created a space for mutual learning where community members were empowered to shape the research agenda based on their collective experiences. The agenda recognizes the shared psychosocial and healthcare experiences of rare disease and offers practical areas of research to address patient and family needs.

Our Next Pandemic Ethics Challenge? Allocating "Normal" Health Care Services

The pandemic creates unprecedented challenges to society and to health care systems around the world. Like all crises, these provide a unique opportunity to rethink the fundamental limiting assumptions and institutional inertia of our established systems. These inertial assumptions have obscured deeply rooted problems in health care and deflected attempts to address them. As hospitals begin to welcome all patients back, they should resist the temptation to go back to business as usual. Instead, they should retain the more deliberative, explicit, and transparent ways of thinking that have informed the development of crisis standards of care. The key lesson to be learned from those exercises in rational deliberation is that justice must be the ethical foundation of all standards of care. Justice demands that hospitals take a safety-net approach to providing services that prioritizes the most vulnerable segments of society, continue to expand telemedicine in ways that improve access without exacerbating disparities, invest in community-based care, and fully staff hospitals and clinics on nights and weekends.

Legal and Ethical Considerations for Requiring Consent for Apnea Testing in Brain Death Determination

The past decade has witnessed escalating legal and ethical challenges to the diagnosis of death by neurologic criteria (DNC). The legal tactic of demanding consent for the apnea test, if successful, can halt the DNC. However, US law is currently unsettled and inconsistent in this matter. Consent has been required in several trial cases in Montana and Kansas but not in Virginia and Nevada. In this paper, we analyze and evaluate the legal and ethical bases for requiring consent before apnea testing and defend such a requirement by appealing to ethical and legal principles of informed consent and battery and the right to refuse medical treatment. We conclude by considering and rebutting two major objections to a consent requirement for apnea testing: (1) a justice-based objection to allocate scarce resources fairly and (2) a social utility objection that halting the diagnosis of brain death will reduce the number of organ donors.

Rethinking the "open future" argument against predictive genetic testing of children

Professional consensus has traditionally discouraged predictive genetic testing when no childhood interventions can reduce future morbidity or mortality. However, advances in genome sequencing and accumulating evidence that children and families cope adequately with predictive genetic information have weakened this consensus. The primary argument remaining against testing appeals to children’s “right to an open future.” It claims that the autonomy of the future adult is violated when others make an irreversible choice to obtain or disclose predictive genetic information during childhood. We evaluate this argument and conclude that children’s interest in an open future should not be understood as a right. Rather an open future is one significant interest to weigh against other important interests when evaluating decisions. Thus, predictive genetic testing is ethically permissible in principle, as long as the interests promoted outweigh potential harms. We conclude by offering an expanded model of children’s interests that might be considered in such circumstances, and present two case analyses to illustrate how this framework better guides decisions about predictive genetic testing in pediatrics.

The Strange Tale of Three Identical Strangers: Cinematic Lessons in Bioethics

Tim Wardle's 2018 documentary film Three Identical Strangers is an exploration of identity, family, and loss. It's also about nature versus nurture and the boundaries of ethically permissible research, particularly research involving children. The film tells the story of identical triplets who were separated soon after birth in 1961. A different family adopted each boy, without being told that their son had two identical brothers. The adoption agency responsible for finding the families was collaborating with a group of researchers working on a study about … something. Three Identical Strangers details the boys' fight to obtain information about the study and for closure. But while the film may have received rave reviews, it left us feeling uneasy. We came away with two sets of questions, one having to do with the story that the film documents and the second with the ethics of filmmaking itself.

When Residents Let Conscience Be Their Guide: Professional Development and Educational Opportunity

Residency is a time of professional identity formation. During this time, residents may first be exposed to conflicts between professional duties and personal beliefs which may lead to a request for a conscience-based exemption. Faculty, whether the supervising attending or the program director, have an important role in the professional and ethical development of residents by acknowledging and supporting residents as they encounter these potential conflicts. In this paper, we highlight three areas of unique issues that arise within the context of residency training programs when a resident makes a request to be excused from clinical duties based on personal conscience: namely, the maintenance of educational standards, the burdens that may be placed on colleagues, and the responsibility for faculty to foster the professional development of ethically sensitive pediatricians.

Ethical issues in pediatric face transplantation

Facial transplantation has become a reality in adult medicine. Children are subject to congenital craniofacial differences, disease-related, traumatic, or thermochemical craniofacial changes and might be suitable for face transplantation. This manuscript addresses unique ethical issues in considering potential pediatric face transplant. These challenges are operant at the individual, technologic, and psychosocial level for clinicians, investigators, and society.

Clinical Sequencing Exploratory Research Consortium: Accelerating Evidence-Based Practice of Genomic Medicine

Despite rapid technical progress and demonstrable effectiveness for some types of diagnosis and therapy, much remains to be learned about clinical genome and exome sequencing (CGES) and its role within the practice of medicine. The Clinical Sequencing Exploratory Research (CSER) consortium includes 18 extramural research projects, one National Human Genome Research Institute (NHGRI) intramural project, and a coordinating center funded by the NHGRI and National Cancer Institute. The consortium is exploring analytic and clinical validity and utility, as well as the ethical, legal, and social implications of sequencing via multidisciplinary approaches; it has thus far recruited 5,577 participants across a spectrum of symptomatic and healthy children and adults by utilizing both germline and cancer sequencing. The CSER consortium is analyzing data and creating publically available procedures and tools related to participant preferences and consent, variant classification, disclosure and management of primary and secondary findings, health outcomes, and integration with electronic health records. Future research directions will refine measures of clinical utility of CGES in both germline and somatic testing, evaluate the use of CGES for screening in healthy individuals, explore the penetrance of pathogenic variants through extensive phenotyping, reduce discordances in public databases of genes and variants, examine social and ethnic disparities in the provision of genomics services, explore regulatory issues, and estimate the value and downstream costs of sequencing. The CSER consortium has established a shared community of research sites by using diverse approaches to pursue the evidence-based development of best practices in genomic medicine.

Two Agendas for Bioethics: Critique and Integration

Many bioethicists view the primary task of bioethics as 'value clarification'. In this article, I argue that the field must embrace two more ambitious agendas that go beyond mere clarification. The first agenda, critique, involves unmasking, interrogating, and challenging the presuppositions that underlie bioethical discourse. These largely unarticulated premises establish the boundaries within which problems can be conceptualized and solutions can be imagined. The function of critique, then, is not merely to clarify these premises but to challenge them and the boundaries they define. The second agenda, integration, involves honoring and unifying what is right in competing values. Integration is the morally ideal response to value conflict, offering the potential for transcending win/lose outcomes. The function of integration, then, is to envision actions or policies that not only resolve conflicts, but that do so by jointly realizing many genuine values in deep and compelling ways. My argument proceeds in stages. After critically examining the role and dominant status of value clarification in bioethical discourse, I describe the nature and value of the two agendas, identify concrete examples of where each has been and could be successful, and explain why a critical integrative bioethics--one that appreciates the joint necessity and symbiotic potential of the two agendas--is crucial to the future of the field. The ultimate goal of all of this is to offer a more compelling vision for how bioethics might conduct itself within the larger intellectual and social world it seeks to understand and serve.

An ethical framework for responding to drug shortages in pediatric oncology

The frequency of drug shortages has increased considerably over the last decade. Important ethical issues arise whenever the supply of an effective drug is insufficient to meet demand. Using the ethical principles of beneficence, non-maleficence, and justice, institutions can guide prioritization of drug distribution before a shortage occurs to avoid unfair and unethical distribution of resources. This analysis will give a historical context for drug shortages, identify, and explore the central ethical concerns raised by drug shortages, and propose an ethical framework for addressing them in the context of pediatric oncology.

Collectivizing rescue obligations in bioethics

Bioethicists invoke a duty to rescue in a wide range of cases. Indeed, arguably, there exists an entire medical paradigm whereby vast numbers of medical encounters are treated as rescue cases. The intuitive power of the rescue paradigm is considerable, but much of this power stems from the problematic way that rescue cases are conceptualized-namely, as random, unanticipated, unavoidable, interpersonal events for which context is irrelevant and beneficence is the paramount value. In this article, I critique the basic assumptions of the rescue paradigm, reframe the ethical landscape in which rescue obligations are understood, and defend the necessity and value of a wider social and institutional view. Along the way, I move back and forth between ethical theory and a concrete case where the duty to rescue has been problematically applied: the purported duty to regularly return incidental findings and individual research results in genomic and genetic research.

A framework for analyzing the ethics of disclosing genetic research findings

Whether researchers have an obligation to disclose secondary genetic research findings, and, if so, in what circumstances, remains a matter of heated debate. This paper suggests that much of this confusion is definitional or conceptual in nature. That is, there is significant variability in the way that threshold terms and concepts such as "incidental," "analytic validity," "clinical validity," "clinical relevance," "clinical utility," "clinical significance," and "actionability," are used in the literature, which is impeding efforts to clarify the scope of an obligation to return findings. This paper analyzes the definitional muddle underlying the debate about returning genetic research findings, first, to explain the range of definitions being used in this debate. We go on to propose that, underlying all the seeming confusion and disagreement, three central and widely agreed upon concepts are at work in this debate - validity, value, and volition. Refocusing attention on these core concepts, and their appropriate conceptualizations, can produce a more productive debate regarding the return of genetic research findings.

Marriage and the well-being of children

Children's well-being has become the focal consideration in legal and public policy debates regarding same-sex marriage. In this article, we critically examine and rebut the central moral argument made by opponents of same-sex marriage: that the state should not license any domestic arrangement other than "traditional marriage" because doing so would be detrimental to children's well-being. Although many have challenged the empirical premise that children raised by same-sex couples fare worse than children in other arrangements, we focus primarily on the normative premises for exclusively licensing traditional (that is, monogamous, heterosexual) marriage. We argue that even if the empirical support for its claims was strong, the argument is morally insufficient for denying state recognition to other types of relationships. Importantly, we affirm the state's vital role in promoting children's well-being. We question, however, the approach of delegitimizing certain relationships as a means to that end. Instead, we argue, the state should encourage and support individuals who want to care for children, presume that any couple or individual is capable of adequate child-rearing, and ensure that all adults who are raising children (whether married or not) have the material resources and support necessary to be good parents. Such a policy would (1) set a reasonable minimal threshold for state recognition, (2) be vigilant in identifying cases falling below this threshold, and then (3) either assist or disqualify underperforming arrangements. It would also, appropriately, decouple arguments about legitimate and illegitimate types of relationships from arguments about what is best for children.

Myenteric plexus of the hind-gut: developmental abnormalities in humans and experimental studies

Intraluminal pressure studies on patients with congenital aganglionosis showed that the aganglionic rectum contracted in an uncoordinated manner and failed to relax. Histochemical assessment of the innervation helped to explain the variable severity of the symptoms in this condition. It is concluded that (1) absence of ganglia prevents normal coordinated peristalsis and creates an obstructive element; (2) absence of reflex relaxation adds to the obstruction; (3) the degree of uncoordinated motor activity in distal aganglionic bowel probably relates to the number of cholinesterase-positive nerves in the circular muscle and adds another variable obstructive element; and (4) deficient innervation of distal ganglionic bowel probably creates a poor propulsive force and so accentuates more distal obstructive factors. Neurohistochemical and functional studies in the anorectum of cats reveal a somewhat different innervation pattern from that in humans but show that sphincteric tone is mainly due to alpha-adrenergic neural activity. Reflex relaxation of the internal anal sphincter is a complex function in which inhibitory responses override motor responses, and it involves an important non-adrenergic non-cholinergic component. The role of cholinergic nerves in the sphincter remains uncertain. Neurohistochemical assessment of full thickness biopsy specimens of rectal muscle from patients with disabling constipation shows that developmental neuronal dysplasias of the hind-gut may be divided into three main categories: (1) aganglionosis (Hirschsprung's disease), (2) hypoganglionosis and (3) hyperganglionosis, and that the different neuronal elements may be affected to differing degrees in individuals within each group. Resection of the aganglionic bowel is required in congenital aganglionosis but the combined diagnostic-therapeutic procedure of anorectal myotomy has been found beneficial in patients with hypoganglionosis.

Preganglionic parasympathectomy decreases salivary SIgA secretion rates from the rat submandibular gland

Immunoglobulin A (IgA) is transported into saliva by salivary cells expressing the polymeric immunoglobulin receptor (pIgR). In rat salivary glands, autonomic nerves stimulate this process. To examine how nerves affect pIgR-mediated IgA secretion, the chorda-lingual nerve was sectioned. One week after preganglionic parasympathectomy, both the stimulated and unstimulated rates of salivary IgA secretion were reduced, despite similar glandular amounts of IgA. Biochemical analysis of cells from parasympathectomised and control glands indicated reduced membrane expression of pIgR. It appears the removal of long-term parasympathetic input has affected the routing of pIgR within salivary cells and reduced the SIgA transport into saliva.

Salivary secretion of immunoglobulin A by submandibular glands in response to autonomimetic infusions in anaesthetised rats

Salivary secretion of immunoglobulin A (lgA) by submandibular glands is increased by stimuli from autonomic nerves. Since it is unclear which specific autonomic receptors transduce such stimuli, we have infused autonomimetics intravenously and compared secretion of fluid, IgA and stored proteins (peroxidase and total protein) with secretory responses during electrical stimulation of the parasympathetic nerve supply in anaesthetized rats. The greatest secretion of IgA was evoked by the alpha-adrenoceptor agonist phenylephrine and this was reduced by the beta-adrenoceptor blocking drug propranolol. The secretion of fluid or proteins but not IgA was increased with frequency of nerve stimulation and dose of methacholine (cholinergic), isoprenaline (beta-adrenergic) or phenylephrine (alpha-adrenergic).

Constitutive secretion of immunoglobulin A and other proteins into lumina of unstimulated submandibular glands in anaesthetised rats

Salivary fluid secretion is dependent upon reflex stimuli mediated by autonomic nerves. In order to determine if immunoglobulin A (IgA) and salivary proteins are secreted in the absence of nerve stimulation, small volumes (< 2 microl) of saliva were consecutively collected from the submandibular duct of anaesthetised rats following rest pauses in order to sample the protein contents of the ductal system. Within the first 5 microl of such saliva collected by parasympathetic nerve stimulation, IgA and other salivary proteins reached peak concentrations that were over 20-fold greater than levels in parasympathetically stimulated saliva subsequently collected during a 5 min period of stimulation. Confocal microscopy of TRITC-labelled IgA added to live, acutely isolated submandibular acini indicated that it did not enter the lumina by paracellular leakage. IgG is thought to enter saliva by paracellular leakage but did not accumulate in luminal saliva in the present study. Electrophoresis suggested that the major proteins secreted in the absence of stimulation were the same as those present in subsequently stimulated saliva. It can be concluded that IgA and other major submandibular proteins are secreted into glandular lumina in the absence of nerve stimulation. The functional significance of such unstimulated protein secretion is at present unclear.

Ultrastructural histochemical studies of secretory granule replenishment in rat submandibular granular tubules after cyclocytidine-induced secretion

Rat submandibular glands have been examined electron microscopically at various times after degranulating the granular tubules by injecting cyclocytidine (75 mg/kg i.p.), to study events in the reformation of secretory granules in these cells. The changes were progressive but not synchronous in the cells. The first evidence of recovery was the re-appearance of glycogen particles 6 h after injection. Residual secretory granules were small and located periluminally at that time. More granules were present at 15 h after injection but they were still small and placed periluminally. There was more glycogen in the cells and some was present in aggregates. At 1 day after injection there were more secretory granules and they tended to be larger than previously. The secretory granules increased in size and number progressively thereafter and the cells appeared like normal controls by day 7. During the recovery, fusion profiles were seen between granules from 2 days onwards. Throughout, few Golgi complexes were detected and this may be related with the low glycosylation of the secretory proteins in these cells. The results confirm that the reformation of the secretory granules in granular tubule cells is a slow process that involves fusions of smaller granules.

Variation in the response to ductal obstruction of feline submandibular and sublingual salivary glands and the importance of the innervation

A variable response following ductal ligation of feline salivary glands corresponds to the human condition but contrasts with a predictable atrophy in obstructed salivary glands of rodents popularly used as a model for human salivary problems. The present investigation is concerned with a possible reason for the variable response, namely the preservation of the innervation. Ducts of feline submandibular and sublingual salivary glands were ligated with or without the inclusion of the chorda tympani. Inclusion led to a delayed initial response followed by progressive atrophy until the parenchyma was extremely atrophic, whereas avoidance of the chorda led to the variable response in which variable numbers of acini of a similar form to normal persisted. The results establish the atrophic effect of inclusion of the chorda tympani in ductal ligation and indicate the caution that should be exercised in the extrapolation of the rodent model to the human condition.

The effects of ductal obstruction on the acinar cells of the parotid of cat

Twenty-nine parotids ligated for between 1 and 365 days were examined by light and electron microscopy. Major changes in the acini were seen at 4 days and included vacuolation, disintegration, extravasation, apoptosis, phagy and a reduction in number and size of secretory granules. There was a further reduction in secretory granules from 7 to 12 days, but acinar cells persisted even up to 365 days, some contained a luminal concentration of small secretory granules and occasionally acinar cells of a similar appearance to normal were found. These findings contrast with a reported absence of acinar cells from the obstructed parotid of rat and show that parotid acinar cells are able to persist and retain an appearance indicative of secretory activity.

Sympathetic decentralization abolishes increased secretion of immunoglobulin A evoked by parasympathetic stimulation of rat submandibular glands

Salivary secretion of immunoglobulin A (IgA) in response to electrical stimulation of the parasympathetic nerve supply was assessed bilaterally in the submandibular glands of anaesthetized rats 1 week following unilateral pre-ganglionic sympathectomy (decentralization). Nerve-mediated stimulation on the non-denervated side increased IgA secretion several fold above an unstimulated rate of secretion whereas sympathetic decentralization reduced the parasympathetically stimulated secretion of IgA without affecting the basal rate. Glandular levels of IgA were increased following decentralization compared to the control glands. Salivary levels of free secretory component (FSC), the cleaved polymeric immunoglobulin receptor (plgR), were increased by parasympathetic stimulation and reduced by sympathectomy, though not as much as IgA. The decreased secretion of FSC suggests a reduced production of plgR and may account in part, for reduced IgA secretion following long-term removal of sympathetic nerve impulses.

Nerve-evoked secretion of immunoglobulin A in relation to other proteins by parotid glands in anaesthetized rat

Secretion of fluid and proteins by salivary cells is under the control of parasympathetic and sympathetic autonomic nerves. In a recent study we have shown that, in the rat submandibular gland, autonomic nerves can also increase the secretion of IgA, a product of plasma cells secreted into saliva as SIgA (IgA bound to Secretory Component, the cleaved poly-immunoglobulin receptor). The present study aimed to determine if parotid secretion of SIgA is increased by autonomic nerves and to compare SIgA secretion with other parotid proteins stored and secreted by acinar and ductal cells. Assay of IgA in saliva evoked by parasympathetic nerve stimulation immediately following an extended rest period under anaesthesia indicated that it had been secreted into intraductal saliva in the absence of stimulation during the rest period. The mean rate of unstimulated IgA secretion (2.77+/-0.28 microg min(-1) g(-1)) and the 2.5-fold increase in IgA secretion evoked by parasympathetic stimulation were similar to results found previously in the rat submandibular gland. Sympathetic nerve stimulation increased SIgA secretion 2.7-fold, much less than in the submandibular gland. SDS-PAGE and Western blot analysis with anti-IgA and anti-Secretory Component antibodies confirmed that SIgA was the predominant form of IgA in saliva. Acinar-derived amylase and ductal-derived tissue kallikrein were more profoundly increased by parasympathetic and particularly sympathetic stimulation than SIgA. Overall, the results of the present study indicate that SIgA forms a prominent component of unstimulated parotid salivary protein secretion and that its secretion is similarly increased by stimulation of either autonomic nerve supply. The secretion of other parotid salivary proteins that are synthesized and stored by acinar or ductal cells is upregulated to a much greater extent by parasympathetic and particularly sympathetic stimulation.

Reflex secretion of proteins into submandibular saliva in conscious rats, before and after preganglionic sympathectomy

1. An indwelling catheter was placed in the left submandibular duct of rats, under pentobarbitone anaesthesia, and connected to an outflow cannula that emerged above the skull. 2. Saliva was collected from the outflow cannula in conscious rats, the same day after recovery from anaesthesia, under four different reflex conditions: grooming, heat exposure, rejection of a bitter tasting substance and feeding on softened chow, repeated in different orders. 3. Saliva flow was greatest for grooming and least for rejection. Protein concentrations were least with heat but much greater and similar for the other stimulations. Acinar peroxidase activity was high for feeding, intermediate for grooming and rejection, and again lowest with heat. Tubular tissue kallikrein activities were moderately low, being greatest with feeding and least with grooming. Secretory immunoglobulin A (SIgA) concentration was least with heat and similar for the other stimulations. 4. The next day, under pentobarbitone anaesthesia, the left preganglionic sympathetic trunk was sectioned (sympathetic decentralization) and, after recovery, the preceding stimulations were repeated. Flow of saliva showed little change, but protein and peroxidase concentrations and outputs decreased dramatically with grooming, rejection and feeding to levels similar to those with heat, which showed little change. Tissue kallikrein was lowered less dramatically, but the reductions in output were significant except with heat. Patterns of proteins resolved by electrophoresis changed for grooming, rejection and feeding and became similar to saliva from heat, which showed little change. No significant effects on SIgA concentrations occurred. 5. Gland weights from the sympathetically decentralized side were greater than from the intact side at the end of the experiments and histologically showed retention of acinar mucin. 6. Thus reflex sympathetic drive varied with the different stimulations; it was least during heat, but it had pronounced effects on acinar secretion of proteins during the other stimulations. At the same time this sympathetic drive had less impact on tissue kallikrein secretion from tubules and had little influence on flow or the concentration of SIgA secreted.

Immunoglobulin A secretion into saliva during dual sympathetic and parasympathetic nerve stimulation of rat submandibular glands

Salivary secretion of proteins from rat submandibular glands was studied using graded stimulation of the parasympathetic nerve in isolation, and then at a fixed rate in combination with graded sympathetic nerve stimulation. Increasing the frequency of parasympathetic nerve stimulation per se caused a gradual increase in the secretion of peroxidase (from acini) but only small increases in proteinase (from ductal cells) and IgA outputs. Dual stimulations, with an increasing frequency of sympathetic nerve stimulation on a background of low frequency parasympathetic nerve stimulation, showed that maximal acinar secretion of peroxidase required only a low frequency of additional sympathetic stimulation, whereas ductal secretion of kallikrein was greatest with the highest frequency of additional sympathetic stimulation (20 Hz in bursts). IgA secretion also required high frequency additional sympathetic stimulation in bursts for greatest output. Although a synergism occurred with parasympathetic plus sympathetic nerve stimulation for the secretion of both peroxidase and kallikrein it was not evident for the secretion of IgA. This presumably reflects a difference for exocytosis of proteins stored in granules (e.g. peroxidase and kallikrein) compared to those proteins continuously transported across the plasma membrane in vesicles by transcytosis. This work confirms that vesicular movement of secretory IgA can be increased by both parasympathetic and sympathetic nerve stimulation, but the frequency parameters differ for each nerve.

Ultrastructural histochemical studies of secretory processes in rat submandibular granular tubules during intermittent sympathetic nerve stimulation

Secretory changes in the cells of granular tubules in rat submandibular glands have been studied sequentially during electrical stimulation of their sympathetic nerves. Results were assessed in a series of biopsied lobes from the same gland, taken at different times during the sympathetic stimulation. Changes were not synchronous between adjacent cells and it appeared that the time for the onset of secretory events differed between cells but, once set in action, a chain of similar events occurred. Nevertheless, some cells appeared to remain refractory throughout. Initially, some alignment of granules to the adjacent plasma membrane occurred and occasional evidence for classical exocytosis was seen. However, from early on microvesicles appeared in more luminally located granule membranes and were associated with granule fusions, that became common and led to the formation of large irregular aggregates. Most of the secretion of granule contents appeared to be through openings of aggregates into lumina. With granule fusions the intra-membrane microvesicles became internalised and tended to increase in size with time; they were commonly expelled with the contents of the aggregates. Fragments of cytoplasm also became incorporated in aggregate formation. Cytoplasm, often containing glycogen, also formed luminal blebs over some granular tubule cells and appeared to pass into the secretion by an apocrine process. At the end of stimulation multivesicular bodies were seen in association with redundant aggregates.

The influence of nerves on the secretion of immunoglobulin A into submandibular saliva in rats

1. The influence of sympathetic and parasympathetic nerve stimulations on salivary secretion of immunoglobulin A (IgA) was studied in the submandibular glands of anaesthetized rats by stimulating the nerve supplies with bipolar electrodes. 2. Although the flow of saliva from sympathetically stimulated glands was only 23% of that from parasympathetically stimulated glands the output of IgA was over 2-fold greater. This difference was attributable to influences of the nerves on IgA secretion through the epithelial cell polymeric immunoglobulin receptor-mediated pathway, as Western blotting with specific antibodies to IgA and secretory component revealed that secretory IgA (SIgA) dominated in all saliva samples. 3. Study of saliva secreted in sequential periods of nerve stimulation or following rest pauses suggested that SIgA secretion occurred in the absence of stimulation but this was upregulated 2.6- and 6-fold by parasympathetic and sympathetic nerve stimulations, respectively, compared with the calculated unstimulated rate. 4. The IgA content of extensively stimulated glands was 77% of levels in unstimulated contralateral control glands despite a secretion into saliva equivalent to almost 90% of the glandular IgA content. The IgA may be synthesized and secreted by glandular plasma cells at a rate which exceeds demand and/or such synthesis may be upregulated by nerve impulses. 5. The results indicate that salivary secretion of SIgA is upregulated by nerve impulses and that sympathetic nerves induce a greater effect than parasympathetic nerves.

Constitutive secretion of kallikreins in vivo from rat submandibular glands

In parasympathetic saliva from rat submandibular glands the relative proportions of the various tissue kallikreins differ from those in sympathetic saliva. Kallikreins in sympathetic saliva arise from exocytosis of prepackaged granules in granular tubules, so the kallikreins in parasympathetic saliva must come from a non-granular pool, and are likely to be secreted through a constitutive vesicular route. During periods devoid of stimulation in anaesthetised rats, the kallikreins have been found to accumulate progressively in glandular lumina in parasympathetic-like proportions. As this transport of kallikrein into lumina occurs continuously in vivo, independently of any stimulation or any secretion of fluid, it must arise by constitutive vesicular secretion. During parasympathetic stimulation, the kallikreins are secreted into the saliva at a greater rate than in the resting state but their proportions remain the same and the means by which this increase occurs is open to debate. Constitutively secreted true tissue kallikrein (rK1) has been found to have a different molecular form from that in secretory granules. The submandibular glands also contribute to the kallikreins normally circulating in the blood. Serum levels of kallikrein increased equally during either parasympathetic or sympathetic stimulation and were independent of the amounts secreted into the saliva, so are likely to have arisen from constitutive secretion via the basal sides of the cells, morphological evidence for which has been found in the mouse (Penschow & Coghlan, 1993).