Parameter Space and Potential for Biomarker Development in 25 Years of fMRI Drug Cue Reactivity: A Systematic Review

Importance

In the last 25 years, functional magnetic resonance imaging drug cue reactivity (FDCR) studies have characterized some core aspects in the neurobiology of drug addiction. However, no FDCR-derived biomarkers have been approved for treatment development or clinical adoption. Traversing this translational gap requires a systematic assessment of the FDCR literature evidence, its heterogeneity, and an evaluation of possible clinical uses of FDCR-derived biomarkers.

Objective

To summarize the state of the field of FDCR, assess their potential for biomarker development, and outline a clear process for biomarker qualification to guide future research and validation efforts.

Evidence Review

The PubMed and Medline databases were searched for every original FDCR investigation published from database inception until December 2022. Collected data covered study design, participant characteristics, FDCR task design, and whether each study provided evidence that might potentially help develop susceptibility, diagnostic, response, prognostic, predictive, or severity biomarkers for 1 or more addictive disorders.

Findings

There were 415 FDCR studies published between 1998 and 2022. Most focused on nicotine (122 [29.6%]), alcohol (120 [29.2%]), or cocaine (46 [11.1%]), and most used visual cues (354 [85.3%]). Together, these studies recruited 19 311 participants, including 13 812 individuals with past or current substance use disorders. Most studies could potentially support biomarker development, including diagnostic (143 [32.7%]), treatment response (141 [32.3%]), severity (84 [19.2%]), prognostic (30 [6.9%]), predictive (25 [5.7%]), monitoring (12 [2.7%]), and susceptibility (2 [0.5%]) biomarkers. A total of 155 interventional studies used FDCR, mostly to investigate pharmacological (67 [43.2%]) or cognitive/behavioral (51 [32.9%]) interventions; 141 studies used FDCR as a response measure, of which 125 (88.7%) reported significant interventional FDCR alterations; and 25 studies used FDCR as an intervention outcome predictor, with 24 (96%) finding significant associations between FDCR markers and treatment outcomes.

Conclusions and Relevance

Based on this systematic review and the proposed biomarker development framework, there is a pathway for the development and regulatory qualification of FDCR-based biomarkers of addiction and recovery. Further validation could support the use of FDCR-derived measures, potentially accelerating treatment development and improving diagnostic, prognostic, and predictive clinical judgments.

Superatomic states in nickel clusters: Revising the prospects for transition metal based superatoms

The geometries and electronic structures of small Ni_n^z clusters (n = 8, 9, 10) (z = 0, ±1, 2) have been elucidated for a range of multiplicities for each cluster size and charge, using density functional theory methods. These clusters have been found to conform in part to the existing superatomic model, with each cluster having a filled superatomic S-orbital, filled or partially filled superatomic P-orbitals, and empty or partially filled superatomic D-orbitals. Despite local states of mixed symmetry being present in the immediate vicinity of the Fermi energy, the addition or removal of a single electron from these systems causes a significant shift in the relative energies of the superatomic orbitals. In addition, this study demonstrates the possibility for d-electrons to contribute into superatomic orbitals to a greater or lesser extent, depending on the local environment. In summary, these observations lead to the prospect of a predictive model for electronic shell closings in some transition metal cluster systems.

XBP1 mitigates aminoglycoside-induced endoplasmic reticulum stress and neuronal cell death

Here we study links between aminoglycoside-induced mistranslation, protein misfolding and neuropathy. We demonstrate that aminoglycosides induce misreading in mammalian cells and assess endoplasmic reticulum (ER) stress and unfolded protein response (UPR) pathways. Genome-wide transcriptome and proteome analyses revealed upregulation of genes related to protein folding and degradation. Quantitative PCR confirmed induction of UPR markers including C/EBP homologous protein, glucose-regulated protein 94, binding immunoglobulin protein and X-box binding protein-1 (XBP1) mRNA splicing, which is crucial for UPR activation. We studied the effect of a compromised UPR on aminoglycoside ototoxicity in haploinsufficient XBP1 (XBP1^+/−) mice. Intra-tympanic aminoglycoside treatment caused high-frequency hearing loss in XBP1^+/− mice but not in wild-type littermates. Densities of spiral ganglion cells and synaptic ribbons were decreased in gentamicin-treated XBP1^+/− mice, while sensory cells were preserved. Co-injection of the chemical chaperone tauroursodeoxycholic acid attenuated hearing loss. These results suggest that aminoglycoside-induced ER stress and cell death in spiral ganglion neurons is mitigated by XBP1, masking aminoglycoside neurotoxicity at the organismal level.

Age-related changes in auditory nerve-inner hair cell connections, hair cell numbers, auditory brain stem response and gap detection in UM-HET4 mice

This study compared the timing of appearance of three components of age-related hearing loss that determine the pattern and severity of presbycusis: the functional and structural pathologies of sensory cells and neurons and changes in gap detection (GD), the latter as an indicator of auditory temporal processing. Using UM-HET4 mice, genetically heterogeneous mice derived from four inbred strains, we studied the integrity of inner and outer hair cells by position along the cochlear spiral, inner hair cell-auditory nerve connections, spiral ganglion neurons (SGN), and determined auditory thresholds, as well as pre-pulse and gap inhibition of the acoustic startle reflex (ASR). Comparisons were made between mice of 5-7, 22-24 and 27-29 months of age. There was individual variability among mice in the onset and extent of age-related auditory pathology. At 22-24 months of age a moderate to large loss of outer hair cells was restricted to the apical third of the cochlea and threshold shifts in the auditory brain stem response were minimal. There was also a large and significant loss of inner hair cell-auditory nerve connections and a significant reduction in GD. The expression of Ntf3 in the cochlea was significantly reduced. At 27-29 months of age there was no further change in the mean number of synaptic connections per inner hair cell or in GD, but a moderate to large loss of outer hair cells was found across all cochlear turns as well as significantly increased ABR threshold shifts at 4, 12, 24 and 48 kHz. A statistical analysis of correlations on an individual animal basis revealed that neither the hair cell loss nor the ABR threshold shifts correlated with loss of GD or with the loss of connections, consistent with independent pathological mechanisms.

Relatedness severely impacts accuracy of marker-assisted selection for disease resistance in hybrid wheat

The accuracy of genomic selection depends on the relatedness between the members of the set in which marker effects are estimated based on evaluation data and the types for which performance is predicted. Here, we investigate the impact of relatedness on the performance of marker-assisted selection for fungal disease resistance in hybrid wheat. A large and diverse mapping population of 1739 elite European winter wheat inbred lines and hybrids was evaluated for powdery mildew, leaf rust and stripe rust resistance in multi-location field trials and fingerprinted with 9 k and 90 k SNP arrays. Comparison of the accuracies of prediction achieved with data sets from the two marker arrays revealed a crucial role for a sufficiently high marker density in genome-wide association mapping. Cross-validation studies using test sets with varying degrees of relationship to the corresponding estimation sets revealed that close relatedness leads to a substantial increase in the proportion of total genotypic variance explained by the identified QTL and consequently to an overoptimistic judgment of the precision of marker-assisted selection.

Noise-induced time-dependent changes in oxidative stress in the mouse cochlea and attenuation by D-methionine

Oxidative stress in the cochlea is considered to play an important role in noise-induced hearing loss. This study determined changes in superoxide dismutase (SOD), catalase, lipid peroxidation (LPO) and the auditory brainstem response (ABR) in the cochlea of C57BL/6 mice prior to and immediately, 1, 3, 7, 10, 14 and 21 days after noise exposure (4 kHz octave band at the intensity of 110 dB SPL for 4 h). A significant increase in SOD activity immediately and on 1st day after noise exposure, without a concomitant increase in catalase activity suggested a difference in the time dependent changes in the scavenging enzymes, which facilitates the increase in LPO observed on day 7. The ABR indicated significant noise-induced functional deficits which stabilized in 2 weeks with a permanent threshold shift (PTS) of 15 dB at both 4 kHz and 8 kHz. The antioxidant D-methionine (D-Met) reversed the noise-induced changes in LPO levels and enzyme activities. It also significantly reduced the PTS observed on the 14th day from 15 dB to 5 dB for 4 kHz. In summary, the findings indicate that time-dependent alterations in scavenging enzymes facilitate the production of reactive oxygen species and that D-met effectively attenuates noise-induced oxidative stress and the associated functional loss in the mouse cochlea.

Does vitamin E prevent gentamicin-induced ototoxicity?

A randomized double-blind study was performed to check the protective efficacy of vitamin E against aminoglycoside ototoxicity. 52 patients scheduled for gentamicin therapy because of acute pulmonary infections have been tested. Volunteers were randomly assigned to receive additionally either vitamin E or placebo. The daily dosage of gentamicin amounted to 240 mg and that of vitamin E to 2800 mg. The treatment lasted 7 days. Hearing function was assessed before the start of medication and at the follow-up visit 6 to 8 weeks afterwards. Elevation of auditory thresholds occurred in similar number of patients in the vitamin-E and placebo groups and no statistically significant differences were found between. Vitamin E has been not confirmed thus to possess any protective action against gentamicin-induced ototoxicity.

Age-related hearing loss: gender differences

Hearing thresholds were measured in 224 Tbilisi citizens, 128 females and 96 males, at the frequencies of 0.125-16 kHz. None of the subjects reported any job-related noise exposures or other potentially confounding history. Initial signs of age-related hearing impairments were detected in females and males of 40-49 and 30-39 years of age, respectively. In both genders they involved high frequencies. In the following age decades, 50-59, 60-69, and 70-79 years, the hearing losses increased in magnitudes and extended to lower frequencies. From the age of 30-39 years to that of 40-49 and 50-59 years the dynamics of threshold elevations appeared more rapid in males than in females. The gender differences in hearing acuity increased respectively in this age period. Thereafter, in the ages of 60-69 and 70-79 years, the hearing alterations became steeper in females than in males. As a result, the gender differences in hearing smoothed significantly.

Caspase-independent pathways of hair cell death induced by kanamycin in vivo

Cochlear and vestibular sensory cells undergo apoptosis when exposed to aminoglycoside antibiotics in organ culture, but mechanisms of chronic drug-induced hair cell loss in vivo are unclear. We investigated cell death pathways in a mouse model of progressive kanamycin-induced hair cell loss. Hair cell nuclei showed both apoptotic- and necrotic-like appearances but markers for classic apoptotic pathways (cytochrome c, caspase-9, caspase-3, JNK, TUNEL) were absent. In contrast, drug treatment caused EndoG translocation, activation of mu-calpain, and both the synthesis and activation of cathepsin D. Poly (ADP-ribose) polymerase 1 (PARP1) was decreased, but a caspase-derived 89 kDa PARP1 fragment was not present. The mRNA level of PARP1 remained unchanged. Thus, chronic administration of aminoglycosides causes multiple forms of cell death, without a major contribution by classic apoptosis. These results provide a better understanding of the toxic effects of aminoglycosides and are relevant to design protection from aminoglycoside-induced hearing loss.

Post-exposure treatment attenuates noise-induced hearing loss

Reactive oxygen species (ROS) and reactive nitrogen species (RNS) are involved in sensory cell and neural death in the peripheral nervous system, including damage induced by noise trauma. Antioxidant administration prior to or concomitant with noise exposure can prevent auditory deficits, but the efficacy of a delayed treatment is not known. We have recently found continued reactive oxygen species/reactive nitrogen species formation in the ear for 7-10 days following noise exposure and reasoned that antioxidant intervention during this period should also reduce noise-induced hearing loss. Guinea-pigs were subjected to 4 kHz octave band noise at 120 decibels sound- pressure-level (dB SPL) for 5 hours and received treatment with ROS and RNS scavengers (salicylate and trolox) beginning 3 days prior, 1 hour, 1, 3, or 5 days after noise exposure. Auditory thresholds were assessed by sound-evoked auditory brainstem response at 4, 8, and 16 kHz, before and 10 days after noise exposure. Hair cell damage was analyzed by quantitative histology, and free radical activity was determined immunohistochemically via 4-hydroxynonenal and nitrotyrosine as markers of reactive oxygen species and reactive nitrogen species action. Delivered up to 3 days after noise exposure, salicylate and trolox significantly reduced auditory brainstem response deficits, reduced hair cell damage, and decreased reactive oxygen species and reactive nitrogen species formation. Earlier drug treatment was more effective than later treatment. Our results detail a window of opportunity for rescue from noise trauma, and provide evidence for both morphological and functional protection by delayed pharmacological intervention.

[Aminoglycoside- and cisplatin-ototoxicity: from basic science to clinics]

Gentamicin and cisplatin are clinically widely used pharmacological agents which may induce irreversible hearing loss as a side effect. Concerning the pathomechanisms of ototoxicity as well as preventive strategies there are similarities but also some differences. In this review we focus on the role of reactive oxygen species, the antioxidant system, cellular iron and calcium as well as nitric oxide and neurotrophins on gentamicin- and cisplatin-ototoxicity. Furthermore we deal with apoptotic and necrotic cell death as well as the role of mitochondria in these cell injury processes.

Modulation of activator protein 1/DNA binding activity by acoustic overstimulation in the guinea-pig cochlea

Changes in gene expression are part of the homeostatic machinery with which cells respond to external stimuli or assaults. The activity of the early response transcriptional factor activator protein-1 (AP-1) can be modulated by a variety of environmental stimuli including those that alter the cellular oxidation/reduction status. This study investigates the activation of AP-1/DNA binding in the guinea-pig cochlea in response to acoustic overstimulation which produces reactive oxygen species. Electrophoretic mobility shift assays revealed that binding of AP-1 to its radiolabeled oligonucleotide probe markedly changed in nuclear extracts of inner ear tissues following intense noise exposure (4 kHz octave band, 115 dB, 5 h). AP-1/DNA binding increased in the organ of Corti and the lateral wall tissues immediately after the exposure, returning to near-baseline levels 5 h later. At 15 h after noise, a second peak of binding activity occurred in the organ of Corti whereas stria vascularis showed a lesser but more sustained activity. Binding in nuclear extracts from the spiral ganglion did not change. Incubation of nuclear extracts with antibodies against Fos/Jun family proteins prior to a supershift assay showed Fra-2 as a major component of the AP-1 complex immediately after the noise exposure. In the organ of Corti, Fra-2 immunoreactivity was localized to the middle turn, i.e. the region which is most affected by the 4-kHz octave band exposure. The results suggest the modulation of gene expression via the activation of AP-1 as a consequence of noise trauma but also demonstrate differential responses in cochlear tissues.

Pathways for protection from noise induced hearing loss

There is increasing evidence that at least one function of both the medial and the lateral olivocochlear efferent systems is to provide adjustment of the set point of activity in their postsynaptic target, the outer hair cells and afferent processes, respectively. New results, summarized in this review, suggest that both efferent systems can provide protection from noise through this mechanism. There are also intracellular pathways that can provide protection from noise-induced cellular damage in the cochlea. This review also summarizes new results on the pathways that regulate and react to levels of reactive oxygen species in the cochlea as well as the role of stress pathways for the heat shock proteins and for neurotrophic factors in protection, recovery and repair.

ATP and nitric oxide modulate intracellular calcium in isolated pillar cells of the guinea pig cochlea

Supporting cells in the mammalian cochlea have recently received attention as potential targets of neurotransmitters, neuromodulators, and neurohumoral agents. Calcium homeostasis in Deiters' and Hensen's cells, for example, is regulated by ATP and nitric oxide. We studied the intracellular calcium concentration [Ca2+]i in isolated pillar cells of the guinea pig cochlea in response to extracellular ATP and nitric oxide using the fluorescent indicator fluo-3. [Ca2+]i increased rapidly and significantly throughout the pillar cell in response to a bolus of ATP or 2-methylthio ATP while alpha,beta-methylene ATP was ineffective. The response to ATP was inhibited by suramin and Cibacron Blue but not by pyridoxal phosphate 6-azophenyl-2',4'-disulfonic acid. This pharmacological profile is consistent with a [Ca2+]i increase largely mediated by P2Y receptors. In Ca2+-free medium supplemented with EGTA, the response to extracellularATP was reduced by 33%, suggesting a contribution of calcium influx to the overall effect. The ATP-induced increase of [Ca2+] was attenuated by NO donors (sodium nitroprusside or diethylamine NONOate), and this attenuation was reversed by KT5823, an antagonist to protein kinase G. The results indicate the involvement of purinergic mechanisms and the nitric oxide/cyclic GMP/protein kinase G pathway in the regulation of [Ca2+]i in cochlear pillar cells.

Aminoglycoside ototoxicity in adult CBA, C57BL and BALB mice and the Sprague-Dawley rat

The availability of genetic information, transgenic and knock-out animals make the mouse a primary model in biomedical research. Aminoglycoside ototoxicity, however, has rarely been studied in mature mice because they are considered highly resistant to the drugs. This study presents models for kanamycin ototoxicity in adult CBA/J, C57BL/6 and BALB/c mouse strains and a comparison to Sprague-Dawley rats. Five-week-old mice were injected subcutaneously twice daily with 400-900 mg kanamycin base/kg body weight for 15 days. Kanamycin induced dose-dependent auditory threshold shifts of up to 70 dB at 24 kHz as measured by auditory brain stem-evoked responses. Vestibular function was also affected in all strains. The functional deficits were accompanied by hair cell loss in both cochlear and vestibular neurosensory epithelia. Concomitant administration of the antioxidant 2,3-dihydroxybenzoate significantly attenuated the kanamycin-induced threshold shifts. In adult male Sprague-Dawley rats, doses of 1 x 500 mg or 2 x 300 mg kanamycin base/kg body weight/day x 14 days induced threshold shifts of approximately 50 dB at 20 kHz. These were accompanied by loss of outer hair cells. The order of susceptibility, BALB>CBA>C57, was not due to differences in the pharmacokinetics of kanamycin. It also did not correlate with the presence of Ahl/Ahl2 genes which predispose C57 and BALB strains, respectively, to accelerated age-related hearing loss. Pigmentation, however, paralleled this rank order suggesting an influence of melanin on cochlear antioxidant status.

Overexpression of copper/zinc-superoxide dismutase protects from kanamycin-induced hearing loss

The participation of reactive oxygen species in aminoglycoside-induced ototoxicity has been deduced from observations that aminoglycoside-iron complexes catalyze the formation of superoxide radicals in vitro and that antioxidants attenuate ototoxicity in vivo. We therefore hypothesized that overexpression of Cu/Zn-superoxide dismutase (h-SOD1) should protect transgenic mice from ototoxicity. Immunocytochemistry confirmed expression of h-SOD1 in inner ear tissues of transgenic C57BL/6-TgN[SOD1]3Cje mice. Transgenic and nontransgenic littermates received kanamycin (400 mg/kg body weight/day) for 10 days beginning on day 10 after birth. Auditory thresholds were tested by evoked auditory brain stem responses at 1 month after birth. In nontransgenic animals, the threshold in the kanamycin-treated group was 45-50 dB higher than in saline-injected controls. In the transgenic group, kanamycin increased the threshold by only 15 dB over the respective controls. The effects were similar at 12 and 24 kHz. The protection by overexpression of superoxide dismutase supports the hypothesis that oxidant stress plays a significant role in aminoglycoside-induced ototoxicity. The results also suggest transgenic animals as suitable models to investigate the underlying mechanisms and possible strategies for prevention.

Differential vulnerability of basal and apical hair cells is based on intrinsic susceptibility to free radicals

The base of the cochlea is more vulnerable to trauma than the apex as seen in the pattern of hair cell damage by cisplatin or aminoglycosides. The differential vulnerability is maintained in organotypic cultures exposed directly to these drugs, suggesting there may be an intrinsic difference in sensitivity to damage along the cochlear spiral. We therefore investigated the survival capacity of isolated outer hair cells and strips dissected from different turns of the guinea pig organ of Corti in short-term culture. Cells were stained with fluorescent indicators of viable or dead cells, calcein-AM and ethidium homodimer. After 5 h at room temperature, up to 90% of outer hair cells from the apex survived, but less than 30% from the base. In contrast, basal inner hair cells remained viable, and supporting cells survived for at least 20 h. The difference in survival capacity between basal and apical outer hair cells coincided with a significantly lower level of the antioxidant glutathione in basal outer hair cells compared with apical outer hair cells. This suggested that basal outer hair cells may be more vulnerable to free-radical damage than apical outer hair cells. The survival of basal outer hair cells was significantly improved by addition of the radical scavengers n-acetyl cysteine, p-phenylenediamine, glutathione, mannitol or salicylate. The protection by antioxidants implies that the accelerated death of basal outer hair cells is due to free-radical damage. The results support an intrinsic susceptibility to free radicals that differs among cochlear cell populations. This differential provides a rational explanation for base-to-apex gradients observed in various forms of cochlear pathology.

Acetylcholine-evoked calcium increases in Deiters' cells of the guinea pig cochlea suggest alpha9-like receptors

The medial efferent system innervates outer hair cells in the organ of Corti. Neurotransmission at this synapse is mediated by acetylcholine (ACh) acting on nicotinic ACh receptors containing the alpha9 subunit. In addition to the sensory cells, the supporting cells of the mammalian cochlea also receive efferent innervation but the neurotransmitter(s) at these synapses are not known. We show slow transient increases of intracellular calcium evoked by ACh in isolated Deiters' cells of the guinea pig cochlea. The antagonists atropine, d-tubocurarine and strychnine blocked the ACh-effect. Nicotine was an ineffective agonist. The pharmacologic profile and the kinetics of the calcium response suggest an alpha9-like ACh receptor on Deiters' cells similar but not identical to that on the outer hair cells.

Protection from ototoxicity of intraperitoneal gentamicin in guinea pig

BACKGROUND

Aminoglycoside antibiotics are common to treat peritonitis and exit-site infections in patients on peritoneal dialysis. Ototoxicity (loss of hearing or balance) is a well-documented adverse effect of aminoglycosides, and severe ototoxic reactions have been noted in patients receiving these drugs by intraperitoneal lavage. We have proposed a free-radical hypothesis for the mechanism of aminoglycoside ototoxicity and suggested a therapeutic prevention by the concomitant administration of antioxidants or iron chelators. Here we investigate whether 2, 3-dihydroxybenzoate can prevent the ototoxicity of intraperitoneal gentamicin.

METHODS

Two strains of pigmented guinea pigs received daily intraperitoneal injections of gentamicin. Both strains developed ototoxicity, although different dosages were needed to produce similar auditory deficits (120 mg gentamicin base/kg body weight daily for 19 days vs. 135 mg/kg for 14 days). Dihydroxybenzoate was administered intraperitoneally once or twice daily. Auditory thresholds were measured by evoked brain stem response. Pathology was assessed as a loss of sensory cells in surface preparations of the organ of Corti.

RESULTS

The auditory threshold shifts and hair cell loss were similar to the pathology observed following subcutaneous injections of gentamicin. Animals sustained almost complete loss of outer hair cells in the basal cochlea and a progressive hearing loss with threshold shifts of 60 dB at 18 kHz. The concomitant administration of dihydroxybenzoate significantly attenuated the threshold shift to less than 30 dB and reduced the loss of hair cells. The treatment with dihydroxybenzoate did not affect serum gentamicin levels.

CONCLUSIONS

Antioxidant therapy is a promising approach to prevent aminoglycoside-induced hearing loss following intraperitoneal application.

Intense noise induces formation of vasoactive lipid peroxidation products in the cochlea

This study investigates the correlation between the formation of reactive oxygen species (ROS) and auditory damage in noise-induced hearing loss. The noise exposure (4-kHz octave band, 115 dB SPL, 5 h) created permanent threshold shifts at frequencies from 2 to 20 kHz. The lipid peroxidation product, 8-isoprostane, was determined biochemically and histochemically as an indicator of ROS. Noise exposure increased 8-isoprostane levels in the cochlea in a time-dependent manner. After 5 h of exposure, 8-isoprostane levels were more than 30-fold greater than baseline, and decreased rapidly after the termination of noise. The immunoreactivity to 8-isoprostane was increased in the stria vascularis, spiral ganglion cells and the organ of Corti. In the organ of Corti, immunostaining was restricted to the second turn in a region 10-12 mm from the apex. This region sustained most of the permanent hair cell damage as revealed in surface preparations. Outer hair cells were more heavily immunostained than inner hair cells while Hensen's cells showed still less immunostain. These data are consistent with the view that ROS are involved in noise-induced damage. However, the relationship between ROS formation and tissue damage appears complex. In the organ of Corti, the pattern of noise-induced lipid peroxidation correlates well with subsequent morphological damage. The stria vascularis, however, does not sustain permanent damage despite intense lipid peroxidation. Differences in endogenous antioxidant levels and commitment to different apoptotic or survival pathways may underlie such differential responses.

Glutathione limits noise-induced hearing loss

The generation of reactive oxygen species (ROS) is thought to be part of the mechanism underlying noise-induced hearing loss (NIHL). Glutathione (GSH) is an important cellular antioxidant that limits cell damage by ROS. In this study, we investigated the effectiveness of a GSH supplement to protect GSH-deficient animals from NIHL. Pigmented guinea pigs were exposed to a 4 kHz octave band noise, 115 dB SPL, for 5 h. Group 1 had a normal diet, while groups 2, 3 and 4 were fed a 7% low protein diet (leading to lowered tissue levels of GSH) for 10 days prior to noise exposure. One hour before, immediately after and 5 h after noise exposure, subjects received either an intraperitoneal injection of 5 ml/kg body weight of 0.9% NaCl (groups 1 and 2), 0.4 M glutathione monoethyl ester (GSHE; group 3) or 0.8 M GSHE (group 4). Auditory thresholds were measured by evoked brain stem response at 2, 4, 8, 12, 16 and 20 kHz before and after noise exposure. Ten days post exposure, group 1 showed noise-induced threshold shifts of approximately 20 dB at 2, 16 and 20 kHz and 35 to 40 dB at other frequencies. Threshold shifts in group 2 were significantly greater than baseline at 2, 4, 16 and 20 kHz. GSHE supplementation in a dose-dependent fashion attenuated the threshold shifts in the low protein diet animals. Hair cell loss, as evaluated with cytocochleograms, was consistent with the auditory-evoked brainstem response results. Group 2 exhibited significantly more hair cell loss than any of the other groups; hair cell loss in group 3 was similar to that seen in group 1; group 4 showed less loss than group 1. These results indicate that GSH is a significant factor in limiting noise-induced cochlear damage. This is compatible with the notion that ROS generation plays a role in NIHL and that antioxidant treatment may be an effective prophylactic intervention.

Nitric oxide/cyclic GMP pathway attenuates ATP-evoked intracellular calcium increase in supporting cells of the guinea pig cochlea

We demonstrate here that nitric oxide (NO) attenuates ATP-evoked calcium transients in Deiters' and Hensen's cells, "supporting" (nonsensory) cells of the guinea pig cochlea, by means of activation of soluble guanylyl cyclase and protein kinase G. The enzymatic activities associated with the nitric oxide/cGMP/protein kinase G pathway had previously been demonstrated to be present in Deiters' and Hensen's cells. We now isolate these cells and measure changes in intracellular free calcium by using the calcium indicator fluo-3. In Deiters' cells, calcium increased rapidly in response to the application of ATP. The increase was attenuated when the pathway was stimulated by NO donors (diethylamine NONOate or sodium nitroprusside) or the cyclic GMP analog, 8-bromo-cyclic GMP. When the activation of the pathway was blocked by the additional presence of inhibitors of soluble guanylyl cyclase (LY83583) or protein kinase G (Rp-8-bromo-cyclic GMP or KT5823), the response to ATP was restored. The reactions also occurred in calcium-free media. Hensen's cells responded similarly. These results provide evidence that intracellular calcium is regulated by the NO/cGMP/protein kinase G pathway in the inner ear.

Biochemistry and pharmacology of aminoglycoside-induced hearing loss

Discovered in the 1940s, the aminoglycoside antibiotics were the long-sought remedy for tuberculosis and other serious bacterial infections. They are still one of the most commonly used antibiotics today, thanks to the combination of their high efficacy with low cost. This review begins by addressing some of the history and the acute side effects of aminoglycosides. It then details their chronic toxicity to the inner ear (ototoxicity). The review concludes with recent advances that have demonstrated free-radical reactions as the underlying mechanism and intervention with antioxidant/chelation therapy to prevent aminoglycoside ototoxicity.

Intermolecular and intramolecular reorientations in nonchiral smectic liquid-crystalline phases studied by broadband dielectric spectroscopy

Molecular dynamics has been studied by broadband dielectric relaxation spectroscopy in the Sm-A, Sm-B, and Sm-E phases (Sm denotes smectic) of a homologous series of nonchiral stilbenes. An assignment of modes is presented based on their dependence on temperature and molecular length, and, as far as they obey the Arrhenius law, their activation energy has been determined. In general, reorientations of entire molecules around their short axis are active, whereas reorientations of entire molecules around their long axis are locked out in the Sm-E phase of shorter homologs, yet intramolecular reorientations of polar sites have been established. Strong evidence is presented for an interdependence of reorientations of entire molecules around the short and long axes within the biaxial Sm-E phase of longer homologs.

Antioxidants attenuate gentamicin-induced free radical formation in vitro and ototoxicity in vivo: D-methionine is a potential protectant

We have recently suggested antioxidant therapy against aminoglycoside-induced hearing loss based on the hypothesis of a redox-active aminoglycoside-iron complex causing ototoxicity. The present study compares seven antioxidants and iron chelators for their ability to attenuate gentamicin-induced free radical generation in vitro and ototoxicity in guinea pig in vivo. Free radical formation by gentamicin was measured by chemiluminescence detection both in a non-enzymatic system in vitro and in cell culture. Deferoxamine, 2,3-dihydroxybenzoate, or salicylic acid suppressed gentamicin-induced luminescence in both tests. This indicated the usefulness of the assay as a screen for potential protectants since these agents had previously been shown to attenuate gentamicin-induced ototoxicity in vivo. Histidine and D-methionine, amino acids with chelating and antioxidant properties, also suppressed gentamicin-mediated luminosity both in vitro and in cell culture. In contrast, the metal chelators succimer (2, 3-dimercaptosuccinic acid (DMSA)) and trientine (N, N'-bis[2-aminoethyl]-1,2 ethanediamine) promoted free radical formation and were excluded from further studies. Histidine and D-methionine were then administered to guinea pigs receiving concurrent treatment with gentamicin (120 mg/kgx19 days). Threshold shifts induced by gentamicin were significantly attenuated by twice-daily injections of D-methionine. Once-daily injections of histidine or D-methionine were less effective, pointing to the importance of pharmacokinetics in antioxidant protection in vivo. The study presents a simple screening system for agents with the potential to attenuate gentamicin-induced hearing loss. It also supports the hypothesis of free radical formation as an underlying cause of gentamicin ototoxicity.

Acoustic trauma enhances DNA binding of transcription factor AP-1 in the guinea pig inner ear

Radiolabeled probes for the transcription factor, activator protein-1 (AP-1), bound differentially to nuclear fractions of discrete structures of the guinea pig cochlea (organ of Corti, lateral wall tissues, and spiral ganglion). Noise exposure (4 kHz octave band, 115 dB, for 5 h) significantly increased AP-1 binding in both the organ of Corti and lateral wall tissues but not in the spiral ganglion. Supershift analysis using an antibody against c-Fos protein demonstrated that enhancement of AP-1/DNA binding was at least in part due to the expression of c-Fos protein. These results suggest that AP-1 is involved in the molecular mechanism(s) mediating noise-induced cochlear damage.

Aminoglycoside antibiotics

In the 50 years since their discovery, the aminoglycoside antibiotics have seen unprecedented use. Discovered in the 1940s, they were the long-sought remedy for tuberculosis and other serious bacterial infections. The side effects of renal and auditory toxicity, however, led to a decline of their use in most countries in the 1970s and 1980s. Nevertheless, today the aminoglycosides are still the most commonly used antibiotics worldwide thanks to the combination of their high efficacy with low cost. This review first summarizes the history, chemistry, antibacterial actions and acute side effects of the drugs. It then details the pathophysiology of aminoglycoside ototoxicity including experimental and clinical observations, risk factors and incidence. Pharmacokinetics, cellular actions and our current understanding of the underlying molecular mechanisms of ototoxicity are discussed at length. The review concludes with recent advances towards therapeutic intervention to prevent aminoglycoside ototoxicity.

Antioxidant therapy attenuates aminoglycoside-induced hearing loss

Aminoglycosides have been a mainstay in antibacterial therapy for over 50 years. Worldwide today, they are the most commonly used antibiotics because of high efficacy and low cost. However, nephrotoxicity and ototoxicity are two major side effects. Prevention of these side effects has been attempted for several decades, but no clinical treatment has yet been realized. A therapeutic approach based on a novel hypothesis of the toxic mechanism of aminoglycosides is proposed. Aminoglycosides chelate iron, and the resulting iron-aminoglycoside complex is redox-active, catalyzing the formation of free radicals. The prevention of ototoxicity with antioxidants and iron chelators has been successfully demonstrated in guinea pigs. Both hearing loss and vestibular dysfunction induced by several aminoglycosides were significantly attenuated without compromising the antibacterial efficacy of the drugs. This finding may lead to a safe and effective way to eliminate the threat of ototoxicity of this commonly used class of antibiotics.

Salicylate attenuates gentamicin-induced ototoxicity

Aminoglycosides, primarily gentamicin, are the most commonly used antibiotics worldwide despite their toxicity to the kidney and the inner ear. A preventive therapy against these side effects should combine safety and efficacy with low cost because aminoglycoside-induced deafness is most prevalent in developing countries. We have previously shown that aminoglycosides catalyze the formation of free radicals in an iron-dependent reaction and have delineated the structure of an iron-gentamicin complex. Here we demonstrate that 2-hydroxybenzoate (salicylate), which can act as an iron chelator and antioxidant, effectively protects against gentamicin-induced hearing loss in guinea pigs. Co-therapy with salicylate reduced a profound gentamicin-induced auditory threshold shift of more than 60 dB to less than 20 dB. Morphological assessment of the inner ear confirmed protection of auditory sensory cells. Salicylate altered neither serum levels of gentamicin nor its antibacterial efficacy. Because the required salicylate levels correspond to anti-inflammatory levels in humans, this treatment holds promise for clinical application.

Cyclic GMP-dependent protein kinase-I in the guinea pig cochlea

Recent studies have begun to characterize the nitric oxide/cyclic GMP/protein kinase G pathway in the mammalian cochlea by demonstrating the presence of both the enzyme that produces nitric oxide (NO), nitric oxide synthase, and the NO receptor, soluble guanylate cyclase. The present study investigated protein kinase G (cyclic GMP-dependent protein kinase-I, cGK-I), the downstream enzyme of this pathway that frequently mediates its physiological effects. A commercial antibody to a human cGK-I sequence recognized a protein of appropriate molecular weight in Western blots of guinea pig aorta. Immunostaining of guinea pig aorta was consistent with the expected distribution of cGK-I. In lateral wall tissues of the cochlea, pericytes lining the blood vessels of the spiral ligament were strongly immunoreactive. In the organ of Corti, cGK-I was detected in Hensen's, Deiters', and pillar cells, but not in inner and outer hair cells. This distribution coincides with the localization of soluble guanylate cyclase activity and suggests that cGK-I mediates the effects of the NO/cyclic GMP pathway in the cochlea. It reinforces the hypothesis that the NO/cyclic GMP/cGK-I pathway is involved in regulation of cochlear blood flow and supporting cell physiology.

Formation of reactive oxygen species following bioactivation of gentamicin

The present study investigated the ability of gentamicin to catalyze free radical reactions and probed the underlying mechanisms by hydroethidine imaging, oxygen consumption, and reduction of cytochrome c. In Epstein-Barr virus-transformed lymphoblastoid cells, a respiratory burst was induced by phorbol ester and detected by hydroethidine, a fluorescent indicator of superoxide radical. The addition of gentamicin increased the fluorescence two-fold while gentamicin did not produce fluorescence in the absence of phorbol ester. In membrane preparations, gentamicin did not enhance NADPH consumption ruling out a direct activation of NADPH oxidase. The formation of reactive oxygen species by gentamicin was additionally supported by experiments that showed gentamicin increased oxygen consumption two-fold in intact cells and a cell-free system. In addition, generation of superoxide was indicated by the gentamicin-stimulated reduction of cytochrome c. The stimulation by gentamicin depended upon the presence of iron (FeII/FeIII) and of arachidonic acid as an electron donor. These results support the hypothesis that an iron-gentamicin complex can increase reactive oxygen species in nonenzymatic and in biological systems. The requirement for a reductive activation in intact cells (e.g., by a respiratory burst) is interpreted as the conversion of an inactive FeIII-gentamicin to a redox-active FeII-gentamicin complex.

Stimulation of free radical formation by aminoglycoside antibiotics

We have previously shown gentamicin to form a redox-active iron chelate. This study investigates whether other aminoglycosides can likewise stimulate the generation of reactive oxygen species (free radicals). Kanamycin, neomycin and streptomycin were compared to gentamicin in intact cells and in cell-free in vitro assays using luminescence detection with lucigenin or luminol. Neutrophils and Epstein-Barr virus-transformed lymphoblastoid cells served as cell models in which a respiratory burst of superoxide was induced by phorbol ester. The addition of millimolar amounts of any of the aminoglycosides increased the luminescence significantly. The drugs also increased the formation of free radicals in an enzymatic (hypoxanthine-xanthine oxidase) and a non-enzymatic (phenazine methosulfate-NADH) superoxide-generating system. Half-maximal stimulation was reached with (0.4 mM gentamicin, and there was an absolute requirement for an electron donor, arachidonic acid. In both intact cells and cell-free systems, gentamicin-enhanced luminosity was suppressed by iron chelators. These results demonstrate that different aminoglycoside antibiotics can stimulate the formation of free radicals in biological and in cell-free systems. Luminescence detection is a convenient assay method to investigate the redox properties of these drugs.

Nitric oxide/cyclic guanosine monophosphate pathway in the peripheral and central auditory system of the rat

The neuronal isoform of nitric oxide synthase (nNOS) and soluble guanylate cyclase (sGC) were localized in the cochlea, the cochlear nucleus (CN), and the superior olivary complex (SOC) of Fisher 344 rats. In the cochlea, nNOS was identified in spiral ganglion cells by using nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase histochemistry and in situ hybridization. NADPH-diaphorase staining also was detected in blood vessels of the modiolus. By using immunohistochemistry against cyclic guanosine monophosphate, cochlear sGC activity was localized to pericytes in the spiral ligament as well as nerve fibers innervating outer hair cells. In the lower auditory brainstem, nNOS was localized to principal cells of the medial nucleus of the trapezoid body (MNTB) with NADPH-diaphorase histochemistry and in situ hybridization. NADPH-diaphorase activity also was observed in the lateral and medial superior olive (LSO and MSO, respectively), the superior periolivary nucleus (SPN), the ventral and lateral nuclei of the trapezoid body (VNTB and LNTB, respectively), and the ventral cochlear nucleus (VCN). Transcripts of the beta-subunit of sGC were localized in rat brainstem by using in situ hybridization. mRNA for sGC was expressed in neurons within the SPN, LSO, MSO, LNTB, MNTB, VNTB, and VCN. Highest levels of sGC expression were seen in the SPN. These results suggest that the NO/cGMP pathway is involved in both the ascending and descending pathways of the auditory brainstem.

Attenuation of cochlear damage from noise trauma by an iron chelator, a free radical scavenger and glial cell line-derived neurotrophic factor in vivo

Tissue injury by reactive oxygen species (ROS) may play a role in noise-induced hearing loss (NIHL). Since iron is involved in ROS generation, we studied if an iron chelator, deferoxamine mesylate (DFO), alone or in combination with mannitol, a hydroxyl scavenger and weak iron chelator, attenuates NIHL. Further, we investigated if glial cell line-derived neurotrophic factor (GDNF) provides additive or synergistic protection of the cochlea from acoustic trauma when given together with DFO and mannitol. Pigmented female guinea pigs were exposed to noise (4 kHz octave band, 115 dB SPL, 5 h). One hour before, immediately after, and 5 h after noise exposure, subjects received an injection of 5 ml saline/kg (control, group I), 100 mg DFO/kg (group II), 15 mg mannitol/kg (group III), or both DFO and mannitol (group IV and V). Animals in group V underwent implantation of an osmotic pump filled with GDNF (100 ng/ml) in the left ear 4 days before noise. Each treatment afforded some protection from noise damage. Group I showed significantly greater outer hair cell loss and threshold shifts at two or more frequencies compared to groups II through V. GDNF provided an additive functional, but not morphological, protection with DFO and mannitol. These findings indicate that iron chelators can attenuate NIHL, as do ROS scavengers, supporting the notion that ROS generation plays a role in NIHL. Additional functional protection provided with GDNF suggests that GDNF may attenuate noise-induced cochlear damage through a mechanism that is additive with antioxidants.

Aging does not alter phosphoinositide hydrolysis in the rat cochlear lateral wall

We have previously reported that the inositol 1,4,5-trisphosphate (InsP3) second messenger system is coupled to purinergic P2y receptors in the cochlear sensory epithelium and lateral wall. The tissues of the cochlear lateral wall (stria vascularis and spiral ligament) are responsible for maintaining the ionic composition of the cochlear endolymph. Both the endolymphatic potential and signal transduction processes are well known to be affected by aging. Furthermore, intracellular inositol concentrations decrease with age in the cochlear sensory epithelia. The present study compared the purinergic receptor-mediated release of inositol phosphates (InsPs) in the cochlear lateral wall of young (3 month-old) and aged (24 month-old) Fischer-344 rats. No differences were found in the incorporation of mnyo-[3H]inositol into phosphoinositide lipids. Likewise, the purinergic receptor-mediated release of InsPs remained unchanged. This suggests that the InsPs second messenger system in the cochlear lateral wall, in contrast to the sensory epithelium, may not be affected by aging.

Are aminoglycoside antibiotics excitotoxic?

Guinea pigs received gentamicin to induce a profound hearing loss (61 dB auditory threshold shift at 18 kHz). Concomitant administration of maleic or tartaric acid dissolved in dimethyl sulfoxide (DMSO) significantly reduced the threshold shift to < 40 dB. The results have several important implications. First, they support the hypothesis of a free-radical mechanism of gentamicin toxicity since the protective compounds are metal chelators and scavengers. Second, they caution against these and similar chemicals, commonly found in drug preparations, as vehicles in tests of aminoglycoside toxicity. For example, a recent study by others describing attenuation of aminoglycoside ototoxicity by NMDA antagonists may have been influenced by the presence of maleate, tartrate and DMSO. Third, they suggest simple antioxidants as a potentially efficient and inexpensive clinical prophylaxis of aminoglycoside-induced hearing loss.

Iron chelators protect from aminoglycoside-induced cochleo- and vestibulo-toxicity

The attenuation of gentamicin-induced hearing loss by iron chelators and radical scavengers has recently been demonstrated in guinea pig in vivo. The present study investigated whether this protective treatment is effective against hearing loss and vestibular damage caused by other aminoglycosides. In a direct comparison, dihydroxybenzoate was chosen over deferoxamine because of its more effective action against gentamicin-induced hearing loss. Guinea pigs received daily injections of kanamycin (250 mg/kg/d) or streptomycin (300 mg/kg/d) for 23 d to induce severe cochlear or vestibular toxicity, respectively. Kanamycin injections resulted in a progressive threshold shift of 60 to 80 dB at 18 kHz, while streptomycin injections induced only a small threshold shift. In contrast, streptomycin abolished almost all vestibular responses. Coinjection of aminoglycosides with a mixture of dihydroxybenzoate (100 mg/kg/d) and mannitol (30 mg/kg/d) significantly attenuated kanamycin-induced hearing loss and protected against streptomycin-induced vestibulotoxicity. DHB/mannitol did not affect serum levels or the antibacterial efficacy of either aminoglycoside. This study supports the idea that iron and free radicals play a critical role in the toxic side effects of aminoglycoside antibiotics. Furthermore, the previously proposed therapeutic protection is not limited to gentamicin but applicable to other aminoglycosides as well.

Aminoglycoside ototoxicity: prevention in sight?

Despite the development of new antibiotics, the aminoglycosides are still indispensable in the treatment of life-threatening diseases. Worldwide they are the most commonly used antibiotics, and their use is expected to increase in the wake of the rising incidence of tuberculosis. The most prominent side effects of aminoglycoside treatment--cochlear, vestibular, and renal impairment--are a limiting factor in the utility of these drugs. A novel mechanism of gentamicin ototoxicity is based on observations of iron chelation and free radical formation. Predictions from this mechanism have led to successful therapeutic prevention of ototoxicity by use of iron chelators and radical scavengers in guinea pigs. The drugs used for this interventive treatment affect neither serum levels of gentamicin nor its antibacterial efficacy. Because these drugs are in clinical use, the suggested protective treatment should lend itself to clinical trials.

The nitric oxide/cyclic GMP pathway: a potential major regulator of cochlear physiology

The nitric oxide (NO)/cyclic guanosine monophosphate (GMP) pathway is now recognized as a major regulatory system in cell physiology and tissue homeostasis. This pathway may control processes as diverse as muscle relaxation, gut peristalsis, neurotransmission and hormonal secretion. It is also involved in the development and function of sensory systems such as vision and olfaction. This review will detail the NO/cyclic GMP pathway, evaluate studies in the auditory system and discuss its potential participation in cochlear blood flow, supporting cell physiology and excitotoxicity.

Glutathione-dependent antioxidant systems in the mammalian inner ear: effects of aging, ototoxic drugs and noise

Glutathione and glutathione-related enzymes protect against oxidative (free radical) cell injury. This study presents basic information on this antioxidant system in inner ear tissues and preliminary results of the influence of age, ototoxic drugs and noise. These conditions affect inner ear function, possibly through free radicals, and are therefore expected to affect cellular defense mechanisms. In 24-month old Fischer 344 rats, a standard model for aging, glutathione levels were significantly decreased in the auditory nerve by 86% as compared to 3-month old rats but remained unchanged in other cochlear tissues. In guinea pig, the common model for drug- and noise-induced trauma, glutathione levels in the cochlear sensory epithelium were about 8-fold higher (223 +/- 35 nmol glutathione/mg protein) than in the rat. Cochlear glutathione S-transferase and glutathione reductase activities were similar between the two species, whereas selenium-independent glutathione peroxidase was strikingly lower in guinea pig than in rat (9 +/- 3 nmol vs. 161 +/- 84 nmol glutathione converted/mg protein/min). Cisplatin treatment of guinea pigs (56 dB threshold shift at 18 kHz) significantly lowered cochlear glutathione levels by 65% and glutathione S-transferase activity by 44%. Gentamicin treatment (80 dB threshold shift at 18 kHz) and noise exposure (43 dB threshold shift at 18 kHz) did not affect glutathione at the tissue level. These results demonstrate species differences in cochlear glutathione and glutathione-related enzymes. The antioxidant system is sensitive towards environmental influences as seen for age and cisplatin. For gentamicin and noise trauma, whole tissue glutathione and enzyme levels do not correlate with functional damage. This indicates that glutathione homeostasis is largely maintained in the cochlea and that biochemical changes, if they occur under these conditions, may be limited to specific cells.

Energy metabolism in cochlear outer hair cells in vitro

ATP levels in outer hair cells in vitro were measured using the luciferin/luciferase method. Hair cells were isolated from the guinea pig cochlea and maintained for 2 h in a balanced salt solution with 5.5 mM glucose. Ten to 20 cells sufficed for a robust and reproducible luminescence signal, indicating an ATP content of 6.2 +/- 0.4 fmol/cell. This ATP concentration is similar to that found in cultures of other cell types and agrees well with the classical measurements in freeze-dried preparations. The ATP levels were reduced by the following treatments: (1) the omission of glucose in the culture medium lowered ATP levels by 28%; (2) the inhibition of glycolysis by 2-deoxyglucose lowered ATP levels by 66%; (3) the inhibition of oxidative phosphorylation by carbonyl cyanide m-chlorophenylhydrazine (CCCP) lowered ATP levels by 75%, and (4) the inhibition of both pathways reduced the ATP content to non-detectable levels. Acetoacetate was able to restore ATP levels partially when glycolysis was inhibited. These results suggest that (1) the major pathway of ATP synthesis in outer hair cells is the aerobic metabolism of glucose; (2) endogenous energy stores (e.g. glycogen) can maintain ATP levels in the absence of glucose; and (3) ketone bodies may be alternative energy sources.

Localization of soluble guanylate cyclase activity in the guinea pig cochlea suggests involvement in regulation of blood flow and supporting cell physiology

Although the nitric oxide/cGMP pathway has many important roles in biology, studies of this system in the mammalian cochlea have focused on the first enzyme in the pathway, nitric oxide synthase (NOS). However, characterization of the NO receptor, soluble guanylate cyclase (sGC), is crucial to determine the cells targeted by NO and to develop rational hypotheses of the function of this pathway in auditory processing. In this study we characterized guinea pig cochlear sGC by determining its enzymatic activity and cellular localization. In cytosolic fractions of auditory nerve, lateral wall tissues, and cochlear neuroepithelium, addition of NO donors resulted in three- to 15-fold increases in cGMP formation. NO-stimulated sGC activity was not detected in particulate fractions. We also localized cochlear sGC activity through immunocytochemical detection of NO-stimulated cGMP. sGC activity was detected in Hensen's and Deiters' cells of the organ of Corti, as well as in vascular pericytes surrounding small capillaries in the lateral wall tissues and sensory neuroepithelium. sGC activity was not observed in sensory cells. Using NADPH-diaphorase histochemistry, NOS was localized to pillar cells and nerve fibers underlying hair cells. These results indicate that the NO/cGMP pathway may influence diverse elements of the auditory system, including cochlear blood flow and supporting cell physiology.