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Volume 17, Number 21,
Issue of November 1, 1997
pp. 8402-8407
Copyright ©1997 Society for Neuroscience
Developmental Synaptic Depression Underlying Reorganization of
Visceral Reflex Pathways in the Spinal Cord
Isao Araki and
William C. de
Groat
Department of Pharmacology, University of Pittsburgh School of
Medicine, Pittsburgh, Pennsylvania 15261
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
FOOTNOTES
REFERENCES
ABSTRACT
During development, neuronal connectivity has a remarkable
plasticity. Synaptic refinement in the spinal autonomic nucleus might
be involved in the elimination of primitive segmental reflexes and the
emergence of mature spinobulbospinal reflexes, which occurs a few weeks
after birth. To address this possibility, we examined the postnatal
changes of segmental excitatory synaptic transmission by applying the
whole-cell recording technique to parasympathetic preganglionic neurons
in slice preparations of the rat lumbosacral spinal cord. The mean
magnitude of unitary excitatory synaptic currents evoked in
preganglionic neurons by stimulation of single interneurons remained
unchanged during the first two postnatal weeks but was reduced by 50%
during the third postnatal week. This reduction in synaptic efficacy
was associated with a decrease in the amount of transmitter release
from interneurons. Moreover, this developmental depression of segmental
synaptic transmission was prevented by spinal cord transection at the
thoracic level on postnatal day 14. Thus, developmental modification of
excitatory synapses on preganglionic neurons appears to be attributable
to competition between segmental interneuronal and descending
bulbospinal inputs, which results in the developmental reorganization
of parasympathetic excretory reflex pathways.
Key words:
synaptic plasticity;
developmental synaptic depression;
glutamatergic excitatory synaptic currents;
spinal autonomic nucleus;
parasympathetic preganglionic neurons;
micturition reflex;
chronic
spinal transection;
quantal analysis
INTRODUCTION
During early postnatal life,
synaptic refinements are well known to occur in the central (Hubel and
Wiesel, 1965
; Mendell, 1984
; Fregnac et al., 1988
; Reiter and Stryker,
1988
; Constantine-Paton et al., 1990
) and peripheral (Redfern, 1970
;
Ridge and Betz, 1984
; Dan and Poo, 1992
; Balice-Gorden and Lichtman,
1994
; Colman et al., 1997
) nervous systems. This synaptic remodeling
serves to refine initial coarse-grained and exuberant neuronal
connections and results in formation of highly tuned neural circuits
(Purves and Lichtman, 1985
; Goodman and Shatz, 1993
). In spinal
autonomic reflex pathways, synaptic refinement could be involved in the elimination of primitive segmental reflexes and the emergence of mature
reflex patterns. In neonates of many species, excretory functions
(micturition and defecation) are mediated exclusively by the segmental
parasympathetic reflex pathway, which is activated when the mother
licks the perineum of the neonate (Beach, 1966
; de Groat et al., 1975
;
Thor et al., 1989
). A few weeks after birth, this segmental reflex
begins to disappear and is replaced by the newly developed
spinobulbospinal reflex as the principal mechanism for excretion (de
Groat, 1975
; Fukuda et al., 1981
; Kruse and de Groat, 1990
; de Groat et
al., 1993
). This is also a critical period for the establishment of
synaptic refinements (Purves and Lichtman, 1985
) as well as for the
functional maturation of descending pathways to the spinal cord
(Gilbert and Stelzner, 1979
; Mendell, 1984
). Because the neuronal
connections at developing synapses appear to be refined by competition
between multiple synaptic inputs converging on the same target cell
(Purves and Lichtman, 1985
; Goodman and Shatz, 1993
), it is possible
that the segmental autonomic pathway operating in the early postnatal
life is suppressed by competition with the descending projection from
the brain for synaptic connections to parasympathetic preganglionic
neurons (PGNs). This view is supported by the finding that the
segmental parasympathetic reflex can be restored in adult animals when
the descending tract is impaired by chronic spinal cord transection (de
Groat et al., 1975
, 1993
; Kruse and de Groat, 1990
).
To address this possibility, we examined the postnatal changes in
synaptic transmission between segmental interneurons and PGNs in the
lumbosacral parasympathetic nucleus (SPN) of neonatal rats (Fig.
1). Interneurons located just dorsal to
the SPN appear to mediate disynaptic activation of PGNs by primary
afferents in segmental parasympathetic reflex pathways, as suggested by previous reports (McMahon and Morrison, 1982
; Birder and de Groat, 1992
; Nadelhaft and Vera, 1995
; Araki and de Groat, 1996
; de Groat et
al., 1996
). The present study shows that the amount of transmitter released from single interneurons to PGNs is abruptly reduced during
the third postnatal week. Moreover, this developmental synaptic
depression was prevented when the bulbospinal pathways were eliminated
by chronic spinal cord transection at the thoracic level. These results
suggest that the developmental modification of excitatory synapses on
PGNs is attributable to competition between their segmental and
suprasegmental synaptic inputs, which results in the reorganization of
parasympathetic excretory reflex pathways.
Fig. 1.
Schematic diagram for the neural circuit of
parasympathetic spinal segmental reflex and the neurons studied in
slice preparations of the lumbosacral cord. PGN,
Parasympathetic preganglionic neurons; INT, dorsal
interneurons; LCP, lateral collateral pathway of primary afferents; MPG, major pelvic ganglia.
[View Larger Version of this Image (19K GIF file)]
MATERIALS AND METHODS
Slice preparation. PGNs in the lumbosacral cord were
identified by retrograde labeling with a fluorescent dye. For this
purpose, 5 µl of 4% fast blue (Polyloy, GrossUmstadt, Germany) was
injected into the intraperitoneal space 3-7 d before the
electrophysiological studies. PGNs were clearly labeled by this
procedure, as reported previously (Anderson and Edwards, 1994
; Araki
and de Groat, 1996
).
Sprague Dawley rats, 6-22 d old, were decapitated under ether
anesthesia. The lumbosacral cord (L6-S1) was quickly isolated and
sectioned into 120-150 µm transverse slices with a vibrating slicer
(Vibratome; Technical Products International, St. Louis, MO) as
described previously (Edwards et al., 1989
). The slices were incubated
at 37°C for 1 hr and maintained thereafter by continuous perfusion at
room temperature.
Patch-clamp recording. The basic procedures for recording
whole-cell currents from individual neurons in slice preparations were
identical to those reported previously (Manabe et al., 1991
; Araki,
1994
; Araki and de Groat, 1996
). A slice preparation was placed in a
recording chamber with a volume of 0.6 ml and continuously superfused
by a solution equilibrated with 100% O2 at a rate of 2.5 ml/min. The bathing solution had the following composition (in
mM): 130 NaCl, 5 KCl, 2 CaCl2, 1 MgCl2, 11 glucose, and 10 HEPES, pH 7.4, with NaOH.
One micromolar strychnine (Sigma, St. Louis, MO) and 10 µM bicuculline methiodide (Sigma) were always present in
the bathing solution to eliminate inhibitory synaptic inputs. Each
slice of the lumbosacral cord (L6-S1) was surveyed for fast
blue-containing neurons (i.e., PGNs) along the intermediolateral border
of the gray matter under an upright microscope equipped with
fluorescent optics (BH2; Olympus, Tokyo, Japan) (Fig. 1). After
identification of a PGN, the neuron was viewed with Nomarski optics,
and a patch pipette (3-4 M
) was applied to record whole-cell currents with the use of an Axopatch 200A amplifier (Axon Instruments, Foster City, CA). The pipette solution contained (in mM):
140 potassium gluconate, 4 NaOH, 3 MgCl2, 10 HEPES,
and 0.2 EGTA, pH 7.3, with KOH. The recordings were made at room
temperature (22-25°C). Synaptic responses were evoked in PGNs by
electrical stimulation (50-100 µsec) with a glass micropipette (~2
M
) filled with external solution (Fig. 1). The stimulating pipette
was placed on the cell body of a dorsal interneuron. The dorsal
interneuron was defined as an unlabeled small neuron immediately dorsal
to SPN. Stimulus frequency was 1 Hz. To avoid failures of stimulation, stimulus intensities 1.2-1.5 times higher than the threshold were used. When EPSCs were recorded from dorsal interneurons, primary afferent fibers on the lateral edge of the dorsal horn [the lateral collateral pathway (LCP)] (Nadelhaft and Booth, 1984
; McKenna and
Nadelhaft; 1986) visible with Nomarski optics were stimulated by a
glass pipette with a larger tip (~10 µm). Cells with high series
resistance (>15 M
) or low input resistance (<150 M
) were not
studied. Current records were filtered at 1-3 kHz, digitized with the
use of the Digidata 1200 interface (10 kHz; Axon Instruments), and
stored on an IBM PC-compatible computer by sampling at 5 kHz for
off-line analysis with the use of pClamp6 software (Axon
Instruments).
Quantal analysis. Binned EPSC amplitude histograms were
fitted with sums of Gaussian curves using a least squares criterion (pStat program in pClamp6). In the majority of experiments, peaks in
the amplitude histograms were clearly detectable by eye. The fit was
restricted by the number of Gaussian curves and the amplitude range to
be fitted. When fitting with multiple-component Gaussian curves, pStat
requires entering of estimates (seed values) of the fitting function
parameters (the fractional contribution of each component to the area
under the curve, the mean of each component corresponding to the peak
of the Gaussian distribution, and the SD of the Gaussian distribution)
in advance. These optimal parameters were determined by finding the
best fit in the observed amplitude histogram. The bin width was chosen
to ensure that at least five bins lay between two neighboring peaks.
For all distributions, least squares fits were made at least twice with
different bin widths, and in no case were significant differences seen.
The error function for the least squares fit was minimized with a Simplex method. The value of quantal size (q) was calculated
as the mean peak separation using the following equation (Jonas et al.,
1993
): q = 1/N
Mk/k (N, total
number of peaks; Mk, mean amplitude of
the kth Gaussian component; and k, peak number). The peaks were considered equidistant if the SD of the
Mk/k values was <8% of their
mean (q).
All values in the text give the mean ± SD. Statistical analysis
was made using two-tailed t tests with a significance limit of p < 0.05.
RESULTS
Unitary synaptic currents in segmental parasympathetic
reflex pathways
EPSCs were evoked in PGNs by stimulating interneurons located
immediately dorsal to the lumbosacral parasympathetic nucleus (Fig. 1).
These interneurons are thought to mediate disynaptic activation of PGNs
by primary afferents in the segmental parasympathetic reflex pathway
(McMahon and Morrison, 1982
; Birder and de Groat, 1992
; Nadelhaft and
Vera, 1995
; Araki and de Groat, 1996
; de Groat et al., 1996
). This
notion was examined by recording synaptic responses from the
interneurons following field stimulation of primary afferent fibers
located at the lateral edge of the dorsal horn (LCP) (Nadelhaft and
Booth, 1984
; McKenna and Nadelhaft, 1986
). In 9 of 11 dorsal
interneurons tested, EPSCs could be evoked by stimulating the LCP (Fig.
2A). These evoked
responses were monosynaptic in nature, because the latency was short
(2.2 ± 0.3 msec; n = 9) and constant during
high-frequency stimulation (20 Hz).
Fig. 2.
EPSCs in segmental parasympathetic reflex
pathways. A, Composite EPSCs evoked in a dorsal
interneuron by stimulation of primary afferent fibers. Four responses
evoked by threshold (left) or supramaximal
(right) intensities of stimulus are superimposed. B, Unitary EPSCs evoked in a PGN by stimulation of a
dorsal interneuron. Five responses at each stimulus intensity indicated
above tracing are superimposed. C, Relationship between
the stimulus intensity and the mean peak amplitude of 30 consecutive
EPSCs (including failures) in the same cell as in B.
Vertical bars represent SEM. The holding potential was
60 mV. Scale bars, 10 msec and 40 pA.
[View Larger Version of this Image (15K GIF file)]
Electrical stimulation of single dorsal interneurons evoked EPSCs
in PGNs identified by retrograde labeling (Araki, 1994
; Araki and de
Groat, 1996
). These EPSCs were considered to result from activation of
a single presynaptic neuron (i.e., unitary responses), based on the
following criteria (Takahashi, 1992
; Jonas et al., 1993
; Araki and de
Groat, 1996
): (1) when the stimulating pipette was moved 10-30 µm
away from the interneuron, stimulus intensities two to four times
higher than the original threshold stimulus could not evoke synaptic
responses in PGNs; (2) the latency and the rise time distributions of
individual EPSCs showed a single sharp peak (data not shown) (Araki and
de Groat, 1996
); and (3) the mean EPSC peak amplitude showed
all-or-none behavior as a function of stimulus intensity (Fig.
2B,C).
These synaptic currents were completely blocked by
6-cyano-7-nitroquinoxaline (5 µM) and
2-amino-5-phosphonovalerate (50 µM), indicating that they
are glutamatergic EPSCs (Araki and de Groat, 1996
).
Developmental synaptic depression
We examined whether the mean magnitude of unitary EPSCs elicited
in PGNs by stimulation of the interneuron might change in the early
postnatal period, from 1 to 3 weeks after birth. As shown in Figure
3, the mean peak amplitude of EPSCs
recorded at a holding potential of
60 mV was unchanged during the
first (6-8 d) and second (13-15 d) postnatal weeks (39.5 ± 20.7 pA; n = 14; and 37.4 ± 15.3 pA; n = 15, respectively) but was markedly reduced at 3 weeks of age (20-22
d) (19.3 ± 8.9 pA; n = 14; p < 0.01). The time course of the EPSCs and other parameters (input
capacitance and input resistance) did not differ at these three
periods.
Fig. 3.
Developmental change in the efficacy of excitatory
transmission at interneuronal-PGN synapses and its modification by
chronic spinal transection. Mean peak amplitudes of unitary EPSCs
recorded from PGNs in intact (
) or spinalized (
) rats are plotted
against ages. Mean peak amplitudes were measured from averaged
responses of >30 consecutive EPSCs (including failures). The holding
potential was
60 mV. Each point represents the
mean ± SEM (vertical bar) from 14 or 15 cells. The
asterisk represents significant difference from the
values observed in other preparations (p < 0.006).
[View Larger Version of this Image (9K GIF file)]
Maturation of the descending inputs from the brain has been suggested
to play an important role in the suppression of segmental reflexes
during the postnatal period (de Groat et al., 1975
, 1993
). To examine
this possibility, the spinal cord was transected at the T10
segment on postnatal day 14. This procedure eliminated segmental
synaptic depression expected to occur at 3 weeks of age (38.2 ± 21.6 pA; n = 15) (Fig. 3, open circle).
Thus, the developmental synaptic depression appears to require the
formation of the descending inputs.
Reduction in the transmitter release
The reduced synaptic efficacy could be a result of a reduction in
the amount of the transmitter released from presynaptic terminals or a
reduction in the postsynaptic sensitivity to the transmitter. We
conducted a quantal analysis to examine these possible mechanisms
(Redman, 1990
). In 36 cells that had a sufficient sample size (>300
responses), the peak amplitude histograms of the unitary EPSCs could be
well fitted by the sum of several Gaussian functions with equidistant
peaks, indicating quantal release of the transmitter at the
interneuronal-PGN synapse (Fig. 4). The mean quantal size (Fig. 5A)
measured at a holding potential of
60 mV was 10.3 ± 0.3 pA
(n = 14) at 1-2 weeks of age. A similar value was
obtained in preparations from 3-week-old rats with an intact (10.1 ± 0.5 pA; n = 11) or a transected (10.4 ± 0.5 pA; n = 11) spinal cord. The quantal conductance
change, calculated assuming a reversal potential of 0 mV, was ~170 pS
during these postnatal periods. These results imply that the
postsynaptic sensitivity to the transmitter remained unchanged during
development.
Fig. 4.
Quantal analysis indicated a presynaptic mechanism
for the developmental synaptic depression. Peak amplitude distributions of unitary EPSCs recorded from PGNs at a holding potential of
60 mV.
A, From an 8-d-old rat. Bin width was 1.6 pA.
a, In the standard external solution (2 mM
Ca2+ and 1 mM Mg2+),
23 failures in 339 trials; b, in an external solution
containing 1 mM Ca2+ and 5 mM Mg2+ to reduce the release
probability, 124 failures in 363 trials. B, From a
20-d-old rat. Bin width was 1.2 pA, 48 failures in 363 trials.
C, From a 21-d-old rat spinalized at T10
level 2 weeks after birth. Bin width was 1.6 pA, 27 failures in 581 trials. Insets, Frequency distributions of background
noise. The smooth lines superimposed on the histograms
represent the sum of Gaussian distributions that best fit the data. In
all recordings, the SD of the noise (1.5 ± 0.3 pA;
n = 31) was less than that of any Gaussian curve
fitted to the EPSC amplitude histogram. The failures of response are
not shown.
[View Larger Version of this Image (35K GIF file)]
Fig. 5.
Developmental changes of quantal size (quantal
amplitude) and quantal content. A, Mean quantal
amplitudes measured at a holding potential of
60 mV.
B, Mean quantal contents calculated by dividing the mean
amplitude of unitary EPSCs by the quantal size in each cell.
C, Mean quantal contents calculated from the following
equation, based on Poisson's law: m = loge
(N/n0)
(m, quantal content; N, total number of
trials; and n0, number of failures of
response). Mean values obtained from PGNs in intact (
) or spinalized
(
) rats are plotted against ages. Each mean value was measured from 7 or 11 cells in which >300 responses were evoked. Each
point represents the mean ± SEM (vertical
bar). SEMs <0.15 are omitted. The asterisk
represents significant difference from the values observed in other
preparations (p < 0.03).
[View Larger Version of this Image (11K GIF file)]
In 10 cells, the release probability was reduced by lowering
Ca2+ and increasing Mg2+
concentrations in the external solution. Under this condition, the
frequency of failures increased, and the mean peak amplitude of EPSCs
was decreased without any change in quantal size (Fig. 4A,
b). Thus, the constancy of the quantal size also suggests that the
reduction of evoked synaptic responses results from a reduced quantal
content of the transmitter release.
When the mean quantal content was calculated by dividing the mean
amplitude of unitary EPSCs by the quantal size in each cell (Fig.
5B), it was significantly reduced at 3 weeks of age
(1.8 ± 0.9; n = 11) compared with 1- or
2-week-old rats (3.3 ± 1.6; n = 14;
p < 0.03). However, the developmental decrease in
transmitter release normally seen at 3 weeks of age was eliminated
after chronic spinal cord transection (3.8 ± 2.1;
n = 11; p < 0.01). Essentially, the
same result was obtained when the mean quantal content was estimated
from the number of failures (Fig. 5C). During the first 3 postnatal weeks, this quantal content was reduced from 2.5 ± 0.4 (n = 14; 1-2 weeks of age) to 1.5 ± 0.3 (n = 11; p < 0.001; 3 weeks of age) in
intact animals but not in spinalized rats (2.4 ± 0.6;
n = 11). Thus, this developmental synaptic depression
is most likely attributed to a reduction in the number of quanta released from presynaptic terminals.
DISCUSSION
The interneurons stimulated in our experiments are located in the
region of the intermediate gray matter that receives a prominent input
from the somatovisceral primary afferent pathway (Nadelhaft and Booth,
1984
; McKenna and Nadelhaft, 1986
). The primary afferents enter
Lissauer's tract and then send collaterals ventrally along the lateral
edge of the dorsal horn (LCP) into the dorsal region of the SPN.
Somatovisceral stimulation can activate the interneurons in this region
(McMahon and Morrison, 1982
; Birder and de Groat, 1992
), which in turn
form excitatory synapses on PGNs (Nadelhaft and Vera, 1995
; Araki and
de Groat, 1996
). Thus, the dorsal interneurons could function as relay
neurons in a disynaptic excitatory pathway from primary afferents to
the PGN (Araki and de Groat, 1996
; de Groat et al., 1996
). Consistent
with this notion, monosynaptic EPSCs were evoked in the interneurons by
focal electrical stimulation of the LCP.
We did not explore the detailed time course of changes in synaptic
transmission after spinal transection. At synapses formed by Ia sensory
fibers on motoneurons, enhancement of synaptic efficacy occurs in two
forms after spinal transection (Mendell, 1984
). The acute form lasts
only a few days, whereas the chronic form develops more slowly. The
chronic changes have been suggested to be caused by collateral
sprouting or activation of the already existing but nonfunctional
synapses, in contrast with some nonspecific process (e.g., humoral
factors) responsible presumably for the acute change (Nelson et al.,
1979
; Cope et al., 1980
; Mendell, 1984
). These chronic processes appear
to require partial deafferentation of motoneurons by elimination of
descending and/or segmental inputs. Spinal transection at the thoracic
level cannot particularly disrupt the segmental inputs to PGNs in the
lumbosacral cord. Thus, it seems likely that elimination of the
descending inputs is the primary cause for the changes in synaptic
transmission to PGNs observed after transection in our study.
The major finding in the present study was abrupt depression of
excitatory transmission at interneuronal-PGN synapses in segmental parasympathetic reflex pathways during the third postnatal week. This
coincides with the time when the spinobulbospinal reflex via the
pontine micturition center (PMC) replaces the segmental spinal reflex
as the principal mechanism for micturition (de Groat, 1975
; Kruse and
de Groat, 1990
; de Groat et al., 1993
). In addition, chronic spinal
transection prevented the developmental synaptic depression. This
result is consistent with the observations that primitive excretory
reflex patterns persist or reappear in chronic spinalized animals (de
Groat et al., 1975
, 1993
; Kruse and de Groat, 1990
). Thus, this
synaptic depression could be a mechanism that underlies the suppression
of primitive segmental reflexes during development.
Synaptic depression in the segmental pathway was attributable to a
reduction in the amount of transmitter release. At present, it is not
clear how transmitter release (quantal content) is reduced. Although no
morphological data are currently available, a progressive elimination
of synapses formed on a PGN by an interneuron may occur, as noted for
the competitive refinement of synaptic connections during early
postnatal development (Purves and Lichtman, 1985
; Goodman and Shatz,
1993
). At the neuromuscular junction a reduction of quantal content is
reported to occur before synapse elimination (axonal withdrawal)
(Colman et al., 1997
). It has been suggested recently that some
synapses can be converted to nonfunctional at normal resting potentials
by expressing only NMDA receptors but not AMPA receptors in
postsynaptic neuron (Liao et al., 1995
). This "silent synapse"
mechanism may be implicated in developmental synaptic refinements, as
suggested in the hippocampus and the barrel cortex (Durand et al.,
1996
; Isaac et al. 1997
). However, it is still premature to elaborate
this mechanism further.
The descending projections from the brain (e.g., PMC), which mature
during postnatal development (Gilbert and Stelzner, 1979
), very likely
compete with segmental interneuronal inputs for synaptic space on PGNs
(Fig. 6). Indeed, the elimination of the
bulbospinal inputs by chronic spinal transection prevented this
developmental synaptic depression. Thus, we conclude that developmental
modification of excitatory synapses on PGNs is attributable to
competition between their segmental and suprasegmental inputs, which
results in the reorganization of parasympathetic excretory reflex
pathways. If so, competitive synaptic refinements could serve as a
switching mechanism to replace neural reflex pathways during
development, in addition to making more subtle adjustments in
homogeneous overlapping synaptic connections that have been reported in
other systems (Purves and Lichtman, 1985
; Goodman and Shatz, 1993
).
Fig. 6.
Diagram indicating two sources of excitatory
inputs to PGNs during development. In neonates (broken
lines), interneurons synaptically activated by primary afferent
inputs mediate segmental somatovisceral reflexes. In adults
(solid lines), descending projections from higher center
in the brain (e.g., PMC) control PGN activity. The interneuronal inputs and the bulbospinal inputs could compete for
synaptic sites on PGNs during postnatal development.
[View Larger Version of this Image (17K GIF file)]
It is known that the pattern of electrical activity is a key factor in
synaptic competition in the developing nervous system (Ridge and Betz,
1984
; Fregnac et al., 1988
; Constantine-Paton et al., 1990
; Dan and
Poo, 1992
; Goodman and Shatz, 1993
; Balice-Gorden and Lichtman, 1994
)
as well as in functional plasticity at mature synapses (Madison et al.,
1991
; Linden, 1994
). Although mechanisms for the developmental synaptic
plasticity identified in this study remain to be explored, this slice
preparation, which allows the study of unitary synaptic connections
between identified pairs of neurons, will be useful in elucidating the
cellular mechanisms underlying the refinement of synaptic connections
in the developing CNS.
FOOTNOTES
Received May 5, 1997; revised Aug. 18, 1997; accepted Aug. 20, 1997.
This work was supported by National Institute of Diabetes and Digestive
and Kidney Diseases Grants DK 37241 and DK 49430. We thank Dr. Motoy
Kuno for his critical comments.
Correspondence should be addressed to Isao Araki, Clinical Research
Center and Department of Urology, Utano National Hospital, Narutaki,
Kyoto 616, Japan.
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