Significant outcomes
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Dual-lipopolysaccharide (LPS) treatment causes enhanced locomotor response to d-amphetamine, deficits in recognition memory, and anxiety-like behaviour in rats.
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Rats receiving dual-LPS treatment display kynurenine pathway alterations with increased striatal kynurenic acid levels.
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Dual-LPS treatment is a valuable tool for investigating immune-induced-related psychotic disorders.
Limitations
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Dual-LPS treatment may affect behaviour in rats by altering the level of other neuroactive kynurenine pathway metabolites, such as quinolinic acid (QUIN).
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However, the concentration of QUIN in microdialysis samples was below the limit of quantification and hence not detectable.
Introduction
Accumulating evidence suggests that immune activation is associated with multiple psychiatric disorders, such as depression (Miller and Raison, Reference Miller and Raison2016; Osimo et al., Reference Osimo, Pillinger, Rodriguez, Khandaker, Pariante and Howes2020), schizophrenia (Khandaker et al., Reference Khandaker, Cousins, Deakin, Lennox, Yolken and Jones2015; Orlovska-Waast et al., Reference Orlovska-Waast, Köhler-Forsberg, Brix, Nordentoft, Kondziella, Krogh and Benros2019), bipolar disorder (Goldstein et al., Reference Goldstein, Kemp, Soczynska and McIntyre2009; Söderlund et al., Reference Söderlund, Olsson, Samuelsson, Walther-Jallow, Johansson, Erhardt, Landén and Engberg2011; Rosenblat et al., Reference Rosenblat, Brietzke, Mansur, Maruschak, Lee and McIntyre2015), and anxiety disorders (Vogelzangs et al., Reference Vogelzangs, Beekman, De Jonge and Penninx2013; Costello et al., Reference Costello, Gould, Abrol and Howard2019). Even though the physiological cross-talk between immune activation and psychiatric disorders remains unclear, increasing evidence suggests that the kynurenine pathway of tryptophan degradation may play a crucial pathophysiological role (Savitz, Reference Savitz2020).
The kynurenine pathway constitutes 90–95% of tryptophan degradation in humans and rodents. Notably, pro-inflammatory cytokines activate this metabolism via induction of the rate-limiting enzymes indoldioxygenase 1 and tryptophandioxygenase 2 thereby increasing the production of neuroactive metabolites (Campbell et al., Reference Campbell, Charych, Lee and Möller2014; Sellgren et al., Reference Sellgren, Kegel, Bergen, Ekman, Olsson, Larsson, Vawter, Backlund, Sullivan, Sklar, Smoller, Magnusson, Hultman, Walther-Jallow, Svensson, Lichtenstein, Schalling, Engberg, Erhardt and Landén2016; Erhardt et al., Reference Erhardt, Schwieler, Imbeault and Engberg2017b), such as kynurenic acid (KYNA) and quinolinic acid (QUIN). In this regard, the kynurenine pathway in the brain bridges immune signalling with glutamatergic circuits to induce psychiatric disorders (Erhardt et al., Reference Erhardt, Olsson and Engberg2009; Dantzer et al., Reference Dantzer, O’Connor, Lawson and Kelley2011; Pedraz-Petrozzi et al., Reference Pedraz-Petrozzi, Elyamany, Rummel and Mulert2020; Savitz, Reference Savitz2020). Among the kynurenine pathway metabolites, QUIN and KYNA are neuroactive metabolites that have received the most attention. Both metabolites bind to the N-methyl-D-aspartate (NMDA) receptor and act as agonists and antagonists, respectively (Stone and Perkins, Reference Stone and Perkins1981; Perkins and Stone, Reference Perkins and Stone1983; Ganong and Cotman, Reference Ganong and Cotman1986). Changes in the function of the NMDA receptor are implicated in the pathophysiology of a range of psychiatric disorders (Lakhan et al., Reference Lakhan, Caro and Hadzimichalis2013), especially in mood disorders (Ghasemi et al., Reference Ghasemi, Phillips, Trillo, De Miguel, Das and Salehi2014) and schizophrenia (Balu, Reference Balu2016). A large body of human studies, all demonstrating elevated levels of central KYNA in patients with schizophrenia (Erhardt et al., Reference Erhardt, Blennow, Nordin, Skogh, Lindström and Engberg2001; Schwarcz et al., Reference Schwarcz, Rassoulpour, Wu, Medoff, Tamminga and Roberts2001; Nilsson et al., Reference Nilsson, Nordin, Jönsson, Engberg, Linderholm and Erhardt2007; Sathyasaikumar et al., Reference Sathyasaikumar, Stachowski, Wonodi, Roberts, Rassoulpour, McMahon and Schwarcz2011; Linderholm et al., Reference Linderholm, Skogh, Olsson, Dahl, Holtze, Engberg, Samuelsson and Erhardt2012; Erhardt et al., Reference Erhardt, Lim, Linderholm, Janelidze, Lindqvist, Samuelsson, Lundberg, Postolache, Träskman-Bendz, Guillemin and Brundin2013; Erhardt et al., Reference Erhardt, Schwieler, Imbeault and Engberg2017b) and patients with bipolar disorder with a history of psychosis (Olsson et al., Reference Olsson, Samuelsson, Saetre, Lindström, Jönsson, Nordin, Engberg, Erhardt and Landén2010; Olsson et al., Reference Olsson, Sellgren, Engberg, Landén and Erhardt2012b; Lavebratt et al., Reference Lavebratt, Olsson, Backlund, Frisén, Sellgren, Priebe, Nikamo, Träskman-Bendz, Cichon, Vawter, Ösby, Engberg, Landén, Erhardt and Schalling2014; Sellgren et al., Reference Sellgren, Kegel, Bergen, Ekman, Olsson, Larsson, Vawter, Backlund, Sullivan, Sklar, Smoller, Magnusson, Hultman, Walther-Jallow, Svensson, Lichtenstein, Schalling, Engberg, Erhardt and Landén2016; Kegel et al., Reference Kegel, Johansson, Wetterberg, Bhat, Schwieler, Cannon, Schuppe-Koistinen, Engberg, Landén, Hultman and Erhardt2017; Sellgren et al., Reference Sellgren, Gracias, Jungholm, Perlis, Engberg, Schwieler, Landen and Erhardt2019; Sellgren et al., Reference Sellgren, Imbeault, Larsson, Oliveros, Nilsson, Codeluppi, Orhan, Bhat, Tufvesson-Alm, Gracias, Kegel, Zheng, Faka, Svedberg, Powell, Caldwell, Kamenski, Vawter, Schulmann, Goiny, Svensson, Hökfelt, Schalling, Schwieler, Cervenka, Choi, Landén, Engberg and Erhardt2021; Trepci et al., Reference Trepci, Sellgren, Pålsson, Brundin, Khanlarkhani, Schwieler, Landén and Erhardt2021), implicate the role of KYNA in psychosis as an executive link between neuroinflammation and NMDA receptor activity.
Administration of the endotoxin lipopolysaccharide (LPS) is an animal model widely used to investigate the role of immune activation in psychiatric diseases (Réus et al., Reference Réus, Fries, Stertz, Badawy, Passos, Barichello, Kapczinski and Quevedo2015). LPS is a pathogen-associated molecular pattern generated from gram-negative bacteria, which induces inflammation by binding to toll-like receptor 4, leading to the release of pro-inflammatory cytokines (Buttini and Boddeke, Reference Buttini and Boddeke1995; Wong et al., Reference Wong, Bongiorno, Rettrori, Mccann and Licinio1997; Quan et al., Reference Quan, Stern, Whiteside and Herkenham1999; Lu et al., Reference Lu, Yeh and Ohashi2008). In rodents, systemic LPS treatment elicits behavioural abnormalities associated with psychiatric disorders (Yirmiya, Reference Yirmiya1996; Frenois et al., Reference Frenois, Moreau, O’Connor, Lawson, Micon, Lestage, Kelley, Dantzer and Castanon2007; O’Connor et al., Reference O’Connor, Lawson, André, Moreau, Lestage, Castanon, Kelley and Dantzer2009; Salazar et al., Reference Salazar, Gonzalez-Rivera, Redus, Parrott and O’Connor2012; Oliveros et al., Reference Oliveros, Wininger, Sens, Larsson, Liu, Choi, Faka, Schwieler, Engberg, Erhardt and Choi2017; Peyton et al., Reference Peyton, Oliveros, Tufvesson-Alm, Schwieler, Starski, Engberg, Erhardt and Choi2019; Imbeault et al., Reference Imbeault, Goiny, Liu and Erhardt2020; Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020). The behavioural effects of LPS treatment appear to vary depending on the exposure to LPS. A single injection of LPS induces depressive-like behaviours in rodents (Yirmiya, Reference Yirmiya1996; Frenois et al., Reference Frenois, Moreau, O’Connor, Lawson, Micon, Lestage, Kelley, Dantzer and Castanon2007; O’Connor et al., Reference O’Connor, Lawson, André, Moreau, Lestage, Castanon, Kelley and Dantzer2009; Salazar et al., Reference Salazar, Gonzalez-Rivera, Redus, Parrott and O’Connor2012), whereas dual-LPS treatment elicits aberrant behaviours more relevant to psychotic disorders (Oliveros et al., Reference Oliveros, Wininger, Sens, Larsson, Liu, Choi, Faka, Schwieler, Engberg, Erhardt and Choi2017; Peyton et al., Reference Peyton, Oliveros, Tufvesson-Alm, Schwieler, Starski, Engberg, Erhardt and Choi2019; Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020). Both single- and dual-LPS treatment induce cognitive impairment in rodents (Pugh et al., Reference Pugh, Kumagawa, Fleshner, Watkins, Maier and Rudy1998; Arai et al., Reference Arai, Matsuki, Ikegaya and Nishiyama2001; Sparkman et al., Reference Sparkman, Kohman, Garcia and Boehm2005; Oliveros et al., Reference Oliveros, Wininger, Sens, Larsson, Liu, Choi, Faka, Schwieler, Engberg, Erhardt and Choi2017; Peyton et al., Reference Peyton, Oliveros, Tufvesson-Alm, Schwieler, Starski, Engberg, Erhardt and Choi2019; Imbeault et al., Reference Imbeault, Goiny, Liu and Erhardt2020; Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020; Mao et al., Reference Mao, Zhou, Sun, Wang and Sun2021) and activate the kynurenine pathway following induction of indoleamine 2,3-dioxygenase (IDO), but with differential downstream metabolite profiles (O’Connor et al., Reference O’Connor, Lawson, André, Moreau, Lestage, Castanon, Kelley and Dantzer2009; Larsson et al., Reference Larsson, Faka, Bhat, Imbeault, Goiny, Orhan, Oliveros, Ståhl, Liu, Choi, Sandberg, Engberg, Schwieler and Erhardt2016; Parrott et al., Reference Parrott, Redus and Connor2016a; Parrott et al., Reference Parrott, Redus, Santana-Coelho, Morales, Gao and O’Connor2016b; Imbeault et al., Reference Imbeault, Goiny, Liu and Erhardt2020). Further, LPS exposure, acutely or repeated, promotes neurotoxic kynurenine metabolism in the brain, leading to a rise in the production of 3-hydroxykynurenine and QUIN (Connor et al., Reference Connor, Starr, O’Sullivan and Harkin2008; O’Connor et al., Reference O’Connor, Lawson, André, Moreau, Lestage, Castanon, Kelley and Dantzer2009; Parrott et al., Reference Parrott, Redus and Connor2016a; Parrott et al., Reference Parrott, Redus, Santana-Coelho, Morales, Gao and O’Connor2016b; Rodrigues et al., Reference Rodrigues, de Souza, de Lima C.N., da Silva, da Costa D.V., dos Santos, Miyajima, de Sousa, Vasconcelos, Barichello, Quevedo, Maes, de Lucena and Macedo2018). On the other hand, dual-LPS injection specifically elicits brain kynurenine metabolism towards KYNA (Oliveros et al., Reference Oliveros, Wininger, Sens, Larsson, Liu, Choi, Faka, Schwieler, Engberg, Erhardt and Choi2017; Peyton et al., Reference Peyton, Oliveros, Tufvesson-Alm, Schwieler, Starski, Engberg, Erhardt and Choi2019; Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020). Previous studies also show that a reduction in the kynurenine pathway metabolism abrogates the behavioural effects of LPS treatment. Thus, mice deficient in IDO or receiving IDO inhibitors are protected from the behavioural effects of LPS treatment (O’Connor et al., Reference O’Connor, Lawson, André, Moreau, Lestage, Castanon, Kelley and Dantzer2009; Salazar et al., Reference Salazar, Gonzalez-Rivera, Redus, Parrott and O’Connor2012; Heisler and O’Connor, Reference Heisler and O’Connor2015). Moreover, kynurenine monooxygenase knock-out mice are protected from LPS-induced depression-like behaviours (Parrott et al., Reference Parrott, Redus, Santana-Coelho, Morales, Gao and O’Connor2016b). Collectively, the divergent behavioural profiles seen in LPS-challenged rodent models may be attributed to a distinct composition of kynurenine pathway metabolites.
Our previous data suggest that dual-LPS treatment is a valuable preclinical model for studying the relation between the dynamic activity of the kynurenine pathway and psychotic disorders in response to immune challenges (Larsson et al., Reference Larsson, Faka, Bhat, Imbeault, Goiny, Orhan, Oliveros, Ståhl, Liu, Choi, Sandberg, Engberg, Schwieler and Erhardt2016; Oliveros et al., Reference Oliveros, Wininger, Sens, Larsson, Liu, Choi, Faka, Schwieler, Engberg, Erhardt and Choi2017; Peyton et al., Reference Peyton, Oliveros, Tufvesson-Alm, Schwieler, Starski, Engberg, Erhardt and Choi2019; Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020). However, all published studies on the dual-LPS treatment animal model are limited to mice and previous studies suggest species differences between rats and mice with regard to general behaviour and overall regulation of the kynurenine pathway (Fujigaki et al., Reference Fujigaki, Saito, Takemura, Fujii, Wada, Noma and Seishima1998; Allegri et al., Reference Allegri, Bertazzo, Biasiolo, Costa, Ragazzi, Allegri, Costa, Ragazzi, Steinhart and Varesio2003; Murakami and Saito, Reference Murakami and Saito2013; Saré et al., Reference Saré, Lemons and Smith2021). This study aims to investigate in Sprague Dawley rats how immune activation, induced by dual injections of LPS, affects the kynurenine pathway and behaviour of relevance for psychotic disorders.
Material and method
Animals, animal welfare, and ethical statement
Experiments were carried out on 200–300 g male Sprague-Dawley rats ordered from Janvier Labs. The rats were housed in groups of 2–4 with free access to water and food. Animal tests were carried out at Komparativ Medicin – Biomedicum, Karolinska Institutet. Environmental conditions were checked daily and maintained under constant temperature (25°C), and 40–60% humidity in a room with a regulated 12 h light/dark cycle (lights on at 07:00). Experiments were approved and performed according to the guidelines of the Ethical Committee of Northern Stockholm, Sweden (ethical number: 2546-2019). All efforts were made to minimise the number of animals used and optimise their well-being.
Dual-LPS treatment
Rats were treated with LPS (0.5 mg/kg, i.p.) or equivalent volume vehicle (sterile saline) twice with 16 hours in between. Behavioural assessments as well as in vivo striatal microdialysis were conducted 24 hours after the second injection of LPS or vehicle. In all behaviour tests, the rats were handled for at least 1 min by researchers once a day, starting one week before the tests, to reduce stress. The detailed schedule of each test is shown in Fig. 1. All habituation and testing sessions were conducted between 7 a.m. and 7 p.m.
Behavioural tests
Open-field test
Locomotor activity was assessed in an open-field arena. Each rat was placed in a square Plexiglas box (50 × 50 × 21.6 cm) with a solid, sound-dampened chamber. The chamber was equipped with two rows of photocells that were sensitive to infrared light forming a two-layer grid across the arena (16 cells per row on each side, 3.1 cm apart). A computer recorded each photocell interruption as a single count. Horizontal activity (number of total of beam breaks at the lower level), rearing activity (number of beam breaks at the upper level), and corner time (cumulative time in seconds when two peripheral beams are simultaneously broken) were measured. Rats were habituated following two 60-minute sessions over two consecutive days. Immediately following the second habituation session, animals were treated with LPS or vehicle, as described above. Open field behaviour and basal locomotor activity were assessed 24 hours after the second treatment. After 60 min, rats were immediately injected with either 5 mg/kg d-amphetamine or the same volume of saline, and locomotor activity was recorded during the following 90 minutes. When rats were removed from the chambers, no symptoms of stereotypy were observed. The last 5 minutes of activity before the injection of d-amphetamine was calculated as baseline.
Fear conditioning test
We employed contextual plus-cued fear conditioning with a delay fear conditioning paradigm to determine the effect of dual-LPS treatment on associative learning and memory in rats. The test of fear conditioning was conducted using a fear conditioning chamber (Med Associates Inc., St Albans, VT, USA). Training was conducted 24 hours after the second injection of LPS or saline. Rats were given 100 seconds to explore the chamber before introducing a 20-second, 90-decibel tone signal. After the tone was stopped, the foot shock (2 s duration, 0.5 mA intensity) was delivered through the stainless-steel rods on the apparatus’s floor. Foot shock was delivered immediately after the tone, with no gap in time or overlap. After a 100-second inter-trial interval, a second tone-shock pairing was repeated, and the rat was removed 36 seconds after the last shock. Seventy-two hours later, freezing in the same situation was recorded with no tone or shock exposure to evaluate context-dependent memory. Approximately 3 hours after context memory assessment, the rats were again placed in the apparatus. Freezing in response to the cue was recorded in a novel setting (a plastic floor covered the metal grid, and a pyramidal shape was added to the rectangular box). In the cue session, following a 100-second exploration period, the audio cue was provided for 20 seconds. After a 100-second inter-trial interval, the second 20-second cue was provided. All the sessions were automatically recorded by the Med Associate programme (VideoFreeze v.2.5.0.0). Freezing was defined as the absence of movement other than that necessary for breathing. Freezing during each period was scored by experienced observers blinded to treatment.
Spontaneous alternation Y-maze test
Twenty-four hours after the second injection of LPS or saline, working memory was assessed using spontaneous alternation in the Y-maze with a classical setting (Swonger and Rech, Reference Swonger and Rech1972; Prieur and Jadavji, Reference Prieur and Jadavji2019). Animals were placed in one arm of a Y-maze (each arm had an internal dimension of 50 × 10 × 30 cm) and allowed to freely explore for 8 minutes while being continuously filmed from above. Data were collected using EthoVision XT 16. The parameters used to evaluate the rat performance were calculated using the following formula:
Additionally, the total number of arm entries was computed as an indicator of locomotor activity.
Novel object recognition test
The novel object recognition (NOR) test was conducted in an open-field arena (92 × 92 × 40 cm) using a modified previously published protocol (Mathiasen & Dicamillo, Reference Mathiasen and Dicamillo2010) to evaluate recognition memory. The lighting in the test room was controlled at approximately 30 Lx. The procedure consisted of three phases: acclimation, training, and testing. Rats were first acclimated in the arena without objects for 10 min. Twenty-four hours after acclimation, the rats were returned to the arena with two identical objects and given 5 min to freely explore the arena. The test session took place 1 hour after training, during which one of the training objects was replaced with a novel object in the same position. A digital video tracking system (EthoVision XT 16) was used to record the training and test sessions. Exploration was defined as the action with the nose point reaching an object at a distance of no more than 2 centimetres or touching it (Ennaceur & Delacour, Reference Ennaceur and Delacour1988). The software automatically measured exploration time.
Quantitative analysis of tryptophan, kynurenine, QUIN, and KYNA in striatal extracellular fluid
A separate batch of rats was used for neurochemical investigation. Striatal microdialysis was applied to collect extracellular fluid in rats following dual-LPS (n = 5) or dual-saline treatment (n = 4).
In vivo microdialysis
The rats were anaesthetised with isoflurane. The skull was exposed, and a hole was drilled above the striatum (A/P: + 0.48 mm, M/L: ±3.0 mm). Three additional smaller holes were drilled into the skull, and anchor screws were placed before insertion of the guide cannula. A guide cannula (AT4.9.IC; AgnTho’s AB, Sweden) was then lowered into the striatum (D/V: −3.5 mm) and anchored using dental cement (Dentalonâplus, Heraeus, Hanau, Germany). One day after the surgery, rats received either saline or LPS treatment. Twenty-four hours after the second LPS injection, rats were briefly sedated with isoflurane to insert a microdialysis probe (AT4.9.2., shaft length: 9 mm, membrane length: 2 mm, 6 kD cut-off, PES membrane, AgnTho’s AB, Sweden) into the guide cannula. The probe was connected to the microinfusion pump (Univentor 864, Univentor Ltd, Zejtun, Malta) using polyethylene tubing with a constant flow (1 µL/min) of perfusion fluid (perfusion fluid CNS, CMA Microdialysis AB, Sweden). Fractions were collected at 60 min intervals using a cooled autosampler for 9 hours, and all samples were stored at −20°C until further analysis. The metabolite concentrations measured in the microdialysis samples were not corrected for in vitro probe recovery (10–15%). We used a relatively short 3-day period between probe implantation and sampling to mitigate potential impacts on the results caused by scar tissue formation and an associated inflammatory response mediated by cytokine release (Benveniste and Diemer, Reference Benveniste and Diemer1987; Stenken et al., Reference Stenken, Church, Gill and Clough2010).
Samples preparation
Microdialysis samples (30 µL) were mixed with 30 µL of internal standard (IS) working solution (10 µM Tryptophan-d 3 , 1 µM Kynurenine-d 4 , 1 µM KYNA-d 5 and 1 µM QUIN-d 3 in 1% formic acid) for 15 s in LC-MS Certified Clear Glass 12 × 32 mm vials (Waters, PN: 186005662CV) before transfer to an autosampler (set to 4°C) that injected 3.0 µL into the UPLC–MS/MS system.
Extracellular tryptophan, kynurenine, QUIN, and KYNA analysis by UPLC-MS/MS
Extracellular tryptophan, kynurenine, QUIN, and KYNA values were analysed by UPLC-MS/MS system using a Xevo TQ-XS triple-quadrupole mass spectrometer (Waters, Manchester, UK) equipped with a Z-spray electrospray interface and a Waters Acquity UPLC I-Class FTN system (Waters, MA, USA). In brief, the MS was operated in electrospray-positive multiple reaction monitoring (MRM) mode with a source temperature of 150°C, capillary voltage of +3.0 kV, desolvation temperature of 650°C, desolvation gas flow rate of 1000 L/h, and detector gain 1. The column used was Acquity HSS T3 2.1 × 150 mm, 1.8 μm (Waters, Product Number [PN]: 186,003,540) at a temperature of 50°C. The two mobile phases were composed of A: 0.6% formic acid in water and B: 0.6% formic acid in methanol (UPLC-MS grade). An isolator column (Waters, 2.1 × 50 mm column, PN: 186,004,476) was installed to retain contaminants from the mobile phase. The run time for each sample was 13.0 min, with the flow rate set at 0.3 mL/min. For each individual analyte, the m/z values for MRM were: tryptophan, 206 > 118; kynurenine, 209 > 94; QUIN, 168 > 78; KYNA, 190 > 116. The m/z values for MRM for each IS were tryptophan-d 3 , 208 > 118; kynurenine-d 4 , 213 > 94; QUIN-d 3 , 171 > 81; KYNA-d 5 , 195 > 121. Full details and method evaluation can be found in our previous study (Schwieler et al., Reference Schwieler, Trepci, Krzyzanowski, Hermansson, Granqvist, Piehl, Venckunas, Brazaitis, Kamandulis, Lindqvist, Jones, Erhardt and Brundin2020).
Drugs and chemicals
Lipopolysaccharide (Escherichia coli serotype O111:B4, Sigma-Aldrich, lot no.: 091M4031V) was prepared in a vehicle solution (sterile saline) daily and stored at 4°C before every injection. D-amphetamine (Sigma-Aldrich) was prepared in a vehicle solution (sterile saline).
Statistics
Data are presented as mean ± SEM. Statistical significance was set at P-value <0.05. Data were analysed using unpaired t-test, repeated two-way ANOVA, or mixed-effects model analysis followed by Bonferroni post hoc analysis to determine the differences over time or between treatments. All statistical analyses were performed using GraphPad Prism version 8.3.0 (GraphPad Software, Inc., CA, USA).
Results
Dual-LPS-treated rats show reduced spontaneous locomotor activities and increased corner time
Significant effects of time and treatment were observed in all the measured parameters (Supplementary Table 1). Rats in both treatment groups showed habituation along with session progress (Fig. 2A-E), except for the increasing corner time with session progress (Fig. 2F). Compared to rats treated with dual-saline, rats treated with dual-LPS showed decreased spontaneous locomotor activity with reduced locomotion, horizontal activity, vertical activity, central activity, and peripheral activity (Fig. 2A-E). Moreover, dual-LPS-treated rats showed anxiety-like behaviours reflected as increased time spent in corners compared to saline control (Fig. 2F). A significant effect of interaction between the time and treatment was observed in all measurements of locomotor activities (Supplementary Table 1), with the exception of peripheral activity (Supplementary Table 1).
Enhanced locomotor response to d-amphetamine following dual-LPS treatment in rats
Following habituation, rats were given either d-amphetamine (5 mg/kg, i.p.) or saline. Locomotor activity was measured for 90 minutes. Given the significantly decreased locomotor activity of dual-LPS-treated rats at baseline (the overall activity of both treatment groups of rats can be found in Supplementary Figure 1), we used the area under the curve to analyse the overall effect of d-amphetamine on the locomotor activity in both groups. D-amphetamine treatment showed the effect of treatment on all the measured parameters (Supplementary Table 2). Dual-LPS-treated rats showed a more robust response to d-amphetamine compared to the dual-saline-treated rats, with enhanced locomotion (Fig. 3A, p = 0.0214, t = 2.964, df = 36), horizontal activity (Fig. 3B, p < 0.0001, t = 5.133, df = 36), and peripheral activity (Fig. 3E, p < 0.0001, t = 4.619, df = 36). Compared to dual-saline-treated rats, rats in the dual-LPS treatment group also showed decreased corner time (Fig. 3F, p = 0.0002, t = 4.486, df = 36) following d-amphetamine treatment.
Effects of dual-LPS administration on associative learning and memory
We employed contextual plus-cued fear conditioning with a delay fear conditioning paradigm to determine the effect of dual-LPS treatment on associative learning and memory in rats. During the training phase, both dual-saline-treated and dual-LPS-treated rats showed a tone-shock association (Fig. 4A and Supplementary Table 3). In addition, dual-LPS treatment increased freezing in this phase compared with dual-saline-treated animals (Fig. 4A and Supplementary Table 3), indicating anxiety-like behaviour. Seventy-two hours post-training session, both dual-saline-treated and dual-LPS-treated rats exhibited freezing in this context (Fig. 4B and Supplementary Table 3) as well as tone-cued fear conditioning (Fig. 4C and Supplementary Table 3). However, dual-LPS treatment did not change performance in the contextual (Fig. 4B and Supplementary Table 3) or cued conditioning tests (Fig. 4C and Supplementary Table 3).
Effects of dual-LPS treatment on spatial working memory
In the Y-maze paradigm, dual-LPS treatment failed to induce any significant changes in spontaneous alteration (Fig. 5A, p = 0.4790, t = 0.7273, df = 14), alternate arm returns (Fig. 5B, p = 0.6681, t = 0.4379, df = 14), or same arm returns (Fig. 5C, p = 0.7355, t = 0.3447, df = 14) when compared with dual-saline treatment. However, reduced locomotion was observed in the dual-LPS-treated rats, as reflected by a reduced number of total arm returns (Fig. 5D, p = 0.0134, t = 2.827, df = 14).
Dual-LPS treatment impairs recognition memory in the rat
Here we evaluated the recognition memory of dual-LPS-treated rats and dual-saline-treated rats using NOR tests. During the training sessions, for both saline and LPS rats, no significant differences were found in exploration time between the two identical objects (Fig. 6A and Supplementary Table 4). However, compared to saline-treated rats, dual-LPS-treated rats showed a shorter total exploration time (Fig. 6A and Supplementary Table 4). In the test phase, significant effects of object and treatment were observed on the exploration time (Supplementary Table 4). Dual-saline-treated rats spent significantly more time with the novel object than with the familiar one (Fig. 6B, p = 0.0023, t = 3.785, df = 20). Dual-LPS-treated rats showed no difference in the exploration time between novel and familiar objects (Fig. 6B, p = 0.2455, t = 1.611, df = 20).
Increased striatal extracellular kynurenine and KYNA following dual-LPS treatment
Ultra-performance liquid chromatography-tandem mass spectrometry data showed that striatal extracellular levels of tryptophan, kynurenine, and KYNA, measured in the microdialysis samples, were higher than the lowest level of quantification (LOQ: tryptophan, 0.01 μM; kynurenine, 0.00025 μM; KYNA, 0.0005 μM). However, striatal extracellular levels of QUIN were found to be lower than the LOQ (0.005 μM). Thus, due to the limit of assay sensitivity, we could only quantitatively analyse the levels of tryptophan, kynurenine, and KYNA in the microdialysis perfusates. Dual-LPS-treated rats showed increased striatal extracellular kynurenine and KYNA levels compared with saline-treated rats (Fig. 7B-C and Supplementary Table 5). No difference in striatal extracellular tryptophan levels was found (Fig. 7A and Supplementary Table 5).
Discussion
Previously we reported behavioural effects of dual-LPS treatment in mice by providing solid evidence that such treatment is a promising animal model for studying psychotic disorders with an underlying immune-activated kynurenine pathway, as observed in schizophrenia and bipolar disorder (Larsson et al., Reference Larsson, Faka, Bhat, Imbeault, Goiny, Orhan, Oliveros, Ståhl, Liu, Choi, Sandberg, Engberg, Schwieler and Erhardt2016; Oliveros et al., Reference Oliveros, Wininger, Sens, Larsson, Liu, Choi, Faka, Schwieler, Engberg, Erhardt and Choi2017; Peyton et al., Reference Peyton, Oliveros, Tufvesson-Alm, Schwieler, Starski, Engberg, Erhardt and Choi2019; Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020). The present study shows that dual-LPS treatment induces aberrant behaviour and cognitive dysfunction of relevance for psychotic disorders in rats. In addition, we show that dual-LPS treatment elicited metabolic alterations in the kynurenine pathway with increased extracellular kynurenine and KYNA levels in the striatum.
Our results with dual-LPS treatment agree with those of previous studies showing that systemic single-LPS treatment reduces spontaneous locomotor activity and induces anxiety-like behaviours in rodents (Bluthé et al., Reference Bluthé, Dantzer and Kelley1992; Yirmiya et al., Reference Yirmiya, Rosen, Donchin and Ovadia1994; Bison et al., Reference Bison, Bison, Carboni, Arban, Bate and Gerrard2008; Salazar et al., Reference Salazar, Gonzalez-Rivera, Redus, Parrott and O’Connor2012; Sulakhiya et al., Reference Sulakhiya, Keshavlal, Bezbaruah, Dwivedi, Gurjar, Munde, Jangra, Lahkar and Gogoi2016; Vancassel et al., Reference Vancassel, Fanet, Castanon, De Oliveira, Cussotto and Capuron2022). Notably, anxiety-like behaviour is also observed in mice with elevated brain KYNA, although their spontaneous locomotor activity is decreased or unaffected (Olsson et al., Reference Olsson, Larsson and Erhardt2012a; Erhardt et al., Reference Erhardt, Pocivavsek, Repici, Liu, Imbeault, Maddison, Thomas, Smalley, Larsson, Muchowski, Giorgini and Schwarcz2017a; Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020).
Augmented locomotor response to amphetamine is a well-recognized behavioural abnormality mirroring psychotic symptoms in patients and has repeatedly been observed in validated rodent models of psychotic disorders (Jones et al., Reference Jones, Watson and Fone2011). In line with our previous data in mice (Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020), dual-LPS-treated rats showed enhanced locomotion, and horizontal, and peripheral activity in response to amphetamine treatment, indicative of a psychotic-like phenotype. However, this contrasts with a recent publication reporting a loss of locomotor response to amphetamine in single LPS-treated mice (Vancassel et al., Reference Vancassel, Fanet, Castanon, De Oliveira, Cussotto and Capuron2022). This discrepancy may confirm the distinct neurobehavioural effects of single versus dual-LPS injections. In this regard, the difference might be related to increased brain KYNA, which is only seen following dual LPS treatment (Larsson et al., Reference Larsson, Faka, Bhat, Imbeault, Goiny, Orhan, Oliveros, Ståhl, Liu, Choi, Sandberg, Engberg, Schwieler and Erhardt2016; Parrott et al., Reference Parrott, Redus, Santana-Coelho, Morales, Gao and O’Connor2016b). Indeed, previous studies have shown enhanced amphetamine-induced locomotor activity, likely mediated by dopamine release (Larsson et al., Reference Larsson, Faka, Bhat, Imbeault, Goiny, Orhan, Oliveros, Ståhl, Liu, Choi, Sandberg, Engberg, Schwieler and Erhardt2016), in mice with elevated brain KYNA (Olsson et al., Reference Olsson, Larsson and Erhardt2012a; Erhardt et al., Reference Erhardt, Pocivavsek, Repici, Liu, Imbeault, Maddison, Thomas, Smalley, Larsson, Muchowski, Giorgini and Schwarcz2017a).
Next, we used the fear conditioning test to evaluate associative learning and memory in rats following dual-LPS treatment (Pezze and Feldon, Reference Pezze and Feldon2004; Curzon et al., Reference Curzon, Rustay and Browman2009). Consistent with our previous report in mice (Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020), rats treated with dual injections of LPS displayed enhanced fear acquisition with increased freezing throughout the training session, tentatively indicating anxiety-like behaviours or hypo-locomotor activity.
In contrast to mice (Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020), no differences were observed during the contextual and cued sessions between the dual-saline-treated and dual-LPS-treated rats. The current results suggest intact associative learning and memory in rats following dual-LPS treatment, whereas previous studies describe impaired contextual and cued-dependent fear in LPS-treated mice. Such discrepancies may be species-related. Thus, several previous studies indicate that functional responses to systemic LPS treatment differ between mice and rats (Snyder et al., Reference Snyder, Choe, Clifford, Jeurling, Hurley, Brown, Kamhi and Cameron2009; Lam et al., Reference Lam, Lively and Schlichter2017; Saré et al., Reference Saré, Lemons and Smith2021; Genzel, Reference Genzel2021). Moreover, unpublished data from our lab show that dual-LPS treatment affects downstream brain kynurenine metabolism differently in mice and rats, which may account for the behavioural discrepancies observed.
Similar to results obtained in mice (Peyton et al., Reference Peyton, Oliveros, Tufvesson-Alm, Schwieler, Starski, Engberg, Erhardt and Choi2019; Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020), dual-LPS-treated rats showed unchanged spontaneous arm alternation performance, indicating intact spatial working memory, in the spontaneous alternation Y-maze test. Our findings contrast with those of previous studies showing spatial working memory deficits following systemic single-LPS injection (Arai et al., Reference Arai, Matsuki, Ikegaya and Nishiyama2001; Sparkman et al., Reference Sparkman, Buchanan, Heyen, Chen, Beverly and Johnson2006; Murray et al., Reference Murray, Sanderson, Barkus, Deacon, Rawlins, Bannerman and Cunningham2012; Zhang et al., Reference Zhang, Gao, Zhao, Xia, Yang and Ji2023). Spatial working memory in rodents relies on the interaction of several brain regions, particularly the hippocampus and prefrontal cortex (Swonger and Rech, Reference Swonger and Rech1972; Sarnyai et al., Reference Sarnyai, Sibille, Pavlides, Fenster, McEwen and Tóth2000; Kraeuter et al., Reference Kraeuter, Guest and Sarnyai2019). The different behavioural patterns induced by single-LPS or dual-LPS treatment may suggest that the exposure time to LPS is critical for affecting brain functioning. Besides, we observed reduced total arm entries in dual-LPS-treated rats during the test, confirming locomotor impairment.
In the assessment phase of the NOR test, dual-saline-treated rats spent more time exploring novel objects, whereas dual-LPS-treated rats spent comparable time exploring familiar and novel objects, indicating impaired recognition memory (Antunes and Biala, Reference Antunes and Biala2012). These findings align with those of previous reports, showing that systemic LPS injection impairs recognition memory (Hennigan et al., Reference Hennigan, Trotter and Kelly2007; Frühauf et al., Reference Frühauf, Porto Ineu, Tomazi, Duarte, Mello and Rubin2015; Heisler and O’Connor, Reference Heisler and O’Connor2015; Alzahrani et al., Reference Alzahrani, Bahaidrah, Mansouri, Alsufiani and Alghamdi2022). In contrast, a previous report showed that acute LPS treatment does not affect novel object recognition (Czerniawski et al., Reference Czerniawski, Miyashita, Lewandowski and Guzowski2015). Of note, in that investigation, LPS was given between the training and the test phase, a design likely to reflect the effects on memory retrieval rather than consolidation (Czerniawski et al., Reference Czerniawski, Miyashita, Lewandowski and Guzowski2015). However, in the present study, LPS was administered before training, which would affect both memory consolidation and retrieval. On the other hand, we also need to note that dual-LPS-treated rats already displayed deficits in initial object exploration and spontaneous locomotor activities, which might influence object memory formation.
Dual-LPS rats, like similarly treated mice (Oliveros et al., Reference Oliveros, Wininger, Sens, Larsson, Liu, Choi, Faka, Schwieler, Engberg, Erhardt and Choi2017; Peyton et al., Reference Peyton, Oliveros, Tufvesson-Alm, Schwieler, Starski, Engberg, Erhardt and Choi2019; Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020), displayed distinct behavioural changes relevant to clinical psychotic disorders and cognitive impairment. We hypothesised that this behavioural phenotype is related to alterations in the brain kynurenine pathway, as suggested in previous studies (O’Connor et al., Reference O’Connor, Lawson, André, Moreau, Lestage, Castanon, Kelley and Dantzer2009; Heisler and O’Connor, Reference Heisler and O’Connor2015; Parrott et al., Reference Parrott, Redus and Connor2016a; Parrott et al., Reference Parrott, Redus, Santana-Coelho, Morales, Gao and O’Connor2016b; Oliveros et al., Reference Oliveros, Wininger, Sens, Larsson, Liu, Choi, Faka, Schwieler, Engberg, Erhardt and Choi2017; Peyton et al., Reference Peyton, Oliveros, Tufvesson-Alm, Schwieler, Starski, Engberg, Erhardt and Choi2019; Tufvesson-Alm et al., Reference Tufvesson-Alm, Imbeault, Liu, Zheng, Faka, Choi, Schwieler, Engberg and Erhardt2020). Although one should not ignore the possibility that the implantation probe per se may have affected the inflammatory response by LPS treatment (Stenken et al., Reference Stenken, Church, Gill and Clough2010), we observed increased extracellular kynurenine and KYNA in rat striatum following dual-LPS treatment, which may be attributed to an induction of IDO/TDO and enhanced expression of kynurenine aminotransferase enzymes (O’Connor et al., Reference O’Connor, Lawson, André, Moreau, Lestage, Castanon, Kelley and Dantzer2009; Larsson et al., Reference Larsson, Faka, Bhat, Imbeault, Goiny, Orhan, Oliveros, Ståhl, Liu, Choi, Sandberg, Engberg, Schwieler and Erhardt2016; Parrott et al., Reference Parrott, Redus and Connor2016a; Parrott et al., Reference Parrott, Redus, Santana-Coelho, Morales, Gao and O’Connor2016b). Clinical studies have repeatedly shown that patients with psychotic disorders display centrally elevated KYNA (Erhardt et al., Reference Erhardt, Blennow, Nordin, Skogh, Lindström and Engberg2001; Schwarcz et al., Reference Schwarcz, Rassoulpour, Wu, Medoff, Tamminga and Roberts2001; Nilsson et al., Reference Nilsson, Nordin, Jönsson, Engberg, Linderholm and Erhardt2007; Olsson et al., Reference Olsson, Samuelsson, Saetre, Lindström, Jönsson, Nordin, Engberg, Erhardt and Landén2010; Sathyasaikumar et al., Reference Sathyasaikumar, Stachowski, Wonodi, Roberts, Rassoulpour, McMahon and Schwarcz2011; Olsson et al., Reference Olsson, Sellgren, Engberg, Landén and Erhardt2012b; Erhardt et al., Reference Erhardt, Lim, Linderholm, Janelidze, Lindqvist, Samuelsson, Lundberg, Postolache, Träskman-Bendz, Guillemin and Brundin2013; Lavebratt et al., Reference Lavebratt, Olsson, Backlund, Frisén, Sellgren, Priebe, Nikamo, Träskman-Bendz, Cichon, Vawter, Ösby, Engberg, Landén, Erhardt and Schalling2014; Sellgren et al., Reference Sellgren, Kegel, Bergen, Ekman, Olsson, Larsson, Vawter, Backlund, Sullivan, Sklar, Smoller, Magnusson, Hultman, Walther-Jallow, Svensson, Lichtenstein, Schalling, Engberg, Erhardt and Landén2016; Kegel et al., Reference Kegel, Johansson, Wetterberg, Bhat, Schwieler, Cannon, Schuppe-Koistinen, Engberg, Landén, Hultman and Erhardt2017; Sellgren et al., Reference Sellgren, Gracias, Jungholm, Perlis, Engberg, Schwieler, Landen and Erhardt2019; Sellgren et al., Reference Sellgren, Imbeault, Larsson, Oliveros, Nilsson, Codeluppi, Orhan, Bhat, Tufvesson-Alm, Gracias, Kegel, Zheng, Faka, Svedberg, Powell, Caldwell, Kamenski, Vawter, Schulmann, Goiny, Svensson, Hökfelt, Schalling, Schwieler, Cervenka, Choi, Landén, Engberg and Erhardt2021; Trepci et al., Reference Trepci, Sellgren, Pålsson, Brundin, Khanlarkhani, Schwieler, Landén and Erhardt2021), which has been linked to psychotic symptoms (Atlas et al., Reference Atlas, Gisslén, Nordin, Lindström and Schwieler2007; Olsson et al., Reference Olsson, Sellgren, Engberg, Landén and Erhardt2012b; Lavebratt et al., Reference Lavebratt, Olsson, Backlund, Frisén, Sellgren, Priebe, Nikamo, Träskman-Bendz, Cichon, Vawter, Ösby, Engberg, Landén, Erhardt and Schalling2014) and cognitive dysfunction (Sellgren et al., Reference Sellgren, Kegel, Bergen, Ekman, Olsson, Larsson, Vawter, Backlund, Sullivan, Sklar, Smoller, Magnusson, Hultman, Walther-Jallow, Svensson, Lichtenstein, Schalling, Engberg, Erhardt and Landén2016). Studies in rodents demonstrate that experimentally induced elevation of brain KYNA is associated with alterations in glutamatergic and dopaminergic neurotransmission (Erhardt and Engberg, Reference Erhardt and Engberg2002; Schwieler and Erhardt, Reference Schwieler and Erhardt2003; Nilsson et al., Reference Nilsson, Linderholm and Erhardt2006; Linderholm et al., Reference Linderholm, Andersson, Olsson, Olsson, Snodgrass, Engberg and Erhardt2007; Olsson et al., Reference Olsson, Andersson, Linderholm, Holtze, Nilsson-Todd, Schwieler, Olsson, Larsson, Engberg and Erhardt2009; Pocivavsek et al., Reference Pocivavsek, Wu, Potter, Elmer, Pellicciari and Schwarcz2011; Tufvesson-Alm et al., Reference Tufvesson-Alm, Schwieler, Schwarcz, Goiny, Erhardt and Engberg2018), enhanced amphetamine-induced locomotor activity (Olsson et al., Reference Olsson, Larsson and Erhardt2012a; Liu et al., Reference Liu, Holtze, Powell, Terrando, Larsson, Persson, Olsson, Orhan, Kegel, Asp, Goiny, Schwieler, Engberg, Karlsson and Erhardt2014; Erhardt et al., Reference Erhardt, Pocivavsek, Repici, Liu, Imbeault, Maddison, Thomas, Smalley, Larsson, Muchowski, Giorgini and Schwarcz2017a), decreased spontaneous locomotor activity (Dennison et al., Reference Dennison, Ossenkopp and Cain1992; Chiarugi et al., Reference Chiarugi, Carpenedo, Molina, Mattoli, Pellicciari and Moroni1995), and impaired cognitive function (Shepard et al., Reference Shepard, Joy, Clerkin and Schwarcz2003; Erhardt et al., Reference Erhardt, Schwieler, Emanuelsson and Geyer2004; Chess and Bucci, Reference Chess and Bucci2006; Nilsson et al., Reference Nilsson, Linderholm and Erhardt2006; Pocivavsek et al., Reference Pocivavsek, Wu, Potter, Elmer, Pellicciari and Schwarcz2011). Altogether, it appears likely that the elevation of brain KYNA contributes to the aberrant behaviour seen in rats following dual-LPS treatment.
In developing reliable and predictive animal models for psychotic diseases like schizophrenia and bipolar disorder, corresponding psychosis-related phenotypes are frequently used to understand the neurobiological basis of these conditions (Nestler and Hyman, Reference Nestler and Hyman2010; Powell and Miyakawa, Reference Powell and Miyakawa2014). However, anxiety symptoms are also highly prevalent in bipolar disorder (Freeman et al., Reference Freeman, Freeman and McElroy2002) and schizophrenia spectrum psychiatric disorders (Achim et al., Reference Achim, Maziade, Raymond, Olivier, Mérette and Roy2011), and animal models involving anxiety-related phenotypes may offer a more accurate understanding of psychotic disorders (O'Tuathaigh et al., Reference O’Tuathaigh, Desbonnet, Waddington, Geyer and Gross2012). In the present study, a behavioural phenotype not only involving psychosis but also anxiety was validated in dual-LPS-treated rats with enhanced brain kynurenine and KYNA. Thus, the present results confirm that the dual-LPS injection model shows face and construct validity as an animal model of psychotic disorders.
In conclusion, given the broader and more complex repertoire of social performance in rats than in mice, the present results add to our knowledge of the control of behaviours by the immune system. Thus, the present data show that systemic dual-LPS treatment of adult male rats induces behavioural changes and alterations of brain kynurenine pathway relevant to psychotic disorders. Dual-LPS treatment decreased spontaneous locomotion, increased sensitivity to amphetamine, impaired recognition memory, and possibly, anxiety-related behaviours. These behavioural changes are likely caused by elevated brain KYNA, a compound that signals immune activation to neural circuits.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/neu.2023.40
Acknowledgement
We gratefully thank our colleagues at the Animal Behavior Core Facility Karolinska Institutet for providing insight and knowledge that considerably aided the research. We thank Dr Ana Pocivavsek at University of South Carolina, School of Medicine Colombia, Colombia, USA for her valuable support in preparing this manuscript. We also highly appreciate the help from all our colleagues at the Komparativ Medicin - Biomedicum, Karolinska, for helping us take care of the animals.
Author contribution
Yi-Ran Zheng substantially contributed to the design of the project, acquisition, analysis, and interpretation of the data, and drafting and editing of the manuscript. Maximilian Tufvesson-Alm substantially contributed to the design of the project, acquisition, analysis, and interpretation of the data. Ada Trepci substantially contributed to the acquisition, analysis, and interpretation of the data. Sophie Imbeault substantially contributed to the design of the project, analysis, and interpretation of the data. Xue-Qi Li substantially contributed to the acquisition of the data. Göran Engberg and Lilly Schwieler substantially contributed to revising the manuscript. Sophie Erhardt substantially contributed to the concept and design of the project, as well as revising the manuscript. All authors approved the version to be published.
Financial support
This work was supported by the Swedish Medical Research Council, Sweden (SE: 2021-02251; GE: 2019-01452), the Swedish Brain Foundation (SE, GE) and Åhléns-stiftelsen (GE). Yi-Ran Zheng and Xue-Qi Li are sponsored by KI-China Scholarship Council programme.
Competing interests
None.