Progesterone turnover to its 5α-reduced metabolites in the ventral tegmental area of the midbrain is essential for initiating social and affective behavior and progesterone metabolism in female rats

BACKGROUND

Among women and female rodents, progesterone (P) influences social affiliation and affect. These effects may be partly due to formation of its 5α-reduced, 3α- hydroxylated metabolite, 5α-pregnan-3α-ol-20-one (3α,5α- THP).

AIM

To elucidate whether actions of 3α,5α-THP in the midbrain ventral tegmental area (VTA) are both necessary and sufficient to enhance non-sexual and sexual social behaviors, affect, and central 3α,5α-THP metabolism.

MATERIALS AND METHODS

P and 3α,5α-THP formation were unperturbed or blocked in VTA via infusions of vehicle, PK11195 (400 ng), and/or indomethacin (10 μg). Rats then received subsequent infusions of vehicle or 3α,5α-THP (100 ng) and were assessed in a battery of tasks that included open field (exploration), elevated plus maze (anxiety behavior), social interaction (social affiliation), and paced mating (sexual behavior) or were not tested. Metabolic turnover of P to its 5α-reduced metabolites was assessed in plasma, midbrain, hippocampus, frontal cortex, diencephalon, and remaining subcortical tissues (control interbrain).

RESULTS

Infusions of any combination of inhibitors significantly reduced social and affective behavior in all tasks compared to vehicle, concomitant with reduced turnover of P to its 5α-reduced metabolites, in midbrain only. Subsequent infusions of 3α,5α-THP significantly reinstated/enhanced anti- anxiety behavior, lordosis, and P turnover to its 5α-reduced metabolites in midbrain, as well as hippocampus, cortex, and diencephalon (but not plasma or interbrain).

CONCLUSIONS

These data are the first to provide direct evidence that actions of 3α,5α-THP in the VTA are both necessary and sufficient for social and affective behavior, as well as initiation of central 5α-reduction.

Prenatal Stress Alters Progestogens to Mediate Susceptibility to Sex-Typical, Stress-Sensitive Disorders, such as Drug Abuse: A Review

Maternal-offspring interactions begin prior to birth. Experiences of the mother during gestation play a powerful role in determining the developmental programming of the central nervous system. In particular, stress during gestation alters developmental programming of the offspring resulting in susceptibility to sex-typical and stress-sensitive neurodevelopmental, neuropsychiatric, and neurodegenerative disorders. However, neither these effects, nor the underlying mechanisms, are well understood. Our hypothesis is that allopregnanolone, during gestation, plays a particularly vital role in mitigating effects of stress on the developing fetus and may mediate, in part, alterations apparent throughout the lifespan. Specifically, altered balance between glucocorticoids and progestogens during critical periods of development (stemming from psychological, immunological, and/or endocrinological stressors during gestation) may permanently influence behavior, brain morphology, and/or neuroendocrine-sensitive processes. 5α-reduced progestogens are integral in the developmental programming of sex-typical, stress-sensitive, and/or disorder-relevant phenotypes. Prenatal stress (PNS) may alter these responses and dysregulate allopregnanolone and its normative effects on stress axis function. As an example of a neurodevelopmental, neuropsychiatric, and/or neurodegenerative process, this review focuses on responsiveness to drugs of abuse, which is sensitive to PNS and progestogen milieu. This review explores the notion that allopregnanolone may effect, or be influenced by, PNS, with consequences for neurodevelopmental-, neuropsychiatric-, and/or neurodegenerative- relevant processes, such as addiction.

Juvenile offspring of rats exposed to restraint stress in late gestation have impaired cognitive performance and dysregulated progestogen formation

Gestational stress may have lasting effects on the physical and neurocognitive development of offspring. The mechanisms that may underlie these effects are of interest. Progesterone and its 5α-reduced metabolites, dihydroprogesterone and 5α-pregnan-3α-ol-20-one (3α,5α-THP), maintain pregnancy, have neurotrophic effects, and can enhance cognitive performance. We hypothesized that some of the deleterious effects of gestational stress on the cognitive performance of offspring may be related to progestogen formation. Pregnant rat dams were exposed to restraint under a bright light (thrice daily for 45 min) on gestational days 17-21 or were minimally handled controls. Dams that were exposed to restraint had lower circulating levels of 3α,5α-THP and significantly greater concentrations of corticosterone at the time of birth than did control dams. Male and female offspring, that were gestationally stressed or not, were cross-fostered to non-manipulated dams. Between postnatal days 28-30, offspring were assessed for object recognition, a prefrontal cortex (PFC)-dependent cognitive task. Restraint-exposed offspring performed more poorly in the object recognition task than did control offspring, irrespective of sex. As well, progesterone turnover to its 5α-reduced metabolites in the medial PFC (but not the diencephalon) was significantly reduced among restraint-exposed, compared to control, offspring. Progesterone turnover, and levels of 3α,5α-THP, positively correlated with performance in the object recognition task. Thus, restraint stress in late pregnancy impaired cognitive development and dysregulated progestogen formation in brain.

Effects of neurosteroid actions at N-methyl-D-aspartate and GABA A receptors in the midbrain ventral tegmental area for anxiety-like and mating behavior of female rats

RATIONALE

In the midbrain ventral tegmental area (VTA), actions of neurosteroids, such as the progesterone metabolite, 5α-pregnan-3α-ol-20-one (3α,5α-THP), can facilitate mating and influence stress-related processes. Some actions of 3α,5α-THP may occur via positive modulation of GABA(A) receptors (GBRs), or negative modulation of N-methyl-D: -aspartate receptors (NMDARs), to influence anxiety-like behavior; but this is not known.

OBJECTIVES

We aimed to assess the role that neurosteroids and stress factors play on intra-VTA NMDAR- and/or GBR-mediated anxiety-like and mating behavior.

METHODS

Estradiol-primed, ovariectomized rats, which were partially or completely adrenalectomized (ADX), received infusions of vehicle, an NMDAR blocker (MK-801; 200 ng), or a GBR antagonist (bicuculline, 100 ng) to the VTA. Rats then received intra-VTA vehicle or a neurosteroidogenesis enhancer (N,N-Dihexyl-2-(4-fluorophenyl)indole-3-acetamide, FGIN 1-27, 5 μg) and anxiety-like and sexual behavior was assessed.

RESULTS

Complete, compared to partial, ADX significantly reduced open arm exploration on an elevated plus maze, the proportion of females that engaged in mating, lordosis quotients, pacing of sexual contacts, and defensive aggression towards a sexually vigorous male. Intra-VTA MK-801 enhanced open arm investigation and the proportion of females that engaged in mating. Infusions of either, MK-801 or FGIN 1-27, enhanced lordosis and, when co-administered, FGIN 1-27 attenuated MK-801's lordosis-enhancing effects. Intra-VTA infusions of bicuculline, prior to FGIN 1-27, blocked FGIN 1-27's effects to enhance lordosis.

CONCLUSIONS

Together, these data suggest that reduced NMDAR activity in the VTA may influence motivation to explore and engage in sexual behavior. These data suggest that neurosteroid actions at NMDARs and GBRs in the VTA are important for exploration and/or sexual behavior.

Divergent mechanisms for trophic actions of estrogens in the brain and peripheral tissues

17β-estradiol (E(2)) can enhance reproductive, cognitive, and affective functions; however, the mechanisms by which E(2) has these effects need to be better understood. Pleiotrophic effects of E(2) can occur via traditional and novel actions at various forms of estrogen receptors (ERs). In the central nervous system, trophic effects of E(2) may be related to beneficial effects of hormone replacement therapy (HRT). However, in peripheral reproductive tissues, E(2)'s capacity to evoke growth can increase risk of cancers. This review focuses on investigations aimed at elucidating divergent mechanisms of steroids to promote trophic effects in the brain, independent of effects on peripheral reproductive tissues. First, actions of estrogens via ERα or ERβ for peripheral growth (carcinogen-induced tumors, uterine growth) and hippocampus-dependent behaviors (affect, cognition) are described. Second, factors that influence these effects of estrogens are described (e.g. experience, timing/critical windows, non-ER mechanisms). Third, effects of estrogens at ERβ related to actions of progestogens, such as 5α-pregnan-3α-ol-20-one (3α,5α-THP) are described. In summary, effects of E(2) may occur via multiple mechanisms, which may underlie favorable effects in the brain with minimal peripheral trophic effects.

Conjugated equine estrogen, with medroxyprogesterone acetate, enhances formation of 5alpha-reduced progestogens and reduces anxiety-like behavior of middle-aged rats

The mechanisms by which progestogens influence affective behaviors in females are poorly understood despite clear changes in mood/affect that are associated with their decline during menopause. Conjugated equine estrogens (CEE), with or without medroxyprogesterone acetate (MPA), are commonly prescribed hormone-replacement, but there is heterogeneity in responses to these pharmacotherapies. One way in which these compounds differ is in their capacity to potentiate metabolism of progesterone to its 5alpha-reduced products, dihydroprogesterone and 5alpha-pregnan-3alpha-ol-20-one (3alpha,5alpha-THP). This study investigated whether responses to CEE and MPA may be related to the capacity to metabolize progesterone. Middle-aged female rats that had maintained reproductive status, or those that had a decline, were administered vehicle, CEE and/or MPA. Effects on anxiety-like (open field, elevated plus maze) and social behaviors (social interaction test), and plasma and hippocampus steroid levels were determined. We hypothesized that CEE, but not MPA, would decrease anxiety-like behavior coincident with increased hippocampal metabolism of progesterone. CEE, or CEE+MPA, increased central entries in the open field and time spent on the open arms of the plus maze, but did not alter social interaction of rats that had maintained reproductive status. CEE and/or CEE+MPA increased E2 and 3alpha,5alpha-THP in plasma and/or hippocampus of rats, but MPA increased levels of dihydroprogesterone in the hippocampus of rats with declining reproductive status. Simple regressions showed that hippocampus 3alpha,5alpha-THP levels accounted for a significant proportion of the variance in anxiety-like behavior. Therefore, effects of CEE to reduce anxiety-like behavior of middle-aged rats may be owing, in part, to its capacity to enhance levels of 3alpha,5alpha-THP in the hippocampus.

II. Cognitive performance of middle-aged female rats is influenced by capacity to metabolize progesterone in the prefrontal cortex and hippocampus

Cognitive decline can occur with aging; however, some individuals experience less cognitive decline than do others. Secretion of ovarian hormones is reduced post-menopause and may contribute to cognitive function. The extent to which hormonal effects may be parsed out from other age-related factors to influence cognition is of interest. Middle-aged (12-month-old) female rats that were retired breeders were categorized as maintaining or declining reproductive function based upon their estrous cyclicity (regular 4-5 day cycles), fertility (> 60 % successful pregnancy), and fecundity (>10 pups/litter). Performance in object recognition, Y-maze, water maze, inhibitory avoidance, and contextual-cued fear conditioning was evaluated. Estradiol, progesterone (P(4)), dihydroprogesterone, and 5α-pregnan-3α-ol-20-one (3α,5α-THP) were assessed in medial prefrontal cortex (mPFC) and hippocampus; corticosterone was assessed in plasma. Rats maintaining reproductive function performed significantly better on the object recognition, Y-maze, water maze, inhibitory avoidance, and cued fear conditioning tasks than did rats with declining reproductive function. Steroid concentrations varied greatly within groups. Higher levels of P(4) in mPFC and hippocampus were associated with better Y-maze performance. In mPFC, higher levels of P(4) were associated with poorer inhibitory avoidance performance; greater levels of 3α,5α-THP were associated with better object memory. Neither estradiol nor corticosterone levels significantly contributed to cognitive performance. Thus, the capacity for cortico-limbic P(4) utilization may influence cognitive performance in aging.

Low doses of cocaine decrease, and high doses increase, anxiety-like behavior and brain progestogen levels among intact rats

There are sex and hormonal differences in response to cocaine that have been demonstrated in people and animal models. Cocaine can alter secretion of progestogens, such as progesterone (P), and its neuroactive metabolite, 5alpha-pregnan-3alpha-ol-20-one (3alpha,5alpha-THP). However, little research has been done on the neuroendocrine effects in the initiation phase of cocaine use. We hypothesize that some sex/hormonal differences in initiation phase responses to cocaine may be related to formation of progestogens. To investigate the role of progestogens in sex differences in response to acute cocaine, male and female rats in the high (proestrous) or low (diestrous) progestogen phase of the estrous cycle were administered cocaine (0, 5, 10, or 20mg/kg, IP). We examined cocaine's acute neuroendocrine effects on P and 3alpha,5alpha-THP levels, as well as its effects on acute psychomotor stimulation, anxiety, and sexual behaviors. Among rats that had P and/or 3alpha,5alpha-THP levels increased in response to cocaine, enhanced acute psychomotor stimulation was observed. Results suggest that cocaine produces U-shaped curves for progestogens, and anxiety-like behaviors. Male rats were less susceptible to these effects of cocaine than were proestrous or diestrous female rats. However, cocaine's disruption of sexual behaviors was similar among males and proestrous females. These data suggest a complex interaction between hormonal milieu and the neuroendocrine and behavioral effects of cocaine.

Male gamblers have significantly greater salivary cortisol before and after betting on a horse race, than do female gamblers

Prevalence rates of gambling are influenced by gender. Among normative populations, hypothalamic-pituitary-adrenal (HPA) axis response to stress is affected by gender. However, pathological, compared to recreational, gamblers demonstrate perturbations in HPA activation in response to gambling stimuli. We examined whether there were gender differences in HPA response to gambling in a naturalistic setting among horse-race bettors and scratch-off lottery bettors. Salivary cortisol was collected from horse-race gamblers (n=32) and scratch-off lottery ticket players (n=39) before and after (0, 10, or 20 min) betting on a horse race at an off-track betting establishment. Salivary cortisol levels were significantly higher among men than among women, both prior to and following, betting on a horse race. Among women, but not men, there was a decline in salivary cortisol across time in scratch-off bettors, whereas women horse-race bettors maintained consistent low concentrations of salivary cortisol at every time point sampled. Together these data suggest that engaging in gambling may have different effects on stress responses of men, compared to women. Whether these gender differences in HPA activation contribute to gender-related differences in gambling behavior is the subject of ongoing investigation.

Sex differences in salivary cortisol in response to acute stressors among healthy participants, in recreational or pathological gamblers, and in those with posttraumatic stress disorder

Sex differences in incidence and severity of some stress-related, neuropsychiatric disorders are often reported to favor men, suggesting that women may be more vulnerable to aberrant hypothalamic-pituitary-adrenal (HPA) axis responses to stress. In this review, we discuss several investigations that we, and others, have conducted assessing salivary cortisol as a measure of HPA function. We have examined basal cortisol among healthy men and women and also following acute exposure to stressors. Among healthy participants, men had higher basal cortisol levels than did women. In response to acute stressors, such as carbon dioxide or noise, respectively, cortisol levels were comparable between men and women or higher among women. We have also examined cortisol levels among those with problem eating, gambling, or posttraumatic stress disorder (PTSD). Women with restrained eating habits have higher basal cortisol levels than do women without restrained eating habits. Pathological gamblers have more aberrant stress response to gambling stimuli than do recreational gamblers, and these effects are more prominent among men than women. Men who have motor vehicle accident related PTSD, demonstrate more aberrant cortisol function, than do their female counterparts. Although these sex differences in cortisol seem to vary with type of stress exposure and/or pathophysiological status of the individual, other hormones may influence cortisol response. To address this, cortisol levels among boys and girls with different stress-related experiences, will be the subject of future investigation.

Infusions of bicuculline to the ventral tegmental area attenuates sexual, exploratory, and anti-anxiety behavior of proestrous rats

Actions of 5alpha-pregnan-3alpha-ol-20-one (3alpha,5alpha-THP), in the midbrain ventral tegmental area (VTA) modulate sexual receptivity of female rats. Actions of 3alpha,5alpha-THP at GABAergic substrates in the VTA are known to modulate consummatory aspects of sexual behavior among rodents, such as lordosis. However, the extent to which GABA(A) receptors in the VTA are important for appetitive (exploratory, anti-anxiety, social) aspects of sexual receptivity is not well-understood. Proestrous rats were bilaterally-infused with saline or bicuculline (100 ng), a GABA(A) receptor antagonist, to the VTA or missed control sites. Rats were assessed for exploratory/anti-anxiety (open field/elevated plus maze), social (social interaction), and sexual (paced-mating) behavior. Compared to saline or missed site controls, intra-VTA bicuculline significantly reduced the number of central entries in an open field, time spent on the open arms of an elevated plus maze, frequency and intensity of lordosis, anti-aggression towards a male, pacing of sexual contacts, and 3alpha,5alpha-THP concentrations in midbrain and hippocampus. Bicuculline-infused rats also displayed less affiliation with a novel conspecific, fewer sexual solicitations, and had lower 3alpha,5alpha-THP concentrations in diencephalon and cortex, albeit these were not significant differences. Thus, actions at GABA(A) receptors in the midbrain VTA are essential for appetitive and consummatory aspects of sexual receptivity among rats.

Chronic estradiol replacement to aged female rats reduces anxiety-like and depression-like behavior and enhances cognitive performance

Decline in the ovarian steroid, estradiol (E(2)), with the menopause transition may influence cognitive and affective processing of older women and there is evidence that hormone replacement therapies (HRTs) with E(2)-mimetics may provide benefit in some, but not all, women. The parameters that play a role in determining whether the response to HRTs is positive are of interest. It may be that the likelihood for positive responses is related to the timing of E(2)-replacement following E(2) decline. As such, in the present study an animal model was utilized to investigate this. We investigated the effects of long- versus short-term E(2)-replacement by examining cognitive (object placement task), anxiety (open field, mirror maze, light-dark transition task), and depression (forced swim task) behavior of female rats that were ovariectomized (OVX) at middle-age (14 months) or older (19 months) and implanted with E(2)-filled implants at the time of surgery or after a delay of 5 months, or OVX at 14 months of age and never replaced with E(2). Rats were tested at 20 months of age. The hypothesis that was tested was that rats would have reduced anxiety and depression behavior and improved cognitive performance with E(2)-replacement at ovarian cessation, compared to a delay in E(2)-replacement. Performance in the object placement task was improved in rats that were OVX and then received continuous E(2)-replacement, compared to those that were OVX and continuously administered placebo vehicle. In the open field and forced swim task, there was an increase in anti-anxiety and anti-depression behavior, respectively, among rats that were OVX and then received continuous E(2)-replacement, compared to OVX rats administered vehicle or those that experienced a delay in E(2)-replacement. In the mirror maze and light-dark transition task, E(2)-replacement at OVX, or after a delay, reduced anxiety-like behavior. Thus, E(2)-replacement reduced anxiety and depression behavior and improved cognitive performance of aged female rats; however, delay in E(2) treatment influenced whether there were favorable effects of E(2) in some tasks.

Gambling pathology is associated with dampened cortisol response among men and women

Pathological gambling has many similarities to pharmacological addiction. Notably, both pathological gambling and drug addiction are characterized by aberrations in hypothalamic-pituitary-adrenal (HPA) axis responding. As well, there are indications that gender differences may play a role in these processes. Whether gender and/or HPA response are associated with pathological gambling was of interest. Recreational and pathological gamblers (15 men and 6 women per group) had the HPA factor, cortisol, assessed in saliva before and after watching a video of their preferred mode of gambling (slot machines, horse race betting, scratch-off tickets, blackjack, video poker, craps, sports betting, online casino games, or lottery tickets), and a video of neutral stimuli (a rollercoaster ride). Basal levels of salivary cortisol did not significantly differ among recreational and pathological gamblers. However, recreational gamblers demonstrated significantly increased salivary cortisol levels after the gambling and rollercoaster videos, whereas pathological gamblers demonstrated no salivary cortisol increase in response to either video stimulus. There was also a non-significant trend for women to have a greater cortisol response to video stimuli compared to men. These data suggest that pathological gambling is associated with hypoactive HPA response to gambling stimuli, similar to chronic drug exposure, and gender may contribute to this effect.

Increasing 3alpha,5alpha-THP following inhibition of neurosteroid biosynthesis in the ventral tegmental area reinstates anti-anxiety, social, and sexual behavior of naturally receptive rats

The progesterone metabolite and neurosteroid, 5alpha-pregnan-3alpha-ol-20-one (3alpha,5alpha-THP), has actions in the midbrain ventral tegmental area (VTA) to modulate lordosis, but its effects on other reproductively relevant behaviors are not well understood. Effects on exploration, anxiety, and social behavior resulting from inhibition of 3alpha,5alpha-THP formation, as well as 3alpha,5alpha-THP enhancement, were investigated in the midbrain VTA. Naturally sexually receptive, female rats (n=8-10/group) received infusions aimed at the midbrain VTA of vehicle, PK11195 (an inhibitor of neurosteroidogenesis), and/or indomethacin (an inhibitor of 3alpha,5alpha-THP formation from prohormones), and were subsequently infused with vehicle or FGIN 1-27 (a neurosteroidogenesis enhancer). The rats were then assessed in a behavioral battery that examined exploration (open field), anxiety (elevated plus maze), social (social interaction), and sexual (paced mating) behavior. Inhibition of 3alpha,5alpha-THP formation decreased exploratory, anti-anxiety, social, and sexual behavior, as well as midbrain 3alpha,5alpha-THP levels. Infusions of FGIN 1-27 following 3alpha,5alpha-THP inhibition restored these behaviors and midbrain 3alpha,5alpha-THP levels to those commensurate with control rats that had not been administered inhibitors. These findings suggest that 3alpha,5alpha-THP formation in the midbrain VTA may influence appetitive, as well as consummatory, aspects of mating behavior.

Exploratory, anti-anxiety, social, and sexual behaviors of rats in behavioral estrus is attenuated with inhibition of 3alpha,5alpha-THP formation in the midbrain ventral tegmental area

The progesterone (P(4)) metabolite and neurosteroid, 5alpha-pregnan-3alpha-ol-20-one (3alpha,5alpha-THP) acts in the midbrain ventral tegmental area (VTA) to modulate lordosis of female rats. 3alpha,5alpha-THP also mediates exploratory, affective, and social behaviors; whether actions of 3alpha,5alpha-THP in the VTA mediate these behaviors is of interest. To elucidate the role of the VTA in mediating exploratory, affective, and social behaviors, the present study examined effects of inhibiting 3alpha,5alpha-THP formation in the VTA. Rats received intra-VTA infusions of either PK11195 (400ng/mul, which inhibits de novo 3alpha,5alpha-THP production), indomethacin (10mug/mul, which blocks metabolism of P(4) to 3alpha,5alpha-THP), PK11195 and indomethacin together, or beta-cyclodextrin vehicle and tested on a battery of anxiety (open field and elevated plus maze), social (partner preference and social interaction), and sexual (paced mating) tasks. Compared to rats infused with vehicle to the VTA, rats infused with inhibitor(s) demonstrated significant reductions in central entries in the open field, time on open arms of an elevated plus maze, time spent interacting with a conspecific, initiation and intensity of lordosis, sexual solicitations, and midbrain 3alpha,5alpha-THP levels. These findings suggest that actions of 3alpha,5alpha-THP in the VTA are important for mediating aspects of exploration, anxiety, and social behavior related to mating.

Estrous cycle, pregnancy, and parity enhance performance of rats in object recognition or object placement tasks

Ovarian hormone elevations are associated with enhanced learning/memory. During behavioral estrus or pregnancy, progestins, such as progesterone (P(4)) and its metabolite 5 alpha-pregnan-3 alpha-ol-20-one (3 alpha,5 alpha-THP), are elevated due, in part, to corpora luteal and placental secretion. During 'pseudopregnancy', the induction of corpora luteal functioning results in a hormonal milieu analogous to pregnancy, which ceases after about 12 days, due to the lack of placental formation. Multiparity is also associated with enhanced learning/memory, perhaps due to prior steroid exposure during pregnancy. Given evidence that progestins and/or parity may influence cognition, we investigated how natural alterations in the progestin milieu influence cognitive performance. In Experiment 1, virgin rats (nulliparous) or rats with two prior pregnancies (multiparous) were assessed on the object placement and recognition tasks, when in high-estrogen/P(4) (behavioral estrus) or low-estrogen/P(4) (diestrus) phases of the estrous cycle. In Experiment 2, primiparous or multiparous rats were tested in the object placement and recognition tasks when not pregnant, pseudopregnant, or pregnant (between gestational days (GDs) 6 and 12). In Experiment 3, pregnant primiparous or multiparous rats were assessed daily in the object placement or recognition tasks. Females in natural states associated with higher endogenous progestins (behavioral estrus, pregnancy, multiparity) outperformed rats in low progestin states (diestrus, non-pregnancy, nulliparity) on the object placement and recognition tasks. In earlier pregnancy, multiparous, compared with primiparous, rats had a lower corticosterone, but higher estrogen levels, concomitant with better object placement performance. From GD 13 until post partum, primiparous rats had higher 3 alpha,5 alpha-THP levels and improved object placement performance compared with multiparous rats.

Engaging in paced mating, but neither exploratory, anti-anxiety, nor social behavior, increases 5alpha-reduced progestin concentrations in midbrain, hippocampus, striatum, and cortex

Sequential actions of 17beta-estradiol (E(2)) and progesterone (P(4)) in the hypothalamus and the P(4) metabolite, 5alpha-pregnan-3alpha-ol-20-one (3alpha,5alpha-THP), in the midbrain ventral tegmental area (VTA) respectively mediate the initiation and intensity of lordosis of female rats and may also modulate anxiety and social behaviors, through actions in these, and/or other brain regions. Biosynthesis of E(2), P(4), and 3alpha,5alpha-THP can also occur in brain, independent of peripheral gland secretion, in response to environmental/behavioral stimuli. The extent to which engaging in tasks related to reproductive behaviors and/or mating increased E(2) or progestin concentrations in brain was investigated. In Experiment 1, proestrous rats were randomly assigned to be tested in individual tasks, including the open field, elevated plus maze, partner preference, social interaction, or no test control, in conjunction with paced mating or no mating. Engaging in paced mating, but not other behaviors, significantly increased dihydroprogesterone (DHP) and 3alpha,5alpha-THP levels in midbrain, hippocampus, striatum, and cortex. In Experiment 2, proestrous rats were tested in the combinations of the above tasks (open field and elevated plus maze, partner preference, and social interaction) with or without paced mating. As in Experiment 1, only engaging in paced mating increased DHP and 3alpha,5alpha-THP concentrations in midbrain, hippocampus, striatum, and cortex. Thus, paced mating enhances concentrations of 5alpha-reduced progestins in brain areas associated with reproduction (midbrain), as well as exploration/anxiety (hippocampus and striatum) and social behavior (cortex).

Treatment decision-making for patients with the Herlitz subtype of junctional epidermolysis bullosa

The Herlitz subtype of junctional epidermolysis bullosa (JEB-H) is a lethal genetic disorder characterized by recurrent and persistent erosions of the epithelial surfaces that heal with exuberant granulation tissue. In addition, respiratory distress, refractory anemia and failure to thrive are often seen. Mortality in the first year of life approaches 90%. JEB-H is caused by mutations in the genes that encode the protein laminin 5, a structural molecule involved in the adhesion of epidermis to dermis. There is currently no cure for JEB-H. Medical interventions treat complications but do not ultimately limit mortality. Ethical principles contend that offering comfort and company to the patient and family, not aggressive therapies, should comprise the mainstay of care for affected infants.

Approaches to end-of-life decision-making in the NICU: insights from Dostoevsky's The Grand Inquisitor

For many parents stopping life-sustaining medical treatment on their dying infant is psychologically impossible. Dostoevsky's insights into human behavior, particularly the fact that individuals do not want the anxiety and guilt associated with responsibility for making difficult decisions, might change the way physicians approach parents for permission to withdraw life-prolonging medical interventions on dying infants.

Resuscitation of the preterm infant against parental wishes

Over the past 40 years, the norms on who is to make treatment decisions for newborns, and on what standards, have been significantly altered and revised. Today the standard for treatment of newborns is the "best interest" of the child. A recent ruling of the Texas Supreme Court authorizing a doctor to resuscitate a potentially viable very premature newborn over the parents' objection is a challenge to that standard.

Ethical issues in fetal surgery involving a twin pregnancy

In utero surgery may provide benefit to a compromised fetus. The possibility of fetal surgery in a twin pregnancy extends the risk-benefit calculus beyond that of the fetus and mother to include the companion fetus and raises the issue of when, if ever, may fetus B be placed at substantial risk to benefit fetus A. Insight into the ethical dimensions of this issue is provided by the norms that govern the use of children in nontherapeutic research and the justifications used in twin-to-twin transplant cases.

Managed care, cost control, and the common good

The Clinton administration's revised rules regulating but not prohibiting the common practice in managed care of linking physician compensation with cost cutting and control of services demonstrates the complexity of ethical issues in managed care. As originally proposed, the federal guidelines on payment for Medicare and Medicaid services would have precluded any interrelationship between payment to physicians and delivery of services. Such a restriction would have gutted the primary mechanism in managed care plans to curb the unacceptably high cost of healthcare delivery: making physicians directly responsible for cost control by placing them at direct financial risk. At first blush such a linkage seems to involve an obvious and irreconcilable conflict of interest. How can a physician be responsible for the well-being of a patient while at the same time aware that a proportion of his or her income is linked to the provision of cost-conscious care?

Resuscitation of a micropremie: the case of MacDonald v. Milleville

One of the most unsettling experiences for a neonatologist is having an early gestational-age infant for whom resuscitation has been abandoned or not initiated subsequently begin breathing on his own. That was the experience of Gregory Milleville, MD when at 2:30 AM a nurse brought such an infant with a heart rate of 130 and a temperature of 91.2 degrees F to the neonatal intensive care unit (NICU).

Parental right to determine whether to use aggressive treatment for an early gestational age infant: the Messenger case

Manslaughter charges were brought against Dr. Gregory Messenger, a Michigan (USA) dermatologist, for removing his extremely premature infant son from a ventilator in the neonatal intensive care unit. Prior to delivery the neonatologist had told the parents that at the infant's age there was a 50-70% mortality and that if the child did survive there was a 20-40% chance of severe intraventricular hemorrhage. The newborn infant had been placed on mechanical life support despite the explicit instructions of the parents that they did not want aggressive or resuscitative measures used on their 780g., infant born at 25 weeks gestational age. The defendant argued that given the child's precarious medical status, it was the right of the parents to determine whether or not to institute aggressive medical interventions. The jury acquitted the father of all charges.

Parental discretion in refusal of treatment for newborns. A real but limited right

Manslaughter charges were brought in Lansing, Michigan against Gregory Messenger, a local dermatologist, for removing his extremely premature infant son from a ventilator in a neonatal intensive care unit. The issue in the case was the degree of intervention required for the newborn for whom the parents had been counseled that there was a 50% to 70% mortality and that if the child did survive, there was a 20% to 40% chance of severe intraventricular hemorrhage and a likelihood of substantial respiratory problems. In light of those grim data, the parents requested that no aggressive measures be undertaken. The neonatologist instructed her physician's assistant to ventilate if the child was "vigorous." The homicide charge was based on Gregory Messenger's failure to provide proper medical treatment for his infant son.

Physicians' refusal to provide life-prolonging medical interventions

The intense and ongoing debate on physicians' right to refuse requested life-prolonging medical interventions highlights one of the emerging problems in modern medicine: the limits, if any, to a patient (or proxy's) claim to requested treatment. How is the physician to respond to requests for treatment believed by the physician to be futile, ineffective, or inappropriate? Three cases, Baby L, the extracorporeal membrane oxygenation (ECMO) baby, and Baby K, help focus the ethical and legal issues in this debate.

"Playing God" and the removal of life-prolonging therapy

"Playing God" is the charge frequently leveled when physicians and patients agree to withdraw life-sustaining medical treatments and let the patient die. The accusation rings hollow in the context of four hundred years of moral reflection on the duty of an individual to undergo medical treatments to preserve life. From the teachings of Soto and Banez in the 16th century through the President's, Commission 1983 report 'deciding to forego life-sustaining treatments' there is a clear and constant teaching that though life is sacred it is not an absolute and our moral duty to preserve it is limited and based on rational reflection. No patient need undergo any treatment of procedure that is "disproportionately" costly, burdensome, or painful. The assessment of whether to accept or reject a proposed treatment is in part subjective and belongs to the individual patient. The only remaining issue is how to make that judgement for those unable to speak for themselves.

Stopping dialysis of an incompetent patient over the family's objection: is it ever ethical and legal?

Decisions to stop dialysis or other life-sustaining treatments for incompetent patients are among the most difficult ethical problems faced by physicians and families. This observation is verified by the large number of court cases and the increasing frequency of ethics consultations on these issues. In such instances, in the absence of an advance directive, the usual practice for physicians is to turn to the patient's family for direction on whether to start, continue, or withdraw the treatment. They do so on the presumption that the family best represents the patient's interests. This presumption may not always be correct. A case is presented in which the family's insistence on continued dialysis was contrary to the patient's previously expressed wishes and the treating physician's assessment of the patient's best interests. It is asserted that, in such situations, after thorough conversation with the family, consultation, documentation, and an unsuccessful attempt to transfer the patient's care to another physician, nephrologists have an ethical obligation and legal right to override the family's decision and to stop dialysis. The ethical obligation is supported by the principles of respect for persons, beneficence, and nonmaleficence. The legal right is grounded in common law and state statutes.

Pipes, colanders, and leaky buckets: reflections on the futility debate

The issue of physician refusal of requested treatment has fueled a two-pronged debate in our society-one on the meaning of futility and the other on the limits of patient autonomy. The latter is a genuinely philosophic dispute; the former, it seems, is a modern relapse into nominalism.

It is not the meaning of a word, but the moral basis for the actions of the par-ticipants that should be the focus of our attention, Yet the medical literature distracts us with articles titled “Medical Futility: Its Meaning and Ethical Implica-tions” “The Problem with Futility” “Who Defines Futility?,” “The Illusion of Futility,” and even “Beyond Futility.”

The history of the futility debate, which was launched by a 1983 study of Bedell and Delbanco that demonstrated the ineffectiveness of CPR for certain catego-ries of patients, has been documented elsewhere. Here we will inquire if the term, and its rapid intrusion into the medical lexicon, serves a useful purpose or if, as Truog suggested, we would all be better off if this new buzzword were jettisoned.