Neuroendocrine-immune interactions

Norepinephrine or Dopamine for Septic Shock

Received July 30, 2010, and in revised form September 14, 2010. Accepted for publication September 20, 2010. Background: There is debate as to the vasopressor agent of choice in patients with septic shock. According to current guidelines either dopamine or norepinephrine may be considered as the first-line agent for the management of refractory hypotension of septic shock. Objective: The aim of this systematic review was to evaluate randomized clinical trials which compared norepinephrine versus dopamine in critically ill patients with septic shock or in a population of critically ill patients with shock predominantly secondary to sepsis. Data Sources: MEDLINE, Embase, Scopus, Cochrane Register of Controlled Trials and citation review of relevant primary and review articles. Study Selection: Randomized clinical trials that compared norepinephrine with dopamine in critically ill adults with sepsis and reported the 28-day or in-hospital mortality. Data Extraction: We abstracted data on study design, study setting, patient population, 28-day mortality or in-hospital mortality, rate of arrhythmias, hospital length of stay, and ICU length of stay. Data Synthesis: Six studies met our inclusion criteria. These studies included a total of 2043 participants, with 995 in the norepinephrine and 1048 in the dopamine groups. There were 479 (48%) deaths in the norepinephrine group and 555 (53%) deaths in the dopamine group. There was statistically significant superiority of norepinephrine over dopamine for the outcome of in-hospital or 28-day mortality: pooled RR: 0.91 (95% CI 0.83 to 0.99; P = .028). We also found a statistically significant decrease in the rate of cardiac arrhythmias in the norepinephine group as compared to the dopamine group: pooled RR: 0.43 (95% CI 0.26 to 0.69; P ≤ .001). A subgroup analysis that pooled studies in which all the randomized patients had septic shock demonstrated that norepinephrine improved in-hospital or 28-day mortality; however, the results were no longer statistically significant. Conclusions: The analysis of the pooled studies that included a critically ill population with shock predominantly secondary to sepsis showed superiority of norepinephrine over dopamine for in-hospital or 28-day mortality.

Cortisol levels and adrenal response in severe community-acquired pneumonia: a systematic review of the literature

OBJECTIVES

Our aim was to review the literature on the prevalence and impact of critical-illness related corticosteroid insufficiency (CIRCI) on the outcomes of patients with severe community-acquired pneumonia (CAP).

METHODS

We reviewed Cochrane, Medline, and CINAHL databases (through July 2008) to identify studies evaluating the adrenal function in severe CAP. Main data collected were prevalence of CIRCI and its mortality.

RESULTS

We screened 152 articles and identified 7 valid studies. Evaluation of adrenal function varied, and most studies used baseline total cortisol levels. The prevalence of CIRCI in severe CAP ranged from 0% to 48%. Among 533 patients, 56 (10.7%) had cortisol levels of 10 μg/dL or less and 121 patients (21.2%) had cortisol levels of 15 μg/dL or less. In a raw analysis, there was no significant difference in mortality when patients with cortisol levels less than 10 μg/dL (8.6 vs 15.5%; P = .55) or less than 15 μg/dL (12.4 vs 16%; P = .38) were compared with those with cortisol above these levels. In the meta-analysis, relative risk for mortality were 0.81 (confidence interval, 0.39-1.7; P = .59; χ(2) = 1.04) for cortisol levels less than 10 μg/dL and relative risk was 0.67 (confidence interval, 0.4-1.14; P = .84; χ(2) = 1.4) for cortisol levels less than 15 μg/dL.

CONCLUSIONS

A significant proportion of patients with severe CAP fulfilled criteria for CIRCI. However, CIRCI does not seem to affect the outcomes. Noteworthy, the presence of elevated cortisol levels is associated with increased mortality and may be useful as a prognostic marker in patients with severe CAP.

Selective serotonin reuptake inhibitor suppression of HIV infectivity and replication

OBJECTIVE

To test the hypothesis that the selective serotonin reuptake inhibitor (SSRI) citalopram would down-regulate human immunodeficiency virus (HIV) infectivity and that the greatest effects would be seen in people with depression. Depression is a risk factor for morbidity and mortality in HIV/acquired immune deficiency syndrome. Serotonin (5-HT) neurotransmission has been implicated in the pathobiology of depression, and pharmacologic therapies for depression target this system. The 5-HT transporter and 5-HT receptors are widely distributed throughout the central nervous and immune systems. Depression has been associated with suppression of natural killer cells and CD8(+) lymphocytes, key regulators of HIV infection.

METHODS

Ex vivo models for acute and chronic HIV infection were used to study the effects of citalopram on HIV viral infection and replication in 48 depressed and nondepressed women. For both the acute and chronic infection models, HIV reverse transcriptase activity was measured in the citalopram treatment condition and the control condition.

RESULTS

The SSRI significantly down-regulated the reverse transcriptase response in both the acute and chronic infection models. Specifically, citalopram significantly decreased the acute HIV infectivity of macrophages. Citalopram also significantly decreased HIV viral replication in the latently infected T-cell line and in the latently infected macrophage cell line. There was no difference in down-regulation by depression status.

CONCLUSIONS

These studies suggest that an SSRI enhances natural killer/CD8 noncytolytic HIV suppression in HIV/acquired immune deficiency syndrome and decreases HIV viral infectivity of macrophages, ex vivo, suggesting the need for in vivo studies to determine a potential role for agents targeting serotonin in the host defense against HIV.

Growth and pubertal delay in patients with epidermolysis bullosa

Puberty is the acquisition of secondary sexual characteristics, associated with a growth spurt, resulting in the attainment of reproductive function and final adult height. Delayed puberty is defined as the absence of any pubertal development at an age 2 standard deviations (SD) more than the mean, which corresponds to an age of approximately 14 years for boys and 13 years for girls. The degree to which growth and pubertal development are affected in chronic illness depends on the disease itself, as well as factors such as age of onset, duration and severity; the earlier the onset and the more severe the disease, the greater the effect on growth and pubertal development. Most children with severe types of epidermolysis bullosa have abnormal growth and pubertal delay. The possible pathophysiology is discussed.

Prevalence of occult adrenal insufficiency and the prognostic value of a short corticotropin stimulation test in patients with septic shock

Background:

Corticosteroid insufficiency in acute illness can be difficult to discern clinically. Occult adrenal insufficiency (i.e., Δmax ≤9 μg/dL) after corticotropin may be associated with a high mortality rate.

Objective:

To assess the prevalence of occult adrenal insufficiency and the prognostic value of short corticotropin stimulation test in patients with septic shock.

Materials and Methods:

A total of 30 consecutive patients admitted in the adult intensive care unit of the Sheri Kashmir Institute of Medical Sciences who met the clinical criteria for septic shock were prospectively enrolled in the study. A low dose (1 μg) short corticotropin stimulation test was performed; blood samples were taken before the injection (T0) and 30 (T30) and 60 (T60) minutes afterward.

Results:

The prevalence of occult adrenal insufficiency was 57%. The 28-day mortality rate was 60% and the median time to death was 12 days. The following seven variables remained independently associated with death: organ system failure scores, simplified acute physiology score II score, mean arterial pressure, low platelet count, PaO₂:FIO₂, random baseline cortisol (T0) >34 μg/dL, and maximum variation after test (Δmax) of ≤9 μg/dL. Three different mortality patterns were observed: (I) low (T0 ≤34 μg/dL and Δmax >9 μg/dL; a 28-day mortality rate of 33%),(II) intermediate (T0 >34 μg/dL and Δmax >9 μg/dL or T0 ≤34 μg/dL and Δmax ≤9 μg/dL; a 28-day mortality rate of 71%), and (III) high (T0 >34 μg/dL and Δmax ≤9 μg/dL; a 28-day mortality rate of 82%).

Conclusion:

A short corticotropin test using low-dose corticotropin (1 μg) has a good prognostic value. High basal cortisol and a low increase in cortisol on corticotropin stimulation test are predictors of a poor outcome in patients with septic shock.

Associations between duration of illicit drug use and health conditions: results from the 2005-2007 national surveys on drug use and health

PURPOSE

To estimate and compare prevalence rates of lifetime health conditions by inferred duration of illicit drug use among the general U.S. adult population and to investigate associations between duration of use of each specific illicit drug (marijuana, cocaine, heroin, hallucinogens, or inhalant) and each lifetime health condition after controlling for potential confounding factors.

METHODS

Data from respondents aged 35 to 49 (N = 29,195) from the 2005-2007 National Surveys on Drug Use and Health (NSDUH) were analyzed.

RESULTS

The prevalence rates of a broad range of health conditions by duration of use of specific illicit drug among persons 35 to 49 years of age in the United States were estimated and compared. After adjustment for potential confounding factors, the results of 20 multivariate logistic regression models indicated positive associations between duration of marijuana use and anxiety, depression, sexually transmitted disease (STD), bronchitis, and lung cancer; between duration of cocaine use and anxiety and pancreatitis; between duration of heroin use and anxiety, hepatitis, and tuberculosis; between duration of hallucinogen use and tinnitus and STD; and between duration of inhalant use and anxiety, depression, HIV/AIDS, STD, tuberculosis, bronchitis, asthma, sinusitis, and tinnitus.

CONCLUSIONS

This study provides initial analyses on the relationships between illicit drug use and health conditions based on a large nationally representative sample. These results can help prepare for treating health problems among former and continuing illicit drug users.

What is the mechanism of SIDS? Clues from epidemiology

The cause of sudden infant death syndrome (SIDS) is unknown. Many mechanisms have been postulated, although thermal stress, rebreathing of expired gases and infection/inflammation seem the most viable hypotheses for the causation of SIDS. Deaths from SIDS have reduced dramatically following the recommendation not to place infants to sleep prone. Epidemiological data have shown that prone sleeping position is more risky in winter, colder latitudes, higher altitudes, if the infant is unwell or has excessive bedding or clothing. This suggests prone sleeping position involves either directly or indirectly a thermal mechanism. SIDS caused by an infective/inflammatory mechanism might be associated with deaths occurring during the night. Rebreathing of expired gases, airway obstruction, long QT syndrome and other genetic conditions may explain a small number of sudden unexpected deaths in infancy.

Cognitive behavioral stress management effects on psychosocial and physiological adaptation in women undergoing treatment for breast cancer

BACKGROUND

A diagnosis of breast cancer and treatment are psychologically stressful events, particularly over the first year after diagnosis. Women undergo many demanding and anxiety-arousing treatments such as surgery, radiation and chemotherapy. Psychosocial interventions that promote psychosocial adaptation to these challenges may modulate physiological processes (neuroendocrine and immune) that are relevant for health outcomes in breast cancer patients.

METHODS

Women with Stages 1-3 breast cancer recruited 4-8 weeks after surgery were randomized to either a 10-week group-based cognitive behavioral stress management (CBSM) intervention or a 1-day psychoeducational control group and completed questionnaires and late afternoon blood samples at study entry and 6 and 12 months after assignment to experimental condition.

RESULTS

Of 128 women initially providing psychosocial questionnaire and blood samples at study entry, 97 provided complete data for anxiety measures and cortisol analysis at all time points, and immune assays were run on a subset of 85 of these women. Those assigned to a 10-week group-based CBSM intervention evidenced better psychosocial adaptation (lower reported cancer-specific anxiety and interviewer-rated general anxiety symptoms) and physiological adaptation (lower cortisol, greater Th1 cytokine [interleukin-2 and interferon-gamma] production and IL-2:IL-4 ratio) after their adjuvant treatment compared to those in the control group. Effects on psychosocial adaptation indicators and cortisol appeared to hold across the entire 12-month observation period. Th1 cytokine regulation changes held only over the initial 6-month period.

CONCLUSIONS

This intervention may have facilitated a "recovery or maintenance" of Th1 cytokine regulation during or after the adjuvant therapy period. Behavioral interventions that address dysregulated neuroendocrine function could play a clinically significant role in optimizing host immunologic resistance during a vulnerable period.

Ginsenosides chemistry, biosynthesis, analysis, and potential health effects

Ginsenosides are a special group of triterpenoid saponins that can be classified into two groups by the skeleton of their aglycones, namely dammarane- and oleanane-type. Ginsenosides are found nearly exclusively in Panax species (ginseng) and up to now more than 150 naturally occurring ginsenosides have been isolated from roots, leaves/stems, fruits, and/or flower heads of ginseng. Ginsenosides have been the target of a lot of research as they are believed to be the main active principles behind the claims of ginsengs efficacy. The potential health effects of ginsenosides that are discussed in this chapter include anticarcinogenic, immunomodulatory, anti-inflammatory, antiallergic, antiatherosclerotic, antihypertensive, and antidiabetic effects as well as antistress activity and effects on the central nervous system. Ginsensoides can be metabolized in the stomach (acid hydrolysis) and in the gastrointestinal tract (bacterial hydrolysis) or transformed to other ginsenosides by drying and steaming of ginseng to more bioavailable and bioactive ginsenosides. The metabolization and transformation of intact ginsenosides, which seems to play an important role for their potential health effects, are discussed. Qualitative and quantitative analytical techniques for the analysis of ginsenosides are important in relation to quality control of ginseng products and plant material and for the determination of the effects of processing of plant material as well as for the determination of the metabolism and bioavailability of ginsenosides. Analytical techniques for the analysis of ginsenosides that are described in this chapter are thin-layer chromatography (TLC), high-performance liquid chromatography (HPLC) combined with various detectors, gas chromatography (GC), colorimetry, enzyme immunoassays (EIA), capillary electrophoresis (CE), nuclear magnetic resonance (NMR) spectroscopy, and spectrophotometric methods.

Amniotic fluid and umbilical cord plasma corticotropin-releasing factor (CRF), CRF-binding protein, adrenocorticotropin, and cortisol concentrations in intraamniotic infection and inflammation at term

CONTEXT

Pregnant tissues express corticotropin-releasing factor (CRF), a peptide modulating fetal and placental ACTH and cortisol secretion. These actions are modulated by the locally expressed CRF-binding protein (CRF-BP).

OBJECTIVE

The objective of the study was to determine whether CRF, CRF-BP, ACTH, and cortisol concentrations change in amniotic fluid and umbilical cord plasma in the presence of intraamniotic infection/inflammation (IAI) in women with spontaneous labor at term.

DESIGN

This was a cross-sectional study.

SETTING

The study was conducted at a tertiary referral center for obstetric care.

PATIENTS

Patients included women in active labor at term with (n = 39) and without (controls; n = 78) IAI.

MAIN OUTCOME MEASURES

Amniotic fluid and umbilical cord plasma concentrations of CRF, CRF-BP, ACTH, and cortisol measured by RIA and immunoradiometric assays were measured.

RESULTS

In patients with IAI, amniotic fluid CRF (0.97 +/- 0.18 ng/ml) and CRF-BP (33.06 +/- 5.54 nmol/liter) concentrations were significantly (P < 0.001) higher than in controls (CRF: 0.32 +/- 0.04 ng/ml; CRF-BP: 14.69 +/- 2.79 ml). The umbilical cord plasma CRF and CRF-BP concentrations were significantly (P < 0.001 for all) higher in women with IAI than in controls (CRF: 2.96 +/- 0.35 ng/ml vs. 0.38 +/- 0.18 ng/ml; CRF-BP: 152.12 +/- 5.94 nmol/liter vs. 106.9 +/- 5.97 nmol/liter). In contrast, amniotic fluid and umbilical cord plasma ACTH and cortisol concentrations did not differ between groups.

CONCLUSIONS

Amniotic fluid and umbilical cord plasma CRF and CRF-BP concentrations are increased in women with spontaneous labor at term and IAI. CRF-BP may modulate CRF actions on ACTH and cortisol secretion, playing a pivotal role in limiting the inflammatory process and thus avoiding an overactivation of the fetal/placental hypothalamus-pituitary-adrenal axis at birth.

Selective serotonin reuptake inhibitor and substance P antagonist enhancement of natural killer cell innate immunity in human immunodeficiency virus/acquired immunodeficiency syndrome

BACKGROUND

Natural killer (NK) cells play an important role in innate immunity and are involved in the host defense against human immunodeficiency virus (HIV) infection. This study examines the potential role of three underlying regulatory systems that have been under investigation in central nervous system research as well as immune and viral research: serotonin, neurokinin, and glucocorticoid systems.

METHODS

Fifty-one HIV-seropositive subjects were recruited to achieve a representative sample of depressed and nondepressed women. The effects of a selective serotonin reuptake inhibitor (SSRI), a substance P (SP) antagonist, and a glucocorticoid antagonist on NK cell function were assessed in a series of ex vivo experiments of peripheral blood mononuclear cells from each HIV-seropositive subject.

RESULTS

Natural killer cell cytolytic activity was significantly increased by the SSRI citalopram and by the substance P antagonist CP-96345 relative to control conditions; the glucocorticoid antagonist, RU486, showed no effect on NK cytotoxicity. Our results suggest that the effects of the three agents did not differ as a function of depression.

CONCLUSIONS

Our findings provide evidence that NK cell function in HIV infection may be enhanced by serotonin reuptake inhibition and by substance P antagonism. It remains to be determined if HIV-related impairment in not only NK cytolytic activity but also NK noncytolytic activity can be improved by an SSRI or an SP antagonist. Clinical studies are warranted to address these questions and the potential roles of serotonergic agents and SP antagonists in improving NK cell immunity, delaying HIV disease progression, and extending survival with HIV infection.

Induction of type 2 iodothyronine deiodinase in the mediobasal hypothalamus by bacterial lipopolysaccharide: role of corticosterone

To determine whether endotoxin-induced activation of type 2 iodothyronine deiodinase (D2) in the mediobasal hypothalamus is dependent on circulating levels of corticosterone, the effect of bacterial lipopolysaccharide (LPS) on D2 gene expression was studied in adrenalectomized, corticosterone-clamped adult, male, Sprague Dawley rats. In sham-adrenalectomized animals, LPS (250 microg/100 g body weight) increased circulating levels of corticosterone and IL-6, as well as tanycyte D2 mRNA in the mediobasal hypothalamus. Adrenalectomized, corticosterone-clamped animals showed no significant rise in corticosterone after LPS, compared with saline-treated controls but increased IL-6 levels and tanycyte D2 mRNA similar to LPS-treated sham controls. To further clarify the potential role of corticosterone in the regulation of D2 gene expression by LPS, animals were administered high doses of corticosterone to attain levels similar to that observed in the LPS-treated group. No significant increase in D2 mRNA was observed in the mediobasal hypothalamus with the exception of a small subpopulation of cells in the lateral walls of the third ventricle. These data indicate that the LPS-induced increase in D2 mRNA in the mediobasal hypothalamus is largely independent of circulating corticosterone and indicate that mechanisms other than adrenal activation are involved in the regulation of most tanycyte D2-expressing cells by endotoxin.

Multivitamin supplementation in HIV-positive pregnant women: impact on depression and quality of life in a resource-poor setting

OBJECTIVES

The primary objective of this study was to examine the effect of vitamin supplementation on health-related quality of life and the risk of elevated depressive symptoms comparable to major depressive disorder (MDD) in HIV-positive pregnant women in Dar es Salaam, Tanzania.

METHODS

From April 1995 to July 1997, 1078 HIV-positive pregnant women were enrolled in a randomized controlled trial. We examined the effects of vitamin supplementation on quality of life and the risk of elevated depressive symptoms, assessed longitudinally every 6-12 months.

RESULTS

A substantial prevalence of elevated depressive symptoms (42%) was observed in HIV-positive pregnant women. Multivitamin supplementation (B-complex, C and E) demonstrated a protective effect on depression [relative risk (RR)=0.78; P=0.005] and quality of life [RR=0.72 for social functioning (P=0.001) and vitality (P=0.0001); RR=0.70 for role-physical (P=0.002)]; however, vitamin A showed no effect on these outcomes.

CONCLUSIONS

Multivitamin supplementation (B-complex, C and E) resulted in a reduction in risk of elevated depressive symptoms comparable to MDD and improvement in quality of life in HIV-positive pregnant women in Tanzania.

Tachykinins and Hematopoiesis

Originally discovered in the 1930s, tachykinins have been a subject of renewed interest. Antagonists to the tachykinin receptors have shown potential in the treatment of a variety of maladies including neurodegenerative disorders, heart disease, pain perception and malignancies. Tachykinins have been the subject of intense studies due to their impact on hematopoiesis that has significant effects on endothelial tissue and vascular conditions. Hematopoiesis relies on a relatively small subset of bone marrow-resident hematopoietic stem cells. This review discusses the network developed by cytokines and the tachykinins to regulate hematopoiesis. An understanding of tachykinin effect on normal hematopoietic functions and their involvement in hematological disorders could lead to new treatments for bone marrow disorders such as fibrosis, leukemia and anemia.

Somatostatin receptors: clinical implications for endocrinology and oncology

Somatostatin receptors are present on most hormone-secreting tumours. They are the pathophysiological basis for the successful control of hormonal hypersecretion by pituitary adenomas, metastatic islet cell tumours and carcinoids during treatment with the long-acting somatostatin analogue octreotide. There is also evidence for inhibition of tumour growth in some of these patients. Visualization of somatostatin receptor-positive tumours is possible in vivo after the administration of ([111In]diethylenetriaminepentaacetic acid)octreotide. Primary tumours are detected and often metastases that were previously unrecognized. Tumours that secrete growth hormone or thyroid-stimulating hormone and non-functioning pituitary adenomas, islet cell tumours, carcinoids, paragangliomas, phaeochromocytomas, medullary thyroid carcinomas and small-cell lung cancers are visualized in 70-100% of cases. Meningiomas, renal cell cancers, breast cancers and malignant lymphomas are often somatostatin receptor positive, allowing their localization with this scanning procedure. In some of these tumours discrepancies have been noted between binding studies with somatostatin-14, somatostatin-28 and octreotide, which suggests the presence of somatostatin receptor subtypes on some tumours. Most hormone-secreting tumours react in vitro to octreotide with an inhibition of hormone release and growth. Cultured meningioma cells react to octreotide with a stimulation in growth, possibly by interference with the autocrine inhibitory growth control by interleukin 6. This suggests that the presence of somatostatin receptors on human tumours does not automatically imply a beneficial effect of somatostatin analogue therapy.

The nonthyroidal illness syndrome

This article briefly summarizes thyroid function alterations generally seen in the euthyroid sick syndrome, provides an overview of specific thyroidal adaptations during several clinical conditions and secondary to specific pharmacologic agents, and discusses the current controversy in thyroid hormone treatment of nonthyroidal illness.

Adrenal response in patients with septic shock of abdominal origin: relationship to survival

OBJECTIVE

To evaluate the prognostic value of adrenocortical response to corticotropin in septic shock patients operated on exclusively for an intra-abdominal source of infection.

DESIGN AND SETTING

Prospective, observational, single-center study in a surgical intensive care unit of a university hospital

PATIENTS

118 consecutive septic shock patients undergoing laparotomy or drainage for intra-abdominal infection.

MEASUREMENTS AND RESULTS

Baseline cortisol (t (0)) and cortisol response to corticotropin test (Delta) were measured during the first 24 h following onset of shock. The relationship between adrenal function test results and survival was analyzed as well as the effect of etomidate anesthesia. Cortisol plasma level at t (0) was higher in nonsurvivors than in survivors (33 +/- 23 vs. 25 +/- 14 microg/dl), but the response to corticotropin test did not differ between these two subgroups. ROC analysis showed threshold values for t (0) (32 microg/dl) and Delta (8 microg/dl) that best discriminated survivors from nonsurvivors in our population. We observed no difference in survival at the end of hospital stay using log rank test when patients were separated according to t (0), Delta, or both. In addition, adrenal function tests and survival did not differ in patients who received etomidate anesthesia (n = 69) during the surgical treatment of their abdominal sepsis.

CONCLUSIONS

In this cohort of patients with abdominal septic shock baseline cortisol level and the response to corticotropin test did not discriminate survivors from nonsurvivors. No deleterious impact of etomidate anesthesia on adrenal function tests and survival was observed in these patients.

Stress, visceral obesity, and metabolic complications

Stress is a state of threatened homeostasis or disharmony caused by intrinsic or extrinsic adverse forces and is counteracted by an intricate repertoire of physiologic and behavioral responses that aim to reestablish the challenged body equilibrium. The adaptive stress response depends upon an elaborate neuroendocrine, cellular, and molecular infrastructure, the stress system. Crucial functions of the stress system response are mediated by the hypothalamic-pituitary-adrenal (HPA) axis and the central and peripheral components of the autonomic nervous system (ANS). The integrity of the HPA axis and the ANS and their precise interactions with other CNS components are essential for a successful response to the various stressors. Chronic stress represents a prolonged threat to homeostasis by persistent or frequently repeated stressors and may lead to manifestations that characterize a wide range of diseases and syndromes. Such states progressively lead to a deleterious overload with complications caused by both the persistent stressor and the detrimental prolongation of the adaptive response. The metabolic syndrome can be described as a state of deranged metabolic homeostasis characterized by the combination of central obesity, insulin resistance, dyslipidemia, and hypertension. The incidence of both obesity and the metabolic syndrome in modern Western societies has taken epidemic proportions over the past decades and often correlates with indices of stress in the affected populations. Stress, primarily through hyperactivation of the HPA axis, appears to contribute to the accumulation of fat tissue, and vice versa, obesity itself seems to constitute a chronic stressful state and may cause HPA axis dysfunction. In addition, the description of obesity as a systemic low grade inflammatory condition that contributes to the derangement of the metabolic equilibrium implies that the proinflammatory cytokines which are secreted by the adipocytes hold a potentially important pathogenetic role. In this article we describe the physiology of the stress system response, with emphasis on metabolism, and review the recent data that implicate several neuroendocrine and inflammatory mechanisms mobilized during chronic stress in the development of the metabolic complications that characterize central obesity and the metabolic syndrome.

Triggers of relapse in steroid-dependent and frequently relapsing nephrotic syndrome

An awareness of the triggers of relapse is critical for the control of steroid-dependent, frequently relapsing nephrotic syndrome (SDFRNS). We have investigated the triggers, usually described as 'episodes', to such relapses within a temporal context. Thirty-five patients with SDFRNS were analyzed retrospectively. A total of 442 relapses occurred in 2499 patient-months. The relapses were classified into two groups: those with episodes (E+) and those without episodes (E-). There were 135 E+ relapses and 296 E- relapses. The common cold was the most common episode (52%) of E+ relapse, followed by school events (18%). These E+ relapses occurred almost evenly throughout the 4 weeks between each follow-up visit. Conversely, 161 (55%) of the 296 E-z relapses occurred within the 3-day period preceding the patient's appointment (relapse-related hospital visit, RRHV). McNemar's test revealed that the concentration of relapses in this period was statistically significant (P < 0.00011). In addition, 15 out of 26 RRHV without additional therapy showed a spontaneous remission. From a chronological perspective, the common cold and school events as well as up-coming hospital visits may trigger relapses in SDFRNS patients.

Cerebellar interposed nucleus lesions suppress lymphocyte function in rats

We previously reported that the cerebellar fastigial nucleus, output nucleus of the spinocerebellum, modulates lymphocyte function. To further explore the role of the cerebellum in neuroimmunomodulation, we here lesioned bilaterally the cerebellar interposed nuclei (IN) of rats with kainic acid (KA) injections. On days 8, 16 and 32 after IN lesions, lymphocyte percentage in peripheral white blood cells was examined. Furthermore, proliferation of lymphocytes from mesenteric lymph nodes induced by concanavalin A, sheep red blood cell-specific IgM antibody in the serum and cytotoxicity of natural killer cells from spleen against YAC-1 cells were measured by methyl-thiazole-tetrazolium assay, enzyme-linked immunosorbent assay and flow cytometric assay, respectively. On days 8, 16 and 32 after KA injection in the IN, the lymphocyte percentage in the peripheral white blood cells was notably diminished with respect to control rats injected with saline in the IN. Concanavalin A-induced lymphocyte proliferation, serum sheep red blood cell-specific IgM antibody and natural killer cell toxicity of the IN-lesioned rats were significantly attenuated with respect to IN-saline control rats at all the post-lesion time points. The findings reveal that KA-induced neuronal loss in the IN of both sides exerts an inhibitory effect on number and functions of T, B and natural killer lymphocytes, and indicate that the cerebellar IN participates in regulating immune function. Thus, the data suggest that the cerebellum may be an important brain area for neuroimmunomodulation, besides its well-known role in motor control.

Combinations of biomarkers predictive of later life mortality

A wide range of biomarkers, reflecting activity in a number of biological systems (e.g., neuroendocrine, immune, cardiovascular, and metabolic), have been found to prospectively predict disability, morbidity, and mortality outcomes in older adult populations. Levels of these biomarkers, singly or in combination, may serve as an early warning system of risk for future adverse health outcomes. In the current investigation, 13 biomarkers were examined as predictors of mortality occurrence over a 12-year period in a sample of men and women (n = 1,189) 70-79 years of age at enrollment into the study. Biomarkers examined in analyses included markers of neuroendocrine functioning (epinephrine, norepinephrine, cortisol, and dehydroepiandrosterone), immune activity (C-reactive protein, fibrinogen, IL-6, and albumin), cardiovascular functioning (systolic and diastolic blood pressure), and metabolic activity [high-density lipoprotein (HDL) cholesterol, total to HDL cholesterol ratio, and glycosylated hemoglobin]. Recursive partitioning techniques were used to identify a set of pathways, composed of combinations of different biomarkers, that were associated with a high-risk of mortality over the 12-year period. Of the 13 biomarkers examined, almost all entered into one or more high-risk pathways although combinations of neuroendocrine and immune markers appeared frequently in high-risk male pathways, and systolic blood pressure was present in combination with other biomarkers in all high-risk female pathways. These findings illustrate the utility of recursive partitioning techniques in identifying biomarker combinations predictive of mortal outcomes in older adults, as well as the multiplicity of biological pathways to mortality in elderly populations.

Age-related effect of peptide YY (PYY) on paw edema in the rat: the function of Y1 receptors on inflammatory cells

It is well documented that neuropeptides participate in local inflammatory reaction and modulate functions of inflammatory cells. The aim of the study was to determine a link between in vivo and in vitro effects of NPY-related peptides on inflammatory response with respect to ageing. Peptide YY (PYY) intraplantarly applied decreases concanavalin A-induced paw edema in 3 and 8 months, but not in 24 months old male rats of Albino Oxford strain. The use of NPY-related receptor-specific peptides and Y1 receptor antagonist revealed that anti-inflammatory effect of PYY is mediated via NPY Y1 receptors. PYY in vitro decreases adherence of macrophages from 8 months, but not from 3 and 24 months old rats and this effect is also mediated via NPY Y1 receptor. Additionally, PYY (10(-6)M) decreases NBT reduction in macrophages from 3 and 8 months old rats, and suppresses NO production in cells from 24 months old rats, albeit regardless of absence of in vivo effect of PYY on inflammation in aged rats. It is concluded that aged rats are less responsive to anti-inflammatory action of PYY compared to adult and young rats, and that ageing is associated with altered NPY Y1 receptor functioning.

Elevated mid-trimester amniotic fluid ADAM-8 concentrations as a potential risk factor for preterm delivery

OBJECTIVE

To determine during mid-trimester amniocentesis if elevated concentrations of ADAM-8 (A Disintegrin And Metalloprotease 8) and/or cortisol can recognize women at risk for spontaneous preterm delivery.

METHODS

The study involved 312 women who underwent mid-trimester amniocentesis. Thirteen patients, who progressed to preterm delivery, were matched with 21 controls for age, parity, gestational age at amniocentesis, and year of amniocentesis. ADAM-8 and cortisol levels were measured by enzyme-linked immunosorbent assay and radioimmunoassay, respectively.

RESULTS

ADAM-8 mean amniotic fluid concentrations were significantly higher in women with preterm delivery than in women delivering at term (mean 1213.9 [SE 96.7] pg/mL [range, 780 to 1854 pg/mL] vs mean 937.2 [SE 50.3] pg/mL [range, 486 to 1508 pg/mL], P < .02). Amniotic fluid ADAM-8 concentrations higher than 1149 pg/mL had the highest specificity and odds ratio (OR) in the identification of the women with increased risk for preterm delivery (sensitivity 61.5%; specificity 81.7%; OR, 9.6 [95% confidence interval (CI), 1.8 to 50.3]). Women with preterm delivery had suggestively higher amniotic fluid concentrations of cortisol (mean 1.3 [SE 0.2] microg/dL [range, 0.4 to 2.2 microg/dL]) than women delivering at term (mean 1.0 [SE 0.09] microg/dL [range, 0.6 to 1.7 microg/dL], P < .07). Furthermore, cortisol levels were positively correlated with ADAM-8 levels (Spearman's r = .418, P < .014).

CONCLUSIONS

Elevated mid-trimester amniotic fluid ADAM-8 concentrations possibly are a risk factor for preterm delivery, particularly if ADAM-8 levels are greater than 1149 pg/mL. Potential intrauterine inflammation is also associated with suggestively increased amniotic fluid cortisol levels.

Hypophysectomy and neurointermediate pituitary lobectomy reduce serum immunoglobulin M (IgM) and IgG and intestinal IgA responses to Salmonella enterica serovar Typhimurium infection in rats

The influence of anterior pituitary hormones on the gastrointestinal tract of humans and animals has been reported. Hypophysectomy (HYPOX) in the rat causes atrophy of the intestinal mucosa, reduction of gastric secretion and intestinal absorption, and increased susceptibility to infections. To our knowledge, there are no studies on the humoral immune response of the gut-associated lymphoid tissue after HYPOX. We have reported that decreased secretion of vasopressin and oxytocin due to neurointermediate pituitary lobectomy (NIL) diminishes humoral and cell-mediated immune responses. However, no data have been published on whether NIL can affect intestinal immune responses. We analyzed the effects of HYPOX and NIL on bacterial colonization of the intestinal lumen, Peyer's patches, and spleen as well as the serum immunoglobulin G (IgG) and IgM and specific intestinal IgA levels in response to Salmonella enterica serovar Typhimurium oral infection. Results showed the following: (i) Salmonella serovar Typhimurium was eliminated from the intestinal lumen at the same rate in rats that underwent a sham operation, HYPOX, and NIL; (ii) Salmonella serovar Typhimurium colonization of Peyer's patches and spleen was significantly higher in both HYPOX and NIL rats than in sham-operated rats; (iii) serum IgG and IgM and intestinal IgA against surface proteins of Salmonella serovar Typhimurium were significantly lower in HYPOX and NIL rats than in sham-operated rats; and (iv) compared to NIL rats, higher Peyer's patch and spleen bacterial colonization and decreased IgG, IgM, and IgA production were observed in HYPOX rats. We conclude that hormones from each pituitary lobe affect the systemic and gastrointestinal humoral immune responses through different mechanisms.

Therapeutic modulation of the psychoneuroimmune system by medical acupuncture creates enhanced feelings of well-being

PURPOSE

This article includes an explanation of how stressors disrupt physiologic regulatory mechanisms leading to disease states, how environmental challenges alter the function of the psychoneuroimmune system, and how correction of aberrant action potentials will stabilize homeostatic regulatory functions, inducing an escape response from stressors and leading to enhanced feelings of well-being. An explanation of how medical acupuncture accomplishes this stabilization concludes the article.

DATA SOURCE

Extensive review of the worldwide scientific literature from the 1970s through current literature, on acupuncture, neurophysiology, and psychoneuroimmune system, using the theoretical framework of Martha Rogers.

CONCLUSIONS

It is estimated that 80% of all illnesses are stress induced, although the physiologic mechanisms by which stress induces detrimental changes are not well understood by the medical profession. Introducing specific rhythmic electrical impulses slightly more intense than the nervous system already generates with the intervention of medical acupuncture can therapeutically alter aberrant signals induced by stressors, which may result in the release of neuropeptides and stabilization of homeostatic regulation so that health outcomes are improved. As neurological activity is altered, the firing pattern of nerves is changed. This is a change in the electrical pattern that leads to a change in the biochemical pattern. Thus, medical acupuncture is a therapy that is in agreement with Martha Rogers' conceptual model. Therapeutic techniques may improve the individual's level of wellness by direct actions toward homeostatic stabilization of the autonomic nervous system. These techniques will not change the amount of stressors a person is subject to but will change the physiological response to them. When the nervous system is in homeostatic balance, individuals will report enhanced feelings of well-being, be more effective in coping with their conditions of living, and therefore be less susceptible to illness.

IMPLICATIONS FOR PRACTICE

Nurse practitioners have an opportunity to expand into an unused dimension for nursing care through direct treatment of the central and autonomic nervous system that will influence the psychoneuroimmune system. A prescriptive theory explaining medical acupuncture provides for therapeutic interventions at the primary, secondary, and tertiary level of care. Primary preventive interventions alter the effects of stress before it leads to illness by assisting homeostatic stability of the autonomic nervous system. Secondary interventions allow treatment of many health conditions regulated by neurological activity. Tertiary care provides a method to assist autonomic regulation when the body is no longer able to maintain homeostatic stability because of chronic illness or injury.

Association between Adrenal Insufficiency and Ventilator Weaning

RATIONALE

Adrenal insufficiency is a common disorder in critically ill patients with mechanical ventilation and is usually associated with higher mortality and poor clinical outcome.

OBJECTIVES

To determine whether stress dose corticosteroid supplementation can improve ventilator weaning and clinical outcome in patients with adrenal insufficiency.

METHODS

A prospective, randomized, placebo controlled, double-blinded study was conducted in the intensive care unit of a tertiary teaching hospital. A total of 93 mechanically ventilated patients were enrolled in the ventilator weaning trial. Adrenal function was assessed in all patients. Patients with adrenal insufficiency were randomized to the treatment group (50 mg intravenous hydrocortisone every 6 h) and the placebo group.

MEASUREMENTS AND MAIN RESULTS

The successful ventilator weaning percentage was significantly higher in the adequate adrenal reserve group (88.4%) and in the stress dose hydrocortisone treatment group (91.4%) than in the placebo group (68.6%). The weaning period was shorter in the hydrocortisone treatment group than in the placebo group. No significant adverse effects were observed in the corticosteroid treatment group.

CONCLUSIONS

For patients with respiratory failure, early identification of adrenal insufficiency and appropriate supplementation with stress dose hydrocortisone increase the success of ventilator weaning and shortens the weaning period.

Thyroid Hormone and Insulin-Like Growth Factor-I in Patients with Multiple Myeloma Treated with Melphalan and Prednisone

BACKGROUND

The relationship between endocrine regulation and immune system has recently become the subject of intense investigations. The aim of this study was the comparative assessment of serum levels of selected hormones and insulin-like growth factor-I (IGF-I) in patients with multiple myeloma (MM) during applied therapy.

METHODS

The levels of prolactin, hGH, TSH, fT3, fT4 and IGF-I in serum of 13 untreated patients with MM and in 16 healthy controls were determined. The patients were treated in cyclic courses with melphalan plus prednisone, and investigations were carried out in the first four courses of this therapy. The results were compared in the following manner: (1) at entry between studied MM group and healthy subjects, and (2) during the therapy intragroup-intracyclic comparisons were made in paired serum samples collected from patients before and after every therapeutic course.

RESULTS

At entry, significantly lower levels of TSH and fT3 were obtained in MM patients. The means remained within low normal reference range. Slightly increasing levels of TSH and fT3 during treatment with lower concentrations of these hormones after every therapeutic course and a statistically significant difference of fT3 level in the fourth therapy course were revealed. The levels of fT4 were within the normal reference values and showed a tendency to decrease during therapy with significant differences in the first therapeutic course. After the third and the fourth therapy courses, concentrations of IGF-I were statistically significantly higher than initially.

CONCLUSIONS

Euthyroid sick syndrome can exist in MM patients, and the therapy with melphalan plus prednisone is accompanied by slightly expressed serum changes of thyroid hormone concentrations and IGF-I levels.

Relative Adrenal Failure in the ICU: An Identifiable Problem Requiring Treatment

Critically ill patients at some stage may develop adrenal insufficiency (AI). This article reviews the mechanisms, diagnosis criteria, consequences, and treatment of AI in various ICU conditions. Glucocorticoid insufficiency may be related to a decrease in glucocorticoid synthesis (ie, adrenal insufficiency) or to a reduced delivery of glucocorticoid to target tissues and cells. Diagnosis relies on clinical suspicion and ACTH test results. The length of cortisol replacement therapy should be at least 7 days and the adjunction of fludrocortisone is recommended.

IL-6 levels decrease with SSRI treatment in patients with major depression

OBJECTIVE

Some evidence indicates that an immune response with an increased production of proinflammatory cytokines often accompanies major depression. The objective of this study was to examine the serum levels of IL-6 in patients with major depression and the changes occurring in IL-6 levels during treatment with selective serotonin reuptake inhibitors (SSRI).

METHOD

Twenty-three patients with a DSM-IV diagnosis of major depressive disorder and 23 healthy matched controls were included in the study. The severity of depression was measured with the Hamilton rating scale for depression. Blood samples for IL-6 levels were obtained at baseline and at week 6 of treatment and IL-6 concentrations were evaluated using a solid phase sandwich enzyme immunoassay. All patients were treated with an SSRI.

RESULTS

The IL-6 levels showed no statistically significant difference between the patients and the controls at baseline. However, IL-6 levels after treatment with SSRIs were significantly lower compared with the baseline IL-6 levels of both the patients and the controls.

CONCLUSION

The results of this study suggest that proinflammatory cytokines show some changes during the course of treatment of major depression. These findings might also be considered as supporting the hypothesis of a modulatory role of antidepressants on the immune system.

The role of mast cells in migraine pathophysiology

Mast cells are critical players in allergic reactions, but they have also been shown to be important in immunity and recently also in inflammatory diseases, especially asthma. Migraines are episodic, typically unilateral, throbbing headaches that occur more frequently in patients with allergy and asthma implying involvement of meningeal and/or brain mast cells. These mast cells are located perivascularly, in close association with neurons especially in the dura, where they can be activated following trigeminal nerve, as well as cervical or sphenopalatine ganglion stimulation. Neuropeptides such as calcitonin gene-related peptide (CGRP), hemokinin A, neurotensin (NT), pituitary adenylate cyclase activating peptide (PACAP), and substance P (SP) activate mast cells leading to secretion of vasoactive, pro-inflammatory, and neurosensitizing mediators, thereby contributing to migraine pathogenesis. Brain mast cells can also secrete pro-inflammatory and vasodilatory molecules such as interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF), selectively in response to corticotropin-releasing hormone (CRH), a mediator of stress which is known to precipitate or exacerbate migraines. A better understanding of brain mast cell activation in migraines would be useful and could lead to several points of prophylactic intervention.

Chronic morphine exposure during puberty decreases postpartum prolactin secretion in adult female rats

Opiate use in teenage populations has been increasing in recent years. The potential impact of exposure to high levels of opiates at a time when reproductive systems are maturing has not been well studied, especially in females. The present study used an animal model of adolescent opiate abuse in females to examine the potential impact of high levels of opiates during puberty on several reproductive parameters, including suckling-induced prolactin secretion. Two groups of juvenile female rats were administered increasing doses of morphine sulfate or saline (s.c.) from age 30-50 days, beginning with a dose of 2.5 mg/kg and achieving a maximal dose of 50 mg/kg. As adults, these females were mated and reared either their own or foster pups. On either postpartum day 5 or 10, following a 4 h separation, suckling-induced prolactin secretion was measured. In addition, on postpartum day 5 maternal behavior latencies were determined. The results demonstrate reduced suckling-induced prolactin secretion on postpartum day 5 in females previously exposed to morphine during pubertal development. These effects were observed in females rearing either their own or fostered pups. These effects were not due to any differences in maternal behavior latencies, as retrieval or crouching latencies were unaffected. In summary, chronic morphine exposure during puberty results in changes in the regulation of prolactin secretion during early lactation, which are observed several weeks after cessation of drug treatment. These data suggest that prior opiate use during puberty can continue to affect the regulation of prolactin secretion into adulthood.

Specific ablation of the apoptotic functions of cytochrome C reveals a differential requirement for cytochrome C and Apaf-1 in apoptosis

As components of the apoptosome, a caspase-activating complex, cytochrome c (Cyt c) and Apaf-1 are thought to play critical roles during apoptosis. Due to the obligate function of Cyt c in electron transport, its requirement for apoptosis in animals has been difficult to establish. We generated "knockin" mice expressing a mutant Cyt c (KA allele), which retains normal electron transfer function but fails to activate Apaf-1. Most KA/KA mice displayed embryonic or perinatal lethality caused by defects in the central nervous system, and surviving mice exhibited impaired lymphocyte homeostasis. Although fibroblasts from the KA/KA mice were resistant to apoptosis, their thymocytes were markedly more sensitive to death stimuli than Apaf-1(-/-) thymocytes. Upon treatment with gamma irradiation, procaspases were efficiently activated in apoptotic KA/KA thymocytes, but Apaf-1 oligomerization was not observed. These studies indicate the existence of a Cyt c- and apoptosome-independent but Apaf-1-dependent mechanism(s) for caspase activation.

Corticotropin-releasing hormone contributes to the peripheral inflammatory response in experimental autoimmune encephalomyelitis

Peripheral corticotropin-releasing hormone (CRH) is thought to have proinflammatory effects. We used the model of experimental autoimmune encephalomyelitis (EAE) to study the role of CRH in an immune-mediated disease. We showed that CRH-deficient mice are resistant to EAE, with a decrease in clinical score as well as decreased cellular infiltration in the CNS. Furthermore, Ag-specific responses of primed T cells as well as anti-CD3/anti-CD28 TCR costimulation were decreased in crh(-/-) mice with decreased production of Th1 cytokines and increased production of Th2 cytokines. Wild-type mice treated in vivo with a CRH antagonist showed a decrease in IFN-gamma production by primed T cells in vitro. This effect of CRH is independent of its ability to increase corticosterone production, because adrenalectomized wild-type mice had similar disease course and severity as control mice. We found that IkappaBalpha phosphorylation induced by TCR cross-linking was decreased in crh(-/-) T cells. We conclude that peripheral CRH exerts a proinflammatory effect in EAE with a selective increase in Th1-type responses. These findings have implications for the treatment of Th1-mediated diseases such as multiple sclerosis.

INTERLEUKIN-1 GENE CLUSTER POLYMORPHISMS AND ALCOHOLISM IN SPANISH MEN

AIMS

In an attempt to explain differences in susceptibility to alcoholism and alcohol liver disease (ALD), different genes have been analysed, among them those encoding inflammatory cytokines. Thus, it has been reported recently that both the interleukin 1 receptor antagonist (IL1RN) and the IL1beta (IL1B) genes may influence the risk of ALD in Japanese alcoholics. We analysed the distribution of single nucleotide polymorphisms (SNPs) located in the IL1A, IL1B, IL1R1 and IL1RN genes in alcoholic and non-alcoholic Spanish subjects.

METHODS

DNA samples were obtained from 139 male alcoholics, 78 of whom were diagnosed as alcohol dependent (32 patients with liver cirrhosis and 46 without ALD) and 61 as alcohol abusers (25 with liver cirrhosis and 36 without ALD). As a control, we studied 81 age- and sex-matched healthy volunteers.

RESULTS

Alleles -511 IL1B*1 and IL1RN*1 were represented more in alcoholic patients than in the control group. We did not find any association of alcoholism or ALD with polymorphisms in the IL1A and IL1R1 genes.

CONCLUSIONS

We conclude that the proteins encoded by the IL1RN and IL1B genes may be involved in susceptibility to alcoholism in Spanish men, probably through a different pathway from that involved in the regulation of the inflammatory response.

Effect of lesions of cerebellar fastigial nuclei on lymphocyte functions of rats

The cerebellum, probably owing to its traditional concept limited to motor control, is less well studied in immunoregulation. To obtain more comprehension and knowledge on cerebellar functions, we investigated effect of cerebellar fastigial nucleus (FN), an output nucleus of the spinocerebellum, on lymphocyte functions, and explored central and peripheral pathways involved in the effect. Kainic acid (KA) was microinjected into bilateral FN of rats (0.4 microg KA in 0.4 microl saline for each side) to destroy neurons of the nuclei. On days 8, 16 and 32 following the FN lesions, methyl-thiazole-tetrazolium (MTT) assay and flow cytometry were used to measure proliferation of concanavalin A (Con A)-induced lymphocytes and cytotoxicity of natural killer (NK) cells against YAC-1 cells, respectively. Meanwhile, glutamate and monoamine neurotransmitters, including norepinephrine (NE), dopamine (DA) and 5-hydroxytryptamine (5-HT), in the hypothalamus and the spleen were determined by means of high-performance liquid chromatography (HPLC) assay. Adrenocorticotropic hormone (ACTH) and cortisol in the plasma were also detected respectively by radioimmunoassay and chemiluminescent immunoassay after the FN lesions. We found that the Con A-induced lymphocyte proliferation and the NK cell cytotoxicity were both significantly enhanced on days 8, 16 and 32 following the effective lesions of the bilateral FN in comparison with those of matching control rats microinjected with saline in their FN. Contents of glutamate and NE, not DA and 5-HT, in the hypothalamus, and concentration of NE, not DA, in the spleen were all remarkably reduced on the 16th day following the FN lesions, when both the T lymphocyte proliferation and the NK cell cytotoxicity were dramatically increased. However, levels of ACTH and cortisol in the plasma had no notable differences between FN lesion rats and FN saline ones when the enhanced T and NK cell functions occurred. These findings reveal that the cerebellar FN participates in the modulation of lymphocyte functions and that the hypothalamus and sympathetic nerves innervating lymphoid organs are involved in this neuroimmunomodulation. Thus, a possible central and peripheral pathway for the spinocerebellum to regulate lymphocyte functions is suggested, i.e. cerebellum-hypothalamus-sympathetic nerves-lymphocytes, while the functional axis of hypothalamus-pituitary-adrenal gland may not contribute to mediation of the spinocerebellar immunomodulation.

Role of stress in the pathogenesis of the metabolic syndrome

Excess body fat, obesity, is one of the most common disorders in clinical practice. In addition, there is a clustering of several risk factors with obesity, including hypertension, glucose intolerance, diabetes mellitus, and hyperlipidemia, which is observed more frequently than by chance alone. This has led to the suggestion that these represent a single syndrome and is referred to as the Metabolic Syndrome. A growing body of evidence suggests that glucocorticoid secretion is associated with this complex phenotype. Continuously changing and sometimes threatening external environment may, when the challenge exceeds a threshold, activate central pathways that stimulate the adrenals to release glucocorticoids. In this review, we will discuss how such processes mediate a pathogenetic role in the Metabolic Syndrome.

Serotonin regulates osteoclast differentiation through its transporter

5-HTT mediates antidepressant-sensitive clearance of 5-HT after its release into neural synapses. We found increased expression of 5-HTT in RANKL-induced osteoclast-like cells. Fluoxetine, an inhibitor of 5-HTT, reduced osteoclast differentiation but not activation. Reserpine, an inhibitor of 5-HT intracellular transport, potentiated differentiation. These results indicate a role for 5-HTT in osteoclast function and suggest that commonly used antidepressive agents may affect bone mass.

INTRODUCTION

Interactions between the serotonergic and skeletal systems are suggested by various clinical observations but are poorly understood.

MATERIALS AND METHODS

Using gene microarrays, we found that the serotonin transporter (5-HTT) was strongly expressed in RANKL-induced osteoclasts. Using RANKL stimulation of RAW264.7 cells and mouse bone marrow cells as a model system for osteoclast differentiation, we studied the possible role/s of the different components of the serotonin (5-HT) system on the differentiation process.

RESULTS

Osteoclast 5-HTT exhibited typical 5-HT uptake activity that was inhibitable by fluoxetine (Prozac). Fluoxetine reduced osteoclast differentiation but did not inhibit the activation of preformed osteoclasts, whereas the addition of 5-HT itself enhanced differentiation. Fluoxetine-treated osteoclast precursors had reduced NF-kappa B activation and elevated inhibitory protein kappa B alpha (I kappa B alpha) levels compared with untreated cells. 5-HT, on the other hand, resulted in activation of NF-kappa B. Reserpine inhibition of intracellular transport of 5-HT into cytoplasmic vesicles potentiated RANKL-induced osteoclast formation, suggesting the importance of intracellular 5-HT in regulating osteoclast differentiation. Reserpine also modestly enhanced the expression of the osteoclast marker TRACP in the absence of RANKL.

CONCLUSIONS

Taken together, these data suggest that the 5-HT system plays an important role in bone homeostasis through effects on osteoclast differentiation and implies that commonly used antidepressive agents may affect bone mass.

Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women

OBJECTIVES

We examined associations between depressive symptoms and AIDS-related mortality after controlling for antiretroviral therapy use, mental health treatment, medication adherence, substance abuse, clinical indicators, and demographic factors.

METHODS

One thousand seven hundred sixteen HIV-seropositive women completed semiannual visits from 1994 through 2001 to clinics at 6 sites. Multivariate Cox and logistic regression analyses estimated time to AIDS-related death and depressive symptom severity.

RESULTS

After we controlled for all other factors, AIDS-related deaths were more likely among women with chronic depressive symptoms, and symptoms were more severe among women in the terminal phase of their illness. Mental health service use was associated with reduced mortality.

CONCLUSIONS

Treatment for depression is a critically important component of comprehensive care for HIV-seropositive women, especially those with end-stage disease.

A quantitative assessment of depression and thyroid dysfunction secondary to interferon-alpha therapy in patients with hepatitis C

The most effective treatment for hepatitis C virus (HCV) is interferon-alpha (IFN) therapy in combination with ribavirin. Although symptoms of depression are among the most common side effects of IFN therapy in treating patients with HCV, the mechanisms by which IFN produces these neuropsychiatric side effects remain unclear. In the brain, IFNs are involved in a number of regulatory functions, including but not limited to regulation of the endocrine system via the hypothalamic-pituitary-adrenal and -thyroid axes. The purpose of this study was to assess the effect of IFN therapy on thyroid function and to characterize the relationship between thyroid dysfunction and major depressive disorder during IFN therapy in patients with hepatitis C. Thirty-three patients with HCV were administered the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Axis I Disorders (SCID) and completed the Beck Depression Inventory (BDI). Patients were on IFN for an average of 6 to 12 months depending on their viral genotype. Serum samples were collected at baseline, during and after IFN therapy, and measured for free thryoxine (FT4) and TSH levels. Patients who developed IFN-induced depression were treated with selective serotonin reuptake inhibitor antidepressants. Only one patient developed transient IFN-induced overt hypothyroidism, but he did not develop depression. Analysis of variance showed that there were no significant differences in either FT4 or TSH serum levels between patients who developed major depressive disorder (MDD) (no.= 10) during IFN therapy and those who did not (no.=23). These results illustrate the frequency and severity of depressive symptoms associated with IFN therapy and the apparent absence of a relationship between IFN-induced MDD and changes in thyroid function.

The inhibitory effect of ginseng saponins on the stress-induced plasma interleukin-6 level in mice

The effect of ginseng saponins on plasma interleukin-6 (IL-6) in non-stressed and immobilization-stressed mice were investigated. Ginseng total saponins, ginsenosides Rb2, Rg1 and Rd administered intraperitoneally attenuated the immobilization stress-induced increase in plasma IL-6 level. But, intracerebroventricular injection of each ginsenoside did not affect plasma IL-6 level induced by immobilization stress. Ginsenosides Rb2, Rd and Rg1 significantly decreased norepinephrine and/or epinephrine-induced increase of IL-6 level in macrophage cell line (RAW 264.7). Thus, it can be suggested that the inhibitory action of ginseng saponins against the immobilization stress-induced increase of plasma IL-6 level would be in periphery; at least in part, mediated by blocking norepinephrine- and/or epinephrine-induced increase of IL-6 level in macrophage rather than in the brain. Ginseng saponins might be proposed as a possible candidate in the research or therapeutic modulation of stress-related disorders.

Role of Corticosteroids in Septic Shock

OBJECTIVE

To highlight the role of relative adrenal insufficiency in the outcome of critically ill patients with sepsis and systematically review the literature regarding the use of corticosteroids for management of severe sepsis/septic shock.

DATA SOURCES

A computerized search of MEDLINE, EMBASE, and the Cochrane Database was undertaken from 1966 to March 2003 using the search terms intensive care unit, critical care, corticosteroids, glucocorticoids, adrenal insufficiency, sepsis, and septic shock. Bibliographies of all articles retrieved were searched for relevant articles not identified by the computerized search.

DATA EXTRACTION/SYNTHESIS

Six trials were identified after publication of the meta-analyses (1995), with a total of 505 patients. The results of these trials in septic shock suggest that low-dose corticosteroids can reduce vasopressor requirements and hasten reversal of shock. Some of these trials suggested a possible mortality benefit from therapy, and no trial demonstrated an increase in mortality or significant adverse effects. The benefit of this therapy may depend on the presence of relative adrenal insufficiency, as identified by the adrenocorticotropic hormone stimulation test.

CONCLUSIONS

Low-dose corticosteroids should be administered to patients with septic shock empirically, but should be discontinued if relative adrenal insufficiency is not confirmed.

Cognitive-behavioral stress management increases benefit finding and immune function among women with early-stage breast cancer

OBJECTIVE

This study examined the effect of a cognitive-behavioral stress management (CBSM) intervention on emotional well-being and immune function among women in the months following surgery for early-stage breast cancer.

METHOD

Twenty-nine women were randomly assigned to receive either a 10-week CBSM intervention (n=18) or a comparison experience (n=11). The primary psychological outcome measure was benefit finding. The primary immune function outcome measure was in vitro lymphocyte proliferative response to anti CD3.

RESULTS

Women in the CBSM intervention reported greater perceptions of benefit from having breast cancer compared to the women in the comparison group. At 3-month follow-up, women in the CBSM group also had improved lymphocyte proliferation. Finally, increases in benefit finding after the 10-week intervention predicted increases in lymphocyte proliferation at the 3-month follow-up.

CONCLUSION

A CBSM intervention for women with early-stage breast cancer facilitated positive emotional responses to their breast cancer experience in parallel with later improvement in cellular immune function.