Stress and acquired glucocorticoid resistance: a relationship hanging in the balance

PROMIS Pediatric Psychological Stress Measure: Validity for immigrant Latino youth

Objective

This study assesses the psychometric properties of the four- and eight-item versions of the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Psychological Stress Measure (PPSM) for use with Latino immigrant adolescents.

Background

Immigrant Latino youth are exposed to numerous stressors that can have consequences affecting health well into adulthood. However, few studies have assessed the suitability of psychosocial measures for this group.

Methods

Participants included 286 first- and second-generation immigrant Latino youth in middle school in an urban school district in the United States. Analyses included tests for reliability, validity, item characteristics, and measurement invariance across differing levels of acculturation and gender groups.

Results

Both the four- and the eight-item PPSM are internally consistent, have strong construct validity, and strict factorial invariance across differing levels of acculturation. The four-item PPSM demonstrates strict invariance, but the eight-item version shows only configural invariance by gender.

Conclusion

The PPSM is a rigorous measure when assessing immigrant Latino youth stress level. The four-item PPSM is brief, simple to administer, and appropriate for use with Latino youth across differing levels of acculturation and gender groups.

Implications

The four-item PPSM lessens respondent fatigue and may be incorporated into tools practitioners and researchers use to assess perceived stress among immigrant Latino youth.

COVID-19 and ethnicity: Does reduced responsiveness to glucocorticoids explain the more aggressive nature of disease among minorities?

Marked ethnic variations in complications and mortality have been noted following infection with COVID-19, with Black, Asian, and minority ethnic groups (BAME) being particularly hard hit. We hypothesise that glucocorticoid resistance stemming from several intrinsic reasons such as chronic social stress and lower circulating levels of Vitamin D may contribute to the exaggerated inflammatory response, more severe disease and poorer outcomes observed in BAME.

Endothelial dysfunction in neuroprogressive disorders-causes and suggested treatments

BACKGROUND

Potential routes whereby systemic inflammation, oxidative stress and mitochondrial dysfunction may drive the development of endothelial dysfunction and atherosclerosis, even in an environment of low cholesterol, are examined.

MAIN TEXT

Key molecular players involved in the regulation of endothelial cell function are described, including PECAM-1, VE-cadherin, VEGFRs, SFK, Rho GEF TRIO, RAC-1, ITAM, SHP-2, MAPK/ERK, STAT-3, NF-κB, PI3K/AKT, eNOS, nitric oxide, miRNAs, KLF-4 and KLF-2. The key roles of platelet activation, xanthene oxidase and myeloperoxidase in the genesis of endothelial cell dysfunction and activation are detailed. The following roles of circulating reactive oxygen species (ROS), reactive nitrogen species and pro-inflammatory cytokines in the development of endothelial cell dysfunction are then described: paracrine signalling by circulating hydrogen peroxide, inhibition of eNOS and increased levels of mitochondrial ROS, including compromised mitochondrial dynamics, loss of calcium ion homeostasis and inactivation of SIRT-1-mediated signalling pathways. Next, loss of cellular redox homeostasis is considered, including further aspects of the roles of hydrogen peroxide signalling, the pathological consequences of elevated NF-κB, compromised S-nitrosylation and the development of hypernitrosylation and increased transcription of atherogenic miRNAs. These molecular aspects are then applied to neuroprogressive disorders by considering the following potential generators of endothelial dysfunction and activation in major depressive disorder, bipolar disorder and schizophrenia: NF-κB; platelet activation; atherogenic miRs; myeloperoxidase; xanthene oxidase and uric acid; and inflammation, oxidative stress, nitrosative stress and mitochondrial dysfunction.

CONCLUSIONS

Finally, on the basis of the above molecular mechanisms, details are given of potential treatment options for mitigating endothelial cell dysfunction and activation in neuroprogressive disorders.

Metabolites and metabolic pathways associated with glucocorticoid resistance in pregnant African-American women

Glucocorticoid resistance (GR) is associated with exposure to chronic stress and an increased risk of metabolic and inflammatory disorders in both animal and human populations. Studies on ethnic disparities highlight the African-American (AA) population as having a high propensity to both GR and chronic stress exposure. Glucocorticoids and inflammation play a very important role in pregnancy outcome and fetal development. To date, however, the metabolites and metabolic pathways associated with GR during pregnancy have not been identified, obscuring the mechanisms by which adverse health consequences arise, and thus impeding targeted therapeutic intervention. The objective of this study was to perform untargeted high-resolution metabolomics (HRM) profiling on 273 pregnant AA women, to identify metabolites and metabolic pathways associated with GR during the first trimester of pregnancy and to evaluate their cross-sectional association with birth outcomes and psychosocial variables related to chronic stress exposure. For this study, GR was determined by the concentration of dexamethasone required for 50% inhibition (Dex IC50) of the cytokine tumor-necrosis factor alpha (TNF-alpha) release in vitro in response to a standard dose of lipopolysaccharide. The results for Metabolome-Wide Association Studies (MWAS) and pathway enrichment analysis for serum metabolic associations with Dex IC50, showed energy (nicotinamide and TCA cycle), amino acid, and glycosphingolipid metabolism as top altered pathways. Bioinformatic analysis showed that GR, as indicated by elevated Dex IC50 in the pregnant women, was associated with increased inflammatory metabolites, oxidative stress related metabolites, increased demand for functional amino acids to support growth and development, and disruption in energy-related metabolites. If confirmed in future studies, targeting these physiologically significant metabolites and metabolic pathways may lead to future assessment and intervention strategies to prevent inflammatory and metabolic complications observed in pregnant populations.

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GR is associated with chronic stress and is a risk factor for adverse health outcomes, especially among African Americans.

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Metabolites and metabolic pathways associated with GR relate to energy production, amino acid metabolism, and inflammation.

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Findings provide a foundation for future studies investigating risk factors in this health disparity population.

Activation of the kynurenine pathway and mitochondrial respiration to face allostatic load in a double-hit model of stress

Allostasis is the process by which the body's physiological systems adapt to environmental changes. Chronic stress increases the allostatic load to the body, producing wear and tear that could, over time, become pathological. In this study, young adult male Wistar Kyoto rats were exposed to an unpredictable chronic mild stress (uCMS) protocol to increase allostatic load. First, physiological systems which may be affected by extended uCMS exposure were assessed. Secondly, 5 weeks of uCMS were used to investigate early adaptations in the previously selected systems. Adverse experiences during developmentally sensitive periods like adolescence are known to severely alter the individual stress vulnerability with long-lasting effects. To elucidate how early life adversity impacts stress reactivity in adulthood, an additional group with juvenile single-housing (JSH) prior to uCMS was included in the second cohort. The aim of this work was to assess the impact of chronic stress with or without adversity during adolescence on two domains known to be impacted in numerous stress-related disorders: mitochondrial energy metabolism and the immune system. Both, uCMS and adolescence stress increased kynurenine and kynurenic acid in plasma, suggesting a protective, anti-oxidant response from the kynurenine pathway. Furthermore, uCMS resulted in a down-regulation of immediate early gene expression in the prefrontal cortex and hippocampus, while only rats with the double-hit of adolescent stress and uCMS demonstrated increased mitochondrial activity in the hippocampus. These results suggest that early life adversity may impact on allostatic load by increasing energetic requirements in the brain.

Recovery From Sudden Sensorineural Hearing Loss May Be Linked to Chronic Stress Levels and Steroid Treatment Resistance

Purpose This article investigates the possible connections between the level of chronic stress and success of steroid therapy in patients with sudden sensorineural hearing loss (SSNHL). Method A single-center, retrospective, longitudinal cohort study on 55 patients in a tertiary referral otology center was examined. Patients diagnosed with SSNHL between 2014 and 2017 were asked to complete a Measure of Perceived Stress (Brajac, Tkalcic, Dragojević, & Gruber, 2003 ) questionnaire. Inclusion criteria were patients > 18 years of age, SSNHL diagnosed within 4 previous weeks, completed steroid treatment, and complete documentation. Results There were 30 patients (55%) that showed significant improvement in their pure-tone audiogram (PTA) hearing threshold average (≥ 15 dB) after steroid treatment. Two-step cluster analysis identified 3 clusters based on average PTA hearing threshold recovery and average Measure of Perceived Stress scores. The difference between pretreatment and posttreatment hearing levels was significantly higher in the cluster with moderate stress compared to clusters with mild and high stress levels (Kruskal-Wallis test, Friedman test, p < .001). There were no significant differences in average PTA hearing threshold recovery after steroid therapy between groups of patients with mild and severe stress. Conclusion Patients with moderate stress levels show significantly better results after steroid treatment for SSNHL than patients with low or high stress levels.

A Practical Approach to Severe Asthma in Children

Severe asthma accounts for only a small proportion of the children with asthma but a disproportionately high amount of resource utilization and morbidity. It is a heterogeneous entity and requires a step-wise, evidence-based approach to evaluation and management by pediatric subspecialists. The first step is to confirm the diagnosis by eliciting confirmatory history and objective evidence of asthma and excluding possible masquerading diagnoses. The next step is to differentiate difficult-to-treat asthma, asthma that can be controlled with appropriate management, from asthma that requires the highest level of therapy to maintain control or remains uncontrolled despite management optimization. Evaluation of difficult-to-treat asthma includes an assessment of medication delivery, the home environment, and, if possible, the school and other frequented locations, the psychosocial situation, and comorbid conditions. Once identified, aggressive management of issues related to poor adherence and drug delivery, remediation of environmental triggers, and treatment of comorbid conditions is necessary to characterize the degree of control that can be achieved with standard therapies. For the small proportion of patients whose disease remains poorly controlled with these interventions, the clinician may assess steroid responsiveness and determine the inflammatory pattern and eligibility for biologic therapies. Management of severe asthma refractory to traditional therapies involves considering the various biologic and other newly approved treatments as well as emerging therapies based on the individual patient characteristics.

Air pollution and resistance to inhaled glucocorticoids: Evidence, mechanisms and gaps to fill

Substantial evidence indicates that cigarette smoke exposure induces resistance to glucocorticoids, the primary maintenance medication in asthma treatment. Modest evidence also suggests that air pollution may reduce the effectiveness of these critical medications. Cigarette smoke, which has clear parallels with air pollution, has been shown to induce glucocorticoid resistance in asthma and it has been speculated that air pollution may have similar effects. However, the literature on an association of air pollution with glucocorticoid resistance is modest to date. In this review, we detail the evidence for, and against, the effects of air pollution on glucocorticoid effectiveness, focusing on results from epidemiology and controlled human exposure studies. Epidemiological studies indicate a correlation between increased air pollution exposure and worse asthma symptoms. But these studies also show a mix of beneficial and harmful effects of glucocorticoids on spirometry and asthma symptoms, perhaps due to confounding influences, or the induction of glucocorticoid resistance. We describe mechanisms that may contribute to reductions in glucocorticoid responsiveness following air pollution exposure, including changes to phosphorylation or oxidation of the glucocorticoid receptor, repression by cytokines, or inflammatory pathways, and epigenetic effects. Possible interactions between air pollution and respiratory infections are also briefly discussed. Finally, we detail a number of therapies that may boost glucocorticoid effectiveness or reverse resistance in the presence of air pollution, and comment on the beneficial effects of engineering controls, such as air filtration and asthma action plans. We also call attention to the benefits of improved clean air policy on asthma. This review highlights numerous gaps in our knowledge of the interactions between air pollution and glucocorticoids to encourage further research in this area with a view to reducing the harm caused to those with airways disease.

Qualitative development of the PROMIS(R) pediatric stress response item banks

OBJECTIVE

To describe the qualitative development of the Patient-Reported Outcome Measurement Information System (PROMIS®) Pediatric Stress Response item banks.

METHODS

Stress response concepts were specified through a literature review and interviews with content experts, children, and parents. A library comprising 2,677 items derived from 71 instruments was developed. Items were classified into conceptual categories; new items were written and redundant items were removed. Items were then revised based on cognitive interviews (n = 39 children), readability analyses, and translatability reviews.

RESULTS

2 pediatric Stress Response sub-domains were identified: somatic experiences (43 items) and psychological experiences (64 items). Final item pools cover the full range of children's stress experiences. Items are comprehensible among children aged ≥8 years and ready for translation.

CONCLUSIONS

Child- and parent-report versions of the item banks assess children's somatic and psychological states when demands tax their adaptive capabilities.

Mediators of asthma outcomes

BACKGROUND

Patient adherence, the level of asthma self-management skills, exposure to stress, and depression can have considerable influence on a wide range of asthma outcomes and thus are considered asthma outcome mediators.

OBJECTIVE

National Institutes of Health institutes and other federal agencies convened an expert group to recommend standardized measures for 7 domains of asthma clinical research outcomes measures. Although the review of mediators of these outcomes was not within the scope of any specific outcome topic, a brief summary is presented so that researchers might consider potential mediators.

METHODS

We prepared a summary of key mediators of asthma outcomes based on expertise and knowledge of the literature.

RESULTS

The rationale for including measures of adherence, self-management skills, and exposures to stress in asthma clinical research is presented, along with a brief review of instruments for collecting this information from clinical research participants.

CONCLUSIONS

Appropriate measurement of adherence, self-management skills, and exposures to stress will enhance characterization of study participants and provide information about the potential impact these factors can have on mediating the effects of treatment interventions.

Advances in pediatric asthma in 2009: gaining control of childhood asthma

This year's summary will focus on recent advances in pediatric asthma as reported in Journal of Allergy and Clinical Immunology publications in 2009. New National Asthma Education and Prevention Program asthma guidelines were released in 2007, with a particular emphasis on asthma control. Now that we have worked with the principals of the guidelines for 2 years, new insights are reported on how to implement the guidelines into clinical practice. This year's report will focus on gaps in management that need to be addressed, including health disparities, methods to improve asthma management through opportunities available in school-based asthma programs, and more information on the development of asthma in childhood. This information brings us closer to the point of managing children with controllable asthma and understanding reasons why asthma is not controlled in the remaining children. If we can close these gaps through better communication, improvements in the health care system, and new insights into treatment, we will move closer to better methods to intervene early in the course of the disease and induce clinical remission as quickly as possible in most children.

Overexpression of glucocorticoid receptor-beta in severe allergic rhinitis

OBJECTIVE

To clarify the role of glucocorticoid receptor-beta in resistance to glucocorticoid therapy for allergic rhinitis, we studied 37 tissue samples from 20 patients with severe allergic rhinitis, and samples from age-matched controls.

METHODS

Patients were treated with intranasal fluticasone for 6 months and inferior turbinectomy was performed for patients with poor response to glucocorticoid treatment. The expression of glucocorticoid receptor-alpha (GR-alpha), glucocorticoid receptor-beta (GR-beta), and nuclear factor-kappaB (NF-kappaB) in nasal mucosa was studied immunohistochemically.

RESULTS

GR-alpha and NF-kappaB were expressed to a similar extent in patients and controls, but GR-beta was expressed significantly more in patients, resulting in an increased GR-beta/GR-alpha ratio.

CONCLUSION

Our findings suggest that GR-beta plays an important role in resistance to glucocorticoid therapy for allergic rhinitis, and its expression might be used as an additional parameter indicating steroid resistance in allergic rhinitis.

Lower cortisol levels in children with asthma exposed to recurrent maternal distress from birth

BACKGROUND

Existing evidence supports associations between exposure to maternal distress and the development of childhood asthma, between exposure to maternal distress and an increased cortisol response in children, and between childhood asthma and an attenuated cortisol response.

OBJECTIVE

To investigate the association between children's cortisol levels and the combined predictors of exposure to maternal distress and childhood asthma.

METHODS

Serum cortisol levels were examined at age 7 to 10 years in relation to asthma status and exposure to maternal distress in a representative sample of children (n = 503) born in 1995. Data from health care and prescription databases were linked with additional data collected in this longitudinal study. Maternal distress was defined as a physician diagnosis of a depressive or anxiety disorder or a prescription history of related medications as reported in the mothers' health care records. Children's asthma status was determined via examination by 2 pediatric allergists.

RESULTS

A multiple linear regression analysis revealed that exposure to maternal distress restricted to the first year of life predicted elevated cortisol levels in children, regardless of asthma status (>40% increase). A significant interaction was discovered in the group of children exposed to maternal distress extending beyond the postnatal period such that no asthma predicted a 25.9% increase in cortisol and a diagnosis of asthma predicted a 5.2% decrease in cortisol. Cortisol levels were further lowered in atopic and bronchial hyperresponsive asthma.

CONCLUSION

Among children exposed to recurrent maternal distress, an elevation in cortisol levels occurs in response to an acute stressor when there is no accompanying diagnosis of asthma, whereas, in comparison, children with asthma tend to exhibit lower cortisol levels.