Effects of dexamethasone on K(+)-evoked glutamate release from rat hippocampal slices

Unplanned intensive care unit readmission after surgical treatment in patients with newly diagnosed glioblastoma - forfeiture of surgically achieved advantages?

Postoperative intensive care unit (ICU) monitoring is an established option to ensure patient safety after resection of newly diagnosed glioblastoma. In contrast, secondary unplanned ICU readmission following complicating events during the initial postoperative course might be associated with severe morbidity and impair initially intended surgical benefit. In the present study, we assessed the prognostic impact of secondary ICU readmission and aimed to identify preoperatively ascertainable risk factors for the development of such adverse events in patients treated surgically for newly diagnosed glioblastoma. Between 2013 and 2018, 240 patients were surgically treated for newly diagnosed glioblastoma at the authors' neuro-oncological center. Secondary ICU readmission was defined as any unplanned admission to the ICU during initial hospital stay. A multivariable logistic regression analysis was performed to identify preoperatively measurable risk factors for unplanned ICU readmission. Nineteen of 240 glioblastoma patients (8%) were readmitted to the ICU. Median overall survival of patients with unplanned ICU readmission was 9 months compared to 17 months for patients without secondary ICU readmission (p=0.008). Multivariable analysis identified "preoperative administration of dexamethasone > 7 days" (p=0.002) as a significant and independent predictor of secondary unplanned ICU admission. Secondary ICU readmission following surgery for newly diagnosed glioblastoma is significantly associated with poor survival and thus may negate surgically achieved prerequisites for further treatment. This underlines the indispensability of precise patient selection as well as the importance of further scientific debate on these highly relevant aspects for patient safety.

Risks and benefits of corticosteroids in arthritic diseases in the clinic

Glucocorticoids (GCs) constitute a first line treatment for many autoimmune and inflammatory diseases. Due to their potent anti-inflammatory and immunosuppressive actions, GCs are added frequently to disease modifying antirheumatic drugs (DMARDs) in various arthritic diseases, such as rheumatoid arthritis. However, their prolonged administration or administration at high doses is associated with adverse effects that may be (quality of) life-threatening, including osteoporosis, metabolic, gastrointestinal and cardiovascular side effects. In this review, we summarize the clinical and pharmacological effects of GCs in different arthritic diseases, while documenting the current research efforts towards the identification of novel and more efficient GCs with reduced side effects.

Neurological and Neuropsychiatric Adverse Effects of Dermatologic Medications

Severe, recalcitrant dermatologic conditions often require systemic treatment. Although efficacious, these medications have been associated with wide-ranging adverse reactions. Some are reversible, predictable, and either dose-dependent or treatment length-dependent, while others are unpredictable, irreversible, and potentially fatal. This review examines the neuropsychiatric adverse effects associated with US FDA-approved medications for treatment of the following dermatologic pathologies that typically require systemic therapy: autoimmune dermatoses, acne, psoriasis, and melanoma. A search of the literature was performed, with adverse effects ranging from mild headaches and neuropathy to severe encephalopathies. The medications associated with the most serious reactions were those used to treat psoriasis, especially the older non-biologic medications such as cyclosporine A and methotrexate. Given the importance of these systemic dermatologic therapies in treating severe, recalcitrant conditions, and the wide variety of potentially serious neuropsychiatric adverse effects of these medications, neurologists, psychiatrists, dermatologists, oncologists, and primary care providers must be aware of the potential for these neuropsychiatric adverse reactions to allow for appropriate counseling, management, and medication withdrawal.

Association between insulin-like growth factor-1 and cognitive functions in alcohol-dependent patients

Studies in alcohol-dependent patients show that cognitive function can be influenced by chronic use of alcohol. Alcohol is a known neurotoxin that induces neurodegeneration in the brain. Although there are various causes of cognitive deficiency in alcohol-dependent patients, in this study we focus on the role of corticosteroids. The hypothalamus-pituitary-adrenal system (i.e., the HPA axis) plays a part in the control of corticosteroids. Recent studies show that insulin-like growth factor-1 (IGF-1) reflects the status of growth hormones under the action of the HPA axis. Therefore, IGF-1 is a potential indicator that reflects activity of the HPA axis, and a biomarker that may reflect the decline of cognitive function associated with alcohol-induced hypercortisolism. The purposes of this study are to identify an association between cognitive function and IGF-1, and to investigate IGF as the biological marker of cognitive decline in alcohol-dependent patients. Forty alcohol-dependent patients were selected as the subjects of this study. IGF-1 was measured through an enzyme-linked immunosorbent assay (ELISA). Clinical features were examined using the Korean version of the alcohol dependence scale (ADS-K). Cognitive functions were measured using the Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Comparative analysis was utilized to identify an association between CERAD measurement items and IGF-1. Alcohol-dependent patients demonstrated stable performance of most of the CERAD measures. Among the measures of the CERAD, only trail making test A showed a correlation to IGF-1. Compared to trail making test B, trail making test A is assumed to reflect basic cognitive functions including psychomotor speed, visual search and sequencing in alcohol-dependent patients, regardless of demographic characteristics such as the level of education of patients. Therefore, IGF-1 seems to play an important role in detecting the decline of basic cognitive functions in alcohol-dependent patients.

Corticosteroid-related central nervous system side effects

Corticosteroids have been used since the 50s as anti-inflammatory and immunosuppressive drugs for the treatment of several pathologies such as asthma, allergy, rheumatoid arthritis, and dermatological disorders. Corticosteroids have three principal mechanisms of action: 1) inhibit the synthesis of inflammatory proteins blocking NF-kB, 2) induce the expression of anti-inflammatory proteins by IkB and MAPK phosphatase I, and 3) inhibit 5-lipoxygenase and cyclooxygenase-2. The efficacy of glucocorticoids in alleviating inflammatory disorders results from the pleiotropic effects of the glucocorticoid receptors on multiple signaling pathways. However, they have adverse effects: Growth retardation in children, immunosuppression, hypertension, hyperglycemia, inhibition of wound repair, osteoporosis, metabolic disturbances, glaucoma, and cataracts. Less is known about psychiatric or side effects on central nervous system, as catatonia, decreased concentration, agitation, insomnia, and abnormal behaviors, which are also often underestimated in clinical practice. The aim of this review is to highlight the correlation between the administration of corticosteroids and CNS adverse effects, giving a useful guide for prescribers including a more careful assessment of risk factors and encourage the use of safer doses of this class of drugs.

A randomized, placebo-controlled proof-of-concept, crossover trial of phenytoin for hydrocortisone-induced declarative memory changes

BACKGROUND

Corticosteroid excess is associated with declarative memory impairment and hippocampal atrophy. These findings are clinically important because approximately 1% of the population receives prescription corticosteroids at any time, and major depressive disorder is associated with elevated cortisol levels and hippocampal atrophy. In animals, hippocampal changes with corticosteroids are blocked by phenytoin. The objective of the current study was to extend these preclinical findings to humans. We examined whether phenytoin attenuated the effects of hydrocortisone on declarative memory. Functional magnetic resonance imaging (fMRI) assessed task-related hippocampal activation.

METHODS

A randomized, double-blind, placebo-controlled, within-subject crossover study was conducted in 17 healthy adult volunteers. Participants received hydrocortisone (2.5 days), phenytoin (3.5 days), both medications together, or placebo, with 21-day washouts between conditions. Differences between treatments were estimated using a mixed-effects repeated measures analysis.

RESULTS

Fifteen participants had data from at least two treatment conditions and were used in the analysis. Basal cortisol levels negatively correlated with fMRI BOLD activation in the para-hippocampus with a similar trend observed in the hippocampus. Decrease in declarative memory with hydrocortisone was blocked with concomitant phenytoin administration. Relative to the placebo condition, a significant decrease in hippocampal BOLD activation was observed with hydrocortisone and phenytoin alone, and the two medications in combination. Declarative memory did not show significant correlations with hippocampal activation.

LIMITATIONS

The modest sample size, which limited our statistical power, was a limitation.

CONCLUSIONS

Findings from this pilot study suggest phenytoin attenuated effects of corticosteroids memory in humans, but potentiated the reduction in hippocampal activation.

Effects of glucocorticoids on mood, memory, and the hippocampus. Treatment and preventive therapy

Corticosteroids, such as prednisone and dexamethasone, are commonly prescribed medications that suppress the immune system and decrease inflammation. Common side effects of long-term treatment with corticosteroids include weight gain, osteoporosis, and diabetes mellitus. This paper reviews the literature on psychiatric and cognitive changes during corticosteroid therapy and potential treatment options. Hypomania and mania are the most common mood changes during acute corticosteroid therapy, although depression has also been reported. However, depression is reported to be more common than mania during long-term treatment with corticosteroids. A decline in declarative and working memory is also reported during corticosteroid therapy. Corticosteroids are associated with changes in the temporal lobe, detected by structural, functional, and spectroscopic imaging. The mood and cognitive symptoms are dose dependent and frequently occur during the first few weeks of therapy. Other risk factors are not well characterized. Controlled trials suggest that lithium and phenytoin can prevent mood symptoms associated with corticosteroids. Lamotrigine and memantine also have been shown to reverse, at least partially, the declarative memory effects of corticosteroids. Uncontrolled trials suggest that antipsychotics, anti-seizure medications, and perhaps some antidepressants can also be useful for normalizing mood changes associated with corticosteroids. Thus, both the symptoms and treatment response are similar to those of bipolar disorder. Moreover, corticosteroid-induced mood and cognitive alterations have been shown to be reversible with dose reduction or discontinuation of treatment.

Cloning, distribution, and colocalization of MNAR/PELP1 with glucocorticoid receptors in primate and nonprimate brain

MNAR/PELP1 (see text) is a newly identified scaffold protein/coactivator initially thought to modulate nongenomic and genomic actions of the estrogen receptor; however, it has been recently shown to interact with multiple steroid receptors, including androgen and glucocorticoid receptors. In the present study, we cloned the monkey MNAR/PELP1 gene, deduced its domain structure, examined its localization pattern and colocalization with glucocorticoid receptor in monkey brain, and determined its subcellular localization. PCR-based cloning of MNAR/PELP1 from monkey brain produced a transcript of approximately 3.4 kb which showed high homology to the human and rat MNAR/PELP1 gene. Domain analysis showed that all the key steroid-receptor-interacting (LXXLL) domains, SH3-interacting (PXXP) domains and several C-terminal glutamic-acid-rich clusters, as well as various kinase domains are conserved in the monkey MNAR/PELP1 gene. Anatomical mapping of MNAR/PELP1 immunoreactivity in several regions of the monkey brain showed a similar pattern of MNAR/PELP1 distribution as previously observed in rat and mouse brains. MNAR/PELP1 also showed an absolute colocalization with glucocorticoid receptors in both primate and nonprimate brain, including those regions of the brain, where other steroid receptors are not significantly expressed, such as hippocampus, striatum, and thalamus - suggesting that MNAR/PELP1 may modulate glucocorticoid actions in the brain. Finally, ultrastructural electron microscopic studies showed that MNAR/PELP1-reactive gold particles are located within nucleus, cytoplasm, dendritic/synaptic terminals, and astrocytic processes. As a whole, the studies demonstrate that MNAR/PELP1 is expressed and colocalizes with glucocorticoid receptors in monkey and rat brains and may have multiple cellular functions based on its subcellular localizations.

Stress-induced elevation of glucocorticoids increases microglia proliferation through NMDA receptor activation

The immunosuppressive nature of glucocorticoids has been well documented both in vitro and in vivo. This glucocorticoid-mediated immunosuppression has also been observed in immune cells within the central nervous system (CNS). For example, microglia have previously been shown to exhibit decreased proliferation, cytokine production, and antigen presentation upon treatment with glucocorticoids in vitro. Despite these in vitro findings, the impact of glucocorticoids on microglia function in vivo has not been fully investigated. To determine the interaction between glucocorticoids and microglia within the CNS, we used a restraint model of psychological stress to elevate corticosterone levels in mice. Quantification of microglia from stressed mice indicated that four sessions of stress induced the proliferation of microglia. This proliferation was a function of corticosterone-induced activation of the N-methyl-D-aspartate (NMDA) receptor within the CNS since blockade of corticosterone synthesis, the glucocorticoid receptor, or the NMDA receptor each prevented stress-induced increases in microglia number. In addition, the NMDA receptor antagonist MK-801 prevented increases in microglia following exogenous corticosterone administration to non-stressed mice. We conclude that activation of the NMDA receptor and subsequent microglia proliferation is a downstream effect of elevated corticosterone levels. These findings demonstrate that elevated levels of glucocorticoids are able to activate microglia in vivo and suggest that stress is able to induce a pro-inflammatory response within the CNS. A pro-inflammatory microglia response may be a contributing factor in the development of various stress-induced inflammatory conditions in the CNS.

Chronic prenatal ethanol exposure alters glucocorticoid signalling in the hippocampus of the postnatal Guinea pig

The present study tested the hypothesis that chronic prenatal ethanol exposure causes long-lasting changes in glucocorticoid signalling in postnatal offspring. Pregnant guinea pigs were treated with ethanol (4 g/kg maternal body weight/day), isocaloric-sucrose/pair-feeding or water throughout gestation, and maternal saliva cortisol concentration was determined 2 h after treatment at different stages of gestation. Electrically-stimulated release of glutamate and GABA, in the presence or absence of dexamethasone, as well as glucocorticoid and mineralocorticoid receptor mRNA expression, was determined in the hippocampus and prefrontal cortex of adult offspring of treated pregnant guinea pigs. Maternal saliva cortisol concentration increased throughout pregnancy, which was associated with increased foetal plasma and amniotic fluid cortisol concentration. Ethanol administration to pregnant guinea pigs increased maternal saliva cortisol concentration during early and mid-gestation. In late gestation, ethanol administration did not increase saliva cortisol concentration above that induced by pregnancy. Chronic prenatal ethanol exposure had no effect on stimulated glutamate or GABA release, but selectively prevented dexamethasone-mediated suppression of stimulated glutamate release, and decreased expression of mineralocorticoid, but not glucocorticoid, receptor mRNA in the hippocampus of adult offspring. These data indicate that maternal ethanol administration leads to excessively increased maternal cortisol concentration that can impact negatively the developing foetal brain, leading to persistent postnatal deficits in glucocorticoid regulation of glutamate signalling in the adult hippocampus.

Acute effects of glucocorticoids on ATP-induced Ca2+ mobilization and nitric oxide production in cochlear spiral ganglion neurons

Rapid, non-genomic effects of glucocorticoids on extracellular adenosine 5'-triphosphate (ATP)-induced intracellular Ca(2+) concentration ([Ca(2+)](i)) changes and nitric oxide (NO) production were investigated in type I spiral ganglion neurons (SGNs) of the guinea-pig cochlea using the Ca(2+)-sensitive dye fura-2 and the NO-sensitive dye 4,5-diaminofluorescein (DAF-2). Pretreatment of SGNs with 1 microM dexamethasone for 10 min, a synthetic glucocorticoid hormone, enhanced the ATP-induced [Ca(2+)](i) increase in SGNs. RU 38486, a competitive glucocorticoid receptor antagonist eliminated the effects of dexamethasone on the ATP-induced [Ca(2+)](i) increase in SGNs. These acute effects of dexamethasone were dependent on the presence of extracellular Ca(2+), thereby suggesting that dexamethasone may rapidly enhance the Ca(2+) influx through the activation of ionotropic P2X receptors which may interact with glucocorticoid-mediated membrane receptors. Extracellular ATP increased the intensity of DAF-2 fluorescence, indicating NO production in SGNs. The ATP-induced NO production was mainly due to the Ca(2+) influx through the activation of P2 receptors. S-nitroso-N-acetylpenicillamine, a NO donor, enhanced the ATP-induced [Ca(2+)](i) increase in SGNs while L-N(G)-nitroarginine methyl ester (L-NAME), a NO synthesis inhibitor, inhibited it. Dexamethasone enhanced the ATP-induced NO production in SGNs. The augmentation of dexamethasone on ATP-induced NO production was abolished in the presence of l-NAME. It is concluded that the ATP-induced [Ca(2+)](i) increase induces NO production which enhances a [Ca(2+)](i) increase in SGNs by a positive-feedback mechanism. Dexamethasone enhances the ATP-induced [Ca(2+)](i) increase in SGNs which results in the augmentation of NO production. The present study suggests that NO may play an important role in auditory signal transduction. Our results also indicate that glucocorticoids may rapidly affect auditory neurotransmission due to a novel non-genomic mechanism.

Recent advances in the development of multifactorial therapies for the treatment of traumatic brain injury

Traumatic brain injury (TBI) is one of the leading causes of death and disability in the industrialised world and remains a major health problem with serious socioeconomic consequences. So far, despite encouraging preclinical results, almost all neuroprotection trials have failed to show any significant efficacy in the treatment of clinical TBI. This may be due, in part, to the fact that most of the therapies investigated have targeted an individual injury factor. It is now recognised that TBI is a very heterogeneous type of injury that varies widely in its aetiology, clinical presentation, severity and pathophysiology. The pathophysiological sequelae of TBI are mediated by an interaction of acute and delayed molecular, biochemical and physiological events that are both complex and multifaceted. Accordingly, a successful TBI treatment may have to simultaneously attenuate many injury factors. Recent efforts in experimental TBI have, therefore, focused on the development of neuropharmacotherapies that target multiple injury factors and thus improve the likelihood of a successful outcome. This review will focus on three such novel compounds that are currently being assessed in clinical trials; progesterone, dexanabinol and dexamethasone, and provide an update on the progress of both magnesium and cyclosporin A.

Metabolic flux analysis as a tool for the elucidation of the metabolism of neurotransmitter glutamate

A flux analysis model for the metabolism of neurotransmitter glutamate is constructed, in order to study functional aspects of its metabolism. This work is based on the potassium [K(+)] evoked neurotransmitter glutamate released, as measured in a series of experiments of superfused rat or mouse brain preparations. These measurements are combined with data reported, concerning the metabolism of glutamate and its precursors, glutamine and glucose in rat cerebral cells in vivo. The proposed stoichiometry of the specific reaction network renders the model solvable. The classification procedure establishes that the measured fluxes are all balanceable and all non-measured fluxes can be calculated. The system is well posed with a condition number of 7.8536. The results emphasize the importance of phosphate activated glutaminase and aspartate aminotransferase in the metabolism of neurotransmitter glutamate. Reported data on the rate of the malate-aspartate shuttle, as well as the anaplerotic flux of the glial pyruvate carboxylase reaction are in agreement with the estimations calculated from the proposed model.