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Niebrzydowska-Tatus M, Pełech A, Bień K, Rekowska AK, Domańska A, Kimber-Trojnar Ż, Leszczyńska-Gorzelak B, Trojnar M. Substance P Concentration in Gestational Diabetes and Excessive Gestational Weight Gain and Its Impact on Neonatal Anthropometry. Int J Mol Sci 2024; 25:3759. [PMID: 38612572 PMCID: PMC11011445 DOI: 10.3390/ijms25073759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Fetal programming is a process initiated by intrauterine conditions, leaving a lasting impact on the offspring's health, whether they manifest immediately or later in life. It is believed that children born to mothers with gestational diabetes mellitus (GDM) and excessive gestational weight gain (EGWG) may be at an increased risk of developing type 2 diabetes mellitus (T2DM) and obesity later in their adult lives. Substance P is a neurotransmitter associated with obesity development and impairment of insulin signaling. Dysregulation of substance P could lead to several pregnancy pathologies, such as preeclampsia and preterm birth. Our study aimed to compare substance P concentrations in serum and umbilical cord blood in patients with GDM, EGWG, and healthy women with a family history of gestational weight gain. Substance P levels in umbilical cord blood were significantly higher in the GDM group compared to the EGWG and control groups. Substance P levels in serum and umbilical cord blood were positively correlated in all groups and the GDM group. A very interesting direction for future research is the relationship between the concentration of substance P in newborns of diabetic mothers and the occurrence of respiratory distress syndrome as a complication of impaired surfactant synthesis. To our knowledge, it is the first study assessing substance P concentration in GDM and EGWG patients.
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Affiliation(s)
- Magdalena Niebrzydowska-Tatus
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland; (A.P.); (B.L.-G.)
| | - Aleksandra Pełech
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland; (A.P.); (B.L.-G.)
| | - Katarzyna Bień
- Student’s Scientific Association at the Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland; (K.B.); (A.K.R.); (A.D.)
| | - Anna K. Rekowska
- Student’s Scientific Association at the Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland; (K.B.); (A.K.R.); (A.D.)
| | - Aleksandra Domańska
- Student’s Scientific Association at the Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland; (K.B.); (A.K.R.); (A.D.)
| | - Żaneta Kimber-Trojnar
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland; (A.P.); (B.L.-G.)
| | - Bożena Leszczyńska-Gorzelak
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland; (A.P.); (B.L.-G.)
| | - Marcin Trojnar
- Chair and Department of Internal Diseases, Medical University of Lublin, 20-059 Lublin, Poland;
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Mishra G, Townsend KL. Sensory nerve and neuropeptide diversity in adipose tissues. Mol Cells 2024; 47:100030. [PMID: 38364960 PMCID: PMC10960112 DOI: 10.1016/j.mocell.2024.100030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/06/2024] [Accepted: 02/06/2024] [Indexed: 02/18/2024] Open
Abstract
Both brown and white adipose tissues (BAT/WAT) are innervated by the peripheral nervous system, including efferent sympathetic nerves that communicate from the brain/central nervous system out to the tissue, and afferent sensory nerves that communicate from the tissue back to the brain and locally release neuropeptides to the tissue upon stimulation. This bidirectional neural communication is important for energy balance and metabolic control, as well as maintaining adipose tissue health through processes like browning (development of metabolically healthy brown adipocytes in WAT), thermogenesis, lipolysis, and adipogenesis. Decades of sensory nerve denervation studies have demonstrated the particular importance of adipose sensory nerves for brown adipose tissue and WAT functions, but far less is known about the tissue's sensory innervation compared to the better-studied sympathetic nerves and their neurotransmitter norepinephrine. In this review, we cover what is known and not yet known about sensory nerve activities in adipose, focusing on their effector neuropeptide actions in the tissue.
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Affiliation(s)
- Gargi Mishra
- Department of Neurological Surgery, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Kristy L Townsend
- Department of Neurological Surgery, College of Medicine, The Ohio State University, Columbus, OH, USA.
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Kokabi F, Ebrahimi S, Mirzavi F, Ghiasi Nooghabi N, Hashemi SF, Hashemy SI. The neuropeptide substance P/neurokinin-1 receptor system and diabetes: From mechanism to therapy. Biofactors 2023. [PMID: 36651605 DOI: 10.1002/biof.1935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
Diabetes is a significant public health issue known as the world's fastest-growing disease condition. It is characterized by persistent hyperglycemia and subsequent chronic complications leading to organ dysfunction and, ultimately, the failure of target organs. Substance P (SP) is an undecapeptide that belongs to the family of tachykinin (TK) peptides. The SP-mediated activation of the neurokinin 1 receptor (NK1R) regulates many pathophysiological processes in the body. There is also a relation between the SP/NK1R system and diabetic processes. Importantly, deregulated expression of SP has been reported in diabetes and diabetes-associated chronic complications. SP can induce both diabetogenic and antidiabetogenic effects and thus affect the pathology of diabetes destructively or protectively. Here, we review the current knowledge of the functional relevance of the SP/NK1R system in diabetes pathogenesis and its exploitation for diabetes therapy. A comprehensive understanding of the role of the SP/NK1R system in diabetes is expected to shed further light on developing new therapeutic possibilities for diabetes and its associated chronic conditions.
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Affiliation(s)
- Fariba Kokabi
- Department of Clinical Biochemistry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Safieh Ebrahimi
- Department of Clinical Biochemistry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farshad Mirzavi
- Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | | | | | - Seyed Isaac Hashemy
- Department of Clinical Biochemistry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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The Neuropeptide-Related HERC5/TAC1 Interactions May Be Associated with the Dysregulation of lncRNA GAS5 Expression in Gestational Diabetes Mellitus Exosomes. DISEASE MARKERS 2022; 2022:8075285. [PMID: 35178132 PMCID: PMC8847027 DOI: 10.1155/2022/8075285] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/02/2022] [Accepted: 01/06/2022] [Indexed: 12/12/2022]
Abstract
Objective The goal of this work was to look at the expression and probable role of exosomal long noncoding RNA (lncRNA) GAS5 in gestational diabetes mellitus (GDM), as well as forecast the importance of its interaction with neuropeptides in the progression of the disease. Methods We divided 44 pregnant women visiting the obstetric outpatient clinics at the Affiliated Hospital of Guilin Medical College from January 2021 to December 2021 into healthy and GDM groups. We measured the expression levels of the lncRNA GAS5 in peripheral blood using PCR and compared the expression levels between the 2 groups. The Gene Expression Omnibus (GEO) database and the R software were used to analyse the differences in the genes expressed in the amniotic fluid cells in the GDM and normal groups. catRAPID was used to identify potential target proteins for GAS5. Key neuropeptide-related proteins and potential target proteins of GAS5 were extracted, and protein interaction networks were mapped. AlphaFold 2 was used to predict the structure of the target protein. The ClusPro tool was used to predict protein-protein interactions. ZDOCK was used to further confirm the protein–nucleic acid docking. Results The lncRNA GAS5 was downregulated in the peripheral blood of pregnant women with GDM compared with normal pregnant women. The subcellular localization sites of GAS5 were the nucleus, cytoplasm, and ribosome; in addition, GAS5 was present in exosomes. Intercellular interactions, including neuropeptide receptors, were increased in the amniotic fluid cells of patients with GDM. Venn diagram analysis yielded seven neuropeptide-related proteins and three GAS5 target proteins. Among them, HERC5/TAC1 interacted and GAS5 docked well with HERC5. Conclusion The lncRNA GAS5 in the peripheral blood exosomes in patients with GDM may be a new target for the detection of GDM, and the interaction between GAS5 and HERC5/TAC1 may be involved in the pathogenesis of GDM.
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Insects as a New Complex Model in Hormonal Basis of Obesity. Int J Mol Sci 2021; 22:ijms222011066. [PMID: 34681728 PMCID: PMC8540125 DOI: 10.3390/ijms222011066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/07/2021] [Accepted: 10/09/2021] [Indexed: 11/30/2022] Open
Abstract
Nowadays, one of the biggest problems in healthcare is an obesity epidemic. Consumption of cheap and low-quality energy-rich diets, low physical activity, and sedentary work favor an increase in the number of obesity cases within many populations/nations. This is a burden on society, public health, and the economy with many deleterious consequences. Thus, studies concerning this disorder are extremely needed, including searching for new, effective, and fitting models. Obesity may be related, among other factors, to disrupting adipocytes activity, disturbance of metabolic homeostasis, dysregulation of hormonal balance, cardiovascular problems, or disorders in nutrition which may lead to death. Because of the high complexity of obesity, it is not easy to find an ideal model for its studies which will be suitable for genetic and physiological analysis including specification of different compounds’ (hormones, neuropeptides) functions, as well as for signaling pathways analysis. In recent times, in search of new models for human diseases there has been more and more attention paid to insects, especially in neuro-endocrine regulation. It seems that this group of animals might also be a new model for human obesity. There are many arguments that insects are a good, multidirectional, and complex model for this disease. For example, insect models can have similar conservative signaling pathways (e.g., JAK-STAT signaling pathway), the presence of similar hormonal axis (e.g., brain–gut axis), or occurrence of structural and functional homologues between neuropeptides (e.g., neuropeptide F and human neuropeptide Y, insulin-like peptides, and human insulin) compared to humans. Here we give a hint to use insects as a model for obesity that can be used in multiple ways: as a source of genetic and peptidomic data about etiology and development correlated with obesity occurrence as well as a model for novel hormonal-based drug activity and their impact on mechanism of disease occurrence.
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Atas U, Erin N, Tazegul G, Elpek GO, Yildirim B. Changes in ghrelin, substance P and vasoactive intestinal peptide levels in the gastroduodenal mucosa of patients with morbid obesity. Neuropeptides 2021; 89:102164. [PMID: 34146741 DOI: 10.1016/j.npep.2021.102164] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 05/31/2021] [Accepted: 05/31/2021] [Indexed: 02/08/2023]
Abstract
AIMS The aim of the study was to assess changes in levels of substance P (SP), vasoactive intestinal peptide (VIP) and ghrelin in the gastroduodenal mucosa of obese individuals, which has not been studied before. METHODS Forty-six patients with a body mass index (BMI) of >40 kg/m2 and 20 patients with a BMI of 18-25 kg/m2 were included in the study. VIP and SP levels in the fundus, antrum and duodenal mucosa were measured in freshly frozen tissues using enzyme-linked immunosorbent assay (ELISA). Fasting levels of ghrelin in blood were also measured with ELISA. Tissue levels of ghrelin were assessed by immunohistochemical staining, and immunoreactivity scores were used for ghrelin evaluation in tissues. RESULTS Antrum SP levels were higher in the obese group than in the control group. A significant number of obese patients had low VIP levels in the fundus and antrum. Intense ghrelin staining was observed in a limited number of cells in the mucosal area of the gastric fundus that was similar in the control and patient groups. In the antrum and duodenum, ghrelin staining was low in all the samples examined. CONCLUSION Here, we found that SP levels are increased, while VIP levels are decreased in the antrum of morbidly obese individuals. Previous studies show that SP increases gastroduodenal motility, that VIP slows it down, and that the gastric emptying rate is higher in obese individuals, preventing negative feedback mechanisms upon food intake. Therefore, increases in SP and decreases in VIP levels in the antrum may contribute to obesity by accelerating gastric emptying.
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Affiliation(s)
- Unal Atas
- Akdeniz University Faculty of Medicine, Department of Internal Medicine, Antalya, Turkey.
| | - Nuray Erin
- Akdeniz University Faculty of Medicine, Department of Medical Pharmacology and Immunopharmacology and Immunooncology Unit, Antalya, Turkey.
| | - Gokhan Tazegul
- Akdeniz University Faculty of Medicine, Department of Internal Medicine, Antalya, Turkey.
| | - Gulsum Ozlem Elpek
- Akdeniz University Faculty of Medicine, Department of Pathology, Antalya, Turkey.
| | - Bulent Yildirim
- Akdeniz University Faculty of Medicine, Department of Gastroenterology, Antalya, Turkey.
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Rivera-Mancilla E, Al-Hassany L, Villalón CM, MaassenVanDenBrink A. Metabolic Aspects of Migraine: Association With Obesity and Diabetes Mellitus. Front Neurol 2021; 12:686398. [PMID: 34177788 PMCID: PMC8219973 DOI: 10.3389/fneur.2021.686398] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/29/2021] [Indexed: 12/24/2022] Open
Abstract
Migraine is a disabling neurovascular disorder, characterized by moderate to severe unilateral headaches, nausea, photophobia, and/or phonophobia, with a higher prevalence in women than in men, which can drastically affect the quality of life of migraine patients. In addition, this chronic disorder is related with metabolic comorbidities associated with the patient's lifestyle, including obesity and diabetes mellitus (DM). Beyond the personal and socioeconomic impact caused by migraine, obesity and DM, it has been suggested that these metabolic disorders seem to be related to migraine since: (i) they are a risk factor for developing cardiovascular disorders or chronic diseases; (ii) they can be influenced by genetic and environmental risk factors; and (iii) while clinical and epidemiological studies suggest that obesity is a risk factor for migraine, DM (i.e., type 1 and type 2 DM) have been reported to be either a protective or a risk factor in migraine. On this basis, and given the high worldwide prevalence of migraine, obesity, and DM, this article provides a narrative review of the current literature related to the association between the etiology and pathophysiology of migraine and these metabolic disorders, considering lifestyle aspects, as well as the possible involvement of neurotransmitters, neuropeptides, and/or sex hormones. While a link between migraine and metabolic disorders has been suggested, many studies are contradictory and the mechanisms involved in this association are not yet sufficiently established. Therefore, further research should be focused on understanding the possible mechanisms involved.
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Affiliation(s)
- Eduardo Rivera-Mancilla
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
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Altered circadian feeding behavior and improvement of metabolic syndrome in obese Tac1-deficient mice. Int J Obes (Lond) 2017; 41:1798-1804. [PMID: 28775376 PMCID: PMC5716839 DOI: 10.1038/ijo.2017.185] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/28/2017] [Accepted: 07/22/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Metabolic function is regulated by the interplay of central and peripheral factors that ultimately regulate food intake and energy expenditure. The tachykinin substance P (SP) has been identified as a novel regulator of energy balance, however, the mechanisms underlying this effect are ill-defined and conflicting data regarding the role of SP on food intake have been reported by different groups. OBJECTIVE To further characterize the metabolic role of the Tac1 gene products (SP and neurokinin A (NKA)) in mice through a series of genetic, metabolic and behavioral studies in Tac1 deficient mice. RESULTS Tac1−/− mice are leaner than controls and display reduced food intake and altered feeding circadian rhythm, supported by disrupted expression of the clock genes Cry1/2, Per1/2 in the suprachiasmatic nucleus (SCN), medio-basal hypothalamus (MBH) and liver, as well as increased Pomc expression in the MBH. Tac1 ablation induced resistance to obesity, improved glucose tolerance, prevented insulin resistance under high-fat-diet, increased activation of brown adipose tissue and improved hepatic steatosis. Moreover, deletion of Tac1 in ob/ob mice ameliorated BW gain in females only but was sufficient to decrease fat and triglyceride content in the liver of males. CONCLUSIONS These results provide further evidence that Tac1 controls circadian feeding behavior and metabolism in mice through mechanisms that involve the regulation of the melanocortin system. In addition, these studies suggest that the blockade of SP may offer a new method to treat metabolic syndrome.
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Lui PPY. Tendinopathy in diabetes mellitus patients-Epidemiology, pathogenesis, and management. Scand J Med Sci Sports 2017; 27:776-787. [PMID: 28106286 DOI: 10.1111/sms.12824] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2016] [Indexed: 12/15/2022]
Abstract
Chronic tendinopathy is a frequent and disabling musculo-skeletal problem affecting the athletic and general populations. The affected tendon is presented with local tenderness, swelling, and pain which restrict the activity of the individual. Tendon degeneration reduces the mechanical strength and predisposes it to rupture. The pathogenic mechanisms of chronic tendinopathy are not fully understood and several major non-mutually exclusive hypotheses including activation of the hypoxia-apoptosis-pro-inflammatory cytokines cascade, neurovascular ingrowth, increased production of neuromediators, and erroneous stem cell differentiation have been proposed. Many intrinsic and extrinsic risk/causative factors can predispose to the development of tendinopathy. Among them, diabetes mellitus is an important risk/causative factor. This review aims to appraise the current literature on the epidemiology and pathology of tendinopathy in diabetic patients. Systematic reviews were done to summarize the literature on (a) the association between diabetes mellitus and tendinopathy/tendon tears, (b) the pathological changes in tendon under diabetic or hyperglycemic conditions, and (c) the effects of diabetes mellitus or hyperglycemia on the outcomes of tendon healing. The potential mechanisms of diabetes mellitus in causing and exacerbating tendinopathy with reference to the major non-mutually exclusive hypotheses of the pathogenic mechanisms of chronic tendinopathy as reported in the literature are also discussed. Potential strategies for the management of tendinopathy in diabetic patients are presented.
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Affiliation(s)
- P P Y Lui
- Headquarter, Hospital Authority, Hong Kong SAR, China
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Association between obesity and asthma - epidemiology, pathophysiology and clinical profile. Nutr Res Rev 2016; 29:194-201. [PMID: 27514726 DOI: 10.1017/s0954422416000111] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Obesity is a risk factor for asthma, and obese asthmatics have lower disease control and increased symptom severity. Several putative links have been proposed, including genetics, mechanical restriction of the chest and the intake of corticosteroids. The most consistent evidence, however, comes from studies of cytokines produced by the adipose tissue called adipokines. Adipokine imbalance is associated with both proinflammatory status and asthma. Although reverse causation has been proposed, it is now acknowledged that obesity precedes asthma symptoms. Nevertheless, prenatal origins of both conditions complicate the search for causality. There is a confirmed role of neuro-immune cross-talk mediating obesity-induced asthma, with leptin playing a key role in these processes. Obesity-induced asthma is now considered a distinct asthma phenotype. In fact, it is one of the most important determinants of asthma phenotypes. Two main subphenotypes have been distinguished. The first phenotype, which affects adult women, is characterised by later onset and is more likely to be non-atopic. The childhood obesity-induced asthma phenotype is characterised by primary and predominantly atopic asthma. In obesity-induced asthma, the immune responses are shifted towards T helper (Th) 1 polarisation rather than the typical atopic Th2 immunological profile. Moreover, obese asthmatics might respond differently to environmental triggers. The high cost of treatment of obesity-related asthma, and the burden it causes for the patients and their families call for urgent intervention. Phenotype-specific approaches seem to be crucial for the success of prevention and treatment.
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Yamaguchi R, Yamamoto T, Sakamoto A, Ishimaru Y, Narahara S, Sugiuchi H, Yamaguchi Y. Substance P enhances tissue factor release from granulocyte-macrophage colony-stimulating factor-dependent macrophages via the p22phox/β-arrestin 2/Rho A signaling pathway. Blood Cells Mol Dis 2016; 57:85-90. [PMID: 26852662 DOI: 10.1016/j.bcmd.2016.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 01/18/2016] [Indexed: 12/15/2022]
Abstract
Granulocyte-macrophage colony stimulating factor (GM-CSF) induces procoagulant activity of macrophages. Tissue factor (TF) is a membrane-bound glycoprotein and substance P (SP) is a pro-inflammatory neuropeptide involved in the formation of membrane blebs. This study investigated the role of SP in TF release by GM-CSF-dependent macrophages. SP significantly decreased TF levels in whole-cell lysates of GM-CSF-dependent macrophages. TF was detected in the culture supernatant by enzyme-linked immunosorbent assay after stimulation of macrophages by SP. Aprepitant (an SP/neurokinin 1 receptor antagonist) reduced TF release from macrophages stimulated with SP. Pretreatment of macrophages with a radical scavenger(pyrrolidinedithiocarbamate) also limited the decrease of TF in whole-cell lysates after stimulation with SP. A protein kinase C inhibitor (rottlerin) partially blocked this macrophage response to SP, while it was significantly inhibited by a ROCK inhibitor (Y-27632) or a dynamin inhibitor (dinasore). An Akt inhibitor (perifosine) also partially blocked this response. Furthermore, siRNA targeting p22phox, β-arrestin 2, or Rho A, blunted the release of TF from macrophages stimulated with SP. In other experiments, visceral adipocytes derived from cryopreserved preadipocytes were found to produce SP. In conclusion, SP enhances the release of TF from macrophages via the p22phox/β-arrestin 2/Rho A signaling pathway.
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Affiliation(s)
- Rui Yamaguchi
- Graduate School of Medical Science, Kumamoto Health Science University, Kumamoto, Japan; Graduate School of Medical Science, Kumamoto University Medical School, Kumamoto, Japan
| | - Takatoshi Yamamoto
- Graduate School of Medical Science, Kumamoto Health Science University, Kumamoto, Japan
| | - Arisa Sakamoto
- Graduate School of Medical Science, Kumamoto Health Science University, Kumamoto, Japan
| | - Yasuji Ishimaru
- Graduate School of Medical Science, Kumamoto Health Science University, Kumamoto, Japan
| | - Shinji Narahara
- Graduate School of Medical Science, Kumamoto Health Science University, Kumamoto, Japan
| | - Hiroyuki Sugiuchi
- Graduate School of Medical Science, Kumamoto Health Science University, Kumamoto, Japan
| | - Yasuo Yamaguchi
- Graduate School of Medical Science, Kumamoto Health Science University, Kumamoto, Japan
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Dubon MJ, Byeon Y, Park KS. Substance P enhances the activation of AMPK and cellular lipid accumulation in 3T3‑L1 cells in response to high levels of glucose. Mol Med Rep 2015; 12:8048-54. [PMID: 26499365 PMCID: PMC4758299 DOI: 10.3892/mmr.2015.4453] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 09/25/2015] [Indexed: 12/25/2022] Open
Abstract
The rescue of glucose tolerance and insulin-sensitivity in peripheral tissues, including adipose tissue, is essential in therapeutic strategies for diabetes. The present study demonstrated that substance P (SP) increases the accumulation of lipids in 3T3-L1 cells during their differentiation into adipocytes in response to a high concentration of glucose. SP reciprocally regulated the activities of AMP-activated protein kinase (AMPK) and Akt: SP enhanced the activation of AMPK, although the activity of Akt was downregulated. Notably, SP induced an increase in the expression level of glucose transporter 4 in the 3T3-L1 adipocytes. Therefore, it is possible that SP leads to an increase in glucose uptake and the accumulation of lipids in adipocytes, and may contribute towards the rescue of insulin-sensitivity in diabetes.
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Affiliation(s)
- Maria Jose Dubon
- Department of Genetic Engineering, Graduate School of Biotechnology, Kyung Hee University, Yongin, Gyeonggi 17104, Republic of Korea
| | - Yeji Byeon
- Department of Genetic Engineering, Graduate School of Biotechnology, Kyung Hee University, Yongin, Gyeonggi 17104, Republic of Korea
| | - Ki-Sook Park
- East‑West Medical Research Institute, Kyung Hee University, Seoul 02447, Republic of Korea
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Abstract
Dipeptidyl-peptidase 4 (DPP4) is a glycoprotein of 110 kDa, which is ubiquitously expressed on the surface of a variety of cells. This exopeptidase selectively cleaves N-terminal dipeptides from a variety of substrates, including cytokines, growth factors, neuropeptides, and the incretin hormones. Expression of DPP4 is substantially dysregulated in a variety of disease states including inflammation, cancer, obesity, and diabetes. Since the incretin hormones, glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide (GIP), are major regulators of post-prandial insulin secretion, inhibition of DPP4 by the gliptin family of drugs has gained considerable interest for the therapy of type 2 diabetic patients. In this review, we summarize the current knowledge on the DPP4–incretin axis and evaluate most recent findings on DPP4 inhibitors. Furthermore, DPP4 as a type II transmembrane protein is also known to be cleaved from the cell membrane involving different metalloproteases in a cell-type-specific manner. Circulating, soluble DPP4 has been identified as a new adipokine, which exerts both para- and endocrine effects. Recently, a novel receptor for soluble DPP4 has been identified, and data are accumulating that the adipokine-related effects of DPP4 may play an important role in the pathogenesis of cardiovascular disease. Importantly, circulating DPP4 is augmented in obese and type 2 diabetic subjects, and it may represent a molecular link between obesity and vascular dysfunction. A critical evaluation of the impact of circulating DPP4 is presented, and the potential role of DPP4 inhibition at this level is also discussed.
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Affiliation(s)
- Diana Röhrborn
- Paul-Langerhans-Group for Integrative Physiology, German Diabetes Center , Düsseldorf , Germany
| | - Nina Wronkowitz
- Paul-Langerhans-Group for Integrative Physiology, German Diabetes Center , Düsseldorf , Germany
| | - Juergen Eckel
- Paul-Langerhans-Group for Integrative Physiology, German Diabetes Center , Düsseldorf , Germany
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Reduction of soluble CD163, substance P, programmed death 1 and inflammatory markers: phase 1B trial of aprepitant in HIV-1-infected adults. AIDS 2015; 29:931-9. [PMID: 25915168 PMCID: PMC4472318 DOI: 10.1097/qad.0000000000000638] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We evaluated safety, antiviral, immunomodulatory and anti-inflammatory properties of aprepitant - a neurokinin 1 receptor antagonist. DESIGN Phase IB randomized, placebo-controlled, double-blinded study. METHODS Eighteen patients were randomized (nine to aprepitant and nine to placebo). The patients received once-daily treatment (375 mg aprepitant or placebo by oral administration) for 2 weeks and were followed off drug for 4 weeks. RESULTS There were no significant changes in the plasma viremia or CD4(+) T cells during the dosing period. Aprepitant treatment was associated with significant decreases of median within patient change in percentages of CD4(+) T cells expressing programmed death 1 (-4.8%; P = 0.04), plasma substance P (-34.0 pg/ml; P = 0.05) and soluble CD163 (-563 ng/ml; P = 0.02), with no significant changes in the placebo arm. Mean peak aprepitant plasma concentration on day 14 was 7.6 ± 3.1 μg/ml. The use of aprepitant was associated with moderate increases in total cholesterol, low-density lipoprotein and high-density lipoprotein (median change = +31 mg/dl, P = 0.01; +26 mg/dl, P = 0.02; +3 mg/dl, P = 0.02, respectively). CONCLUSION Aprepitant was safe and well tolerated. At the dose used in this proof-of-concept phase IB study, aprepitant did not show a significant antiviral activity. Aprepitant-treated patients had decreased numbers of CD4(+) programmed death 1-positive cells and decreased plasma levels of substance P and soluble CD163, suggesting that blockade of the neurokinin 1 receptor pathway has a role in modulating monocyte activation in HIV infection. Prospective studies in virologically-suppressed individuals are warranted to evaluate the immunomodulatory properties of aprepitant. Exposures exceeding those attained in this trial are more likely to elicit clinical benefit.
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Mehboob R, Tanvir I, Warraich RA, Perveen S, Yasmeen S, Ahmad FJ. Role of neurotransmitter Substance P in progression of oral squamous cell carcinoma. Pathol Res Pract 2014; 211:203-7. [PMID: 25433994 DOI: 10.1016/j.prp.2014.09.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 08/06/2014] [Accepted: 09/12/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Oral squamous cell carcinoma (OSCC) is the most frequent type of head and neck cancers. OBJECTIVES In the present study, we evaluated the expression and distribution of Substance P (SP) in different grades of OSCC and role of SP in its proliferation and progression. SUBJECTS AND METHODS Forty OSCC biopsies were immunohistochemically analyzed by using SP antibody, including 29 male and 11 female cases. 35% were well differentiated, 35% moderately differentiated and 30% poorly differentiated OSCC. The majority of patients were in the age range of 41-80 years. 62% of the cases were positive for SP. SP positivity was expressed in the cytoplasm of the tumor cells. Most of the positive cases were from the tongue region. RESULTS 93% of moderately differentiated, 92% of poorly differentiated and 8% of well-differentiated carcinomas were SP-positive, but SP expression intensity was highest in poorly differentiated cases (+3). More positive patients were males (68.96% of all male patients) with moderately and poorly differentiated OSCC. Among all positive cases, 48% were poorly differentiated, 48% moderately differentiated and 4% well differentiated. CONCLUSION Strong expression of SP in poorly and moderately differentiated cases suggests a role of SP in the progression and development of tumor. Expression of SP in the current study increased as the proliferation of cells increased. Prevalence of oral cancer in males may be due to the fact that they smoke and use pan, chewing gum, beetle nut etc. in this region. SP antagonists can help in the reduction and inhibition of oral cancer. SP has a diagnostic value with sensitivity of 92.5% and specificity of 93.7%. The positive predictive value is 96.2% and the negative predictive value 88.2%.
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Affiliation(s)
- Riffat Mehboob
- Department of Biomedical Sciences, King Edward Medical University, Lahore, Pakistan.
| | - Imrana Tanvir
- Department of Pathology, Fatima Memorial College of Medicine and Dentistry, Lahore, Pakistan
| | - Riaz Ahmad Warraich
- Department of Oral and Maxillofacial Surgery, King Edward Medical University/Mayo Hospital, Lahore, Pakistan
| | - Shahida Perveen
- Department of Pathology, King Edward Medical University, Lahore, Pakistan
| | - Sehrish Yasmeen
- Center for Research in Molecular Medicine, University of Lahore, Pakistan
| | - Fridoon Jawad Ahmad
- Department of Biomedical Sciences, King Edward Medical University, Lahore, Pakistan
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Devin JK, Pretorius M, Nian H, Yu C, Billings FT, Brown NJ. Substance P increases sympathetic activity during combined angiotensin-converting enzyme and dipeptidyl peptidase-4 inhibition. Hypertension 2014; 63:951-7. [PMID: 24516103 DOI: 10.1161/hypertensionaha.113.02767] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
UNLABELLED Dipeptidyl peptidase-4 inhibitors prevent the degradation of incretin hormones and reduce postprandial hyperglycemia in patients with type 2 diabetes mellitus. Dipeptidyl peptidase-4 degrades other peptides with a penultimate proline or alanine, including bradykinin and substance P, which are also substrates of angiotensin-converting enzyme (ACE). During ACE inhibition, substance P is inactivated primarily by dipeptidyl peptidase-4, whereas bradykinin is first inactivated by aminopeptidase P. This study tested the hypothesis that dipeptidyl peptidase-4 inhibition potentiates vasodilator and fibrinolytic responses to substance P when ACE is inhibited. Twelve healthy subjects participated in this randomized, double-blinded, placebo-controlled crossover study. On each study day, subjects received sitagliptin 200 mg by mouth or placebo. Substance P and bradykinin were infused via brachial artery before and during intra-arterial enalaprilat. Sitagliptin and enalaprilat each reduced forearm vascular resistance and increased forearm blood flow without affecting mean arterial pressure, but there was no interactive effect of the inhibitors. Enalaprilat increased bradykinin-stimulated vasodilation and tissue plasminogen activator release; sitagliptin did not affect these responses to bradykinin. The vasodilator response to substance P was unaffected by sitagliptin and enalaprilat; however, substance P increased heart rate and vascular release of norepinephrine during combined ACE and dipeptidyl peptidase-4 inhibition. In women, sitagliptin diminished tissue plasminogen activator release in response to substance P both alone and during enalaprilat. Substance P increases sympathetic activity during combined ACE and dipeptidyl peptidase-4 inhibition. CLINICAL TRIAL REGISTRATION - URL: http://www.clinicaltrials.gov. Unique identifier: NCT01413542.
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Affiliation(s)
- Jessica K Devin
- Division of Diabetes, Endocrinology and Metabolism, 7465 MRB4, 2213 Garland Ave, Nashville, TN 37232.
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17
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Guerrero-Romero F, Simental-Mendía LE, Rodríguez-Morán M. Association of C-reactive protein levels with fasting and postload glucose levels according to glucose tolerance status. Arch Med Res 2013; 45:70-5. [PMID: 24326321 DOI: 10.1016/j.arcmed.2013.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 10/30/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Several studies show that high serum C-reactive protein (CRP) levels are associated with an increased risk of diabetes, data that strongly supports a possible role for inflammation in diabetogenesis. The aim of this study was to determine whether elevated CRP levels are associated with fasting plasma glucose (FPG) and/or postload glucose levels according to the glucose tolerance status. METHODS A total of 169 healthy males and non-pregnant females aged 18-65 years were enrolled in a population-based cross-sectional study. Individuals were allocated into groups with a new diagnosis of normal glucose tolerance (NGT) (n = 82), impaired fasting glucose (IFG) (n = 54), and impaired glucose tolerance (IGT) (n = 33). Elevated CRP was defined by CRP levels >3.0 and <10.0 mg/L, IFG by FPG ≥100 and <126 mg/dL, and IGT by plasma glucose concentration 2 h postload ≥140 and <200 mg/dL. A multiple regression linear analysis adjusted by body mass index, waist circumference, and lipid profile was performed to evaluate the association between CRP levels (independent variable) with FPG and 2 h postload glucose levels (dependent variables). RESULTS Multivariate linear regression analysis showed a significant association between hsCRP levels with FPG (β = 0.536; 95% CI 1.03-5.1, p = 0.005) and 2 h postload glucose (β = 0.209; 95% CI 1.31-2.97, p = 0.01) in the IGT group, but not with FPG (β = 0.147; 95% CI 0.55-2.0, p = 0.25) and 2 h postload glucose (β = 0.151; 95% CI 0.83-3.2, p = 0.24) in the IFG group. CONCLUSIONS Elevated CRP levels are associated with FPG and 2 h postload glucose in the individuals with IGT, but not in subjects with IFG or NGT.
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Affiliation(s)
- Fernando Guerrero-Romero
- Biomedical Research Unit, Mexican Social Security Institute, Durango, Mexico, and General Hospital, Secretary of Health, Durango, Mexico
| | - Luis E Simental-Mendía
- Biomedical Research Unit, Mexican Social Security Institute, Durango, Mexico, and General Hospital, Secretary of Health, Durango, Mexico.
| | - Martha Rodríguez-Morán
- Biomedical Research Unit, Mexican Social Security Institute, Durango, Mexico, and General Hospital, Secretary of Health, Durango, Mexico
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Miegueu P, St-Pierre DH, Lapointe M, Poursharifi P, Lu H, Gupta A, Cianflone K. Substance P decreases fat storage and increases adipocytokine production in 3T3-L1 adipocytes. Am J Physiol Gastrointest Liver Physiol 2013; 304:G420-7. [PMID: 23257919 DOI: 10.1152/ajpgi.00162.2012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Obesity, inflammation, and insulin resistance are closely linked. Substance P (SP), via its neurokinin 1 receptor (NK1R), mediates inflammatory and, possibly, neuroendocrine processes. We examined SP effects on lipid storage and cytokine production in 3T3-L1 adipocytes and adipose tissues. 3T3-L1 adipocytes and preadipocytes express NK1R, and 8 days of SP supplementation during differentiation to 3T3-L1 preadipocytes decreased lipid droplet accumulation. SP (10 nM, 24 h) increased lipolysis in primary adipocytes (138 ± 7%, P < 0.05) and reduced fatty acid uptake (-31 ± 7%, P < 0.05) and mRNA expression of the differentiation-related transcription factors peroxisome proliferator-activated receptor-γ type 2 (-64 ± 2%, P < 0.001) and CCAAT enhancer-binding protein (CEBP)-α (-65 ± 2%, P < 0.001) and the lipid storage genes fatty acid-binding protein type 4 (-59 ± 2%, P < 0.001) and diacylglycerol O-acyltransferase-1 (-45 ± 2%, P < 0.01) in 3T3-L1 adipocytes, while CD36, a fatty acid transporter (+82 ± 19%, P < 0.01), was augmented. SP increased secretion of complement C3 (148 ± 15%, P < 0.04), monocyte chemoattractant protein-1 (156 ± 16%, P < 0.03), and keratinocyte-derived chemokine (148 ± 18%, P = 0.045) in 3T3-L1 adipocytes and monocyte chemoattractant protein-1 (496 ± 142%, P < 0.02) and complement C3 (152 ± 25%, P < 0.04) in adipose tissue and primary adipocytes, respectively. These SP effects were accompanied by downregulation of insulin receptor substrate 1 (-82 ± 2%, P < 0.01) and GLUT4 (-76 ± 2%, P < 0.01) mRNA expression, and SP acutely blocked insulin-mediated stimulation of fatty acid uptake and Akt phosphorylation. Although adiponectin secretion was unchanged, mRNA expression was decreased (-86 ± 8%, P < 0.001). In humans, NK1R expression correlates positively with plasma insulin, fatty acid, and complement C3 and negatively with adiponectin, CEBPα, CEBPβ, and peroxisome proliferator-activated receptor-γ mRNA expression in omental, but not subcutaneous, adipose tissue. Our results suggest that, beyond its neuroendocrine and inflammatory effects, SP could also be involved in targeting adipose tissue and influencing insulin resistance.
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Affiliation(s)
- Pierre Miegueu
- Centre de Recherche Institut Universitaire de Cardiologie and Pneumologie de Quebec and Department of Medicine, Université Laval, Quebec, Quebec, Canada
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Ramalho R, Almeida J, Beltrão M, Pirraco A, Costa R, Sokhatska O, Guardão L, Palmares C, Guimarães JT, Delgado L, Moreira A, Soares R. Substance P antagonist improves both obesity and asthma in a mouse model. Allergy 2013; 68:48-54. [PMID: 23176443 DOI: 10.1111/all.12052] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence suggests a causal relationship between obesity and asthma; however, the underlying mechanisms remain unknown. Substance P (SP), involved in neurogenic inflammation by acting through its receptor NK1-R, seems to participate in obese-asthma phenotype in mice. OBJECTIVES To evaluate the effect of a selective substance P receptor antagonist on a mouse model of diet-induced obesity and asthma. METHODS Diet-induced obese Balb/c mice were sensitized and challenged with ovalbumin (OVA) and treated with a selective NK1-R antagonist or placebo. Serum glucose, insulin, IL-6, resistin, and OVA-specific IgE levels were quantified. A score for peribronchial inflammation in lung histology was used. Cells were counted in bronchoalveolar lavage fluid. Adipocyte sizes were measured. RESULTS Ovalbumin-obese mice treated with NK1-R antagonist had lower weight (P = 0.0002), reduced daily food intake (P = 0.0021), reduced daily energy intake (P = 0.0021), reduced surface adipocyte areas (P < 0.0001), lower serum glucose (P = 0.04), lower serum insulin (P = 0.03), lower serum IL-(P = 0.0022), lower serum resistin (P = 0.0043), lower serum OVA-specific IgE (P = 0.035), and lower peribronchial inflammation score (P < 0.0001) than nontreated OVA-obese mice. We observed an interaction between obesity, allergen sensitization, and treatment with NK1-R antagonist for metabolic and systemic biomarkers, and for allergen sensitization and bronchial inflammation, showing a synergy between these variables. CONCLUSION & CLINICAL RELEVANCE In an experimental model of obesity and asthma in mice, NK1-R blockade improved metabolic and systemic biomarkers, as well as allergen sensitization and bronchial inflammation. These positive effects support a common pathway in the obese-asthma phenotype and highlight SP as a target with potential clinical interest in the obese-asthma epidemics.
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Affiliation(s)
- R. Ramalho
- Immunology; Faculty of Medicine; University of Porto; Porto; Portugal
| | - J. Almeida
- Ciências Químicas e das Biomoléculas; Escola Superior de Tecnologia da Saúde do Porto; Instituto Politécnico do Porto; Porto; Portugal
| | - M. Beltrão
- Immunology; Faculty of Medicine; University of Porto; Porto; Portugal
| | - A. Pirraco
- Biochemistry (U38-FCT); Faculty of Medicine; University of Porto; Porto; Portugal
| | - R. Costa
- Biochemistry (U38-FCT); Faculty of Medicine; University of Porto; Porto; Portugal
| | - O. Sokhatska
- Immunology; Faculty of Medicine; University of Porto; Porto; Portugal
| | - L. Guardão
- Animal House Unit; Faculty of Medicine; University of Porto; Porto; Portugal
| | - C. Palmares
- Immunology; Faculty of Medicine; University of Porto; Porto; Portugal
| | | | | | | | - R. Soares
- Biochemistry (U38-FCT); Faculty of Medicine; University of Porto; Porto; Portugal
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Ramalho R, Almeida J, Beltrão M, Pirraco A, Costa R, Sokhatska O, Guardão L, Palmares C, Guimarães JT, Delgado L, Moreira A, Soares R. Neurogenic inflammation in allergen-challenged obese mice: A missing link in the obesity-asthma association? Exp Lung Res 2012; 38:316-24. [PMID: 22734814 DOI: 10.3109/01902148.2012.699589] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AIM A number of studies have shown an association between obesity and asthma. Controversy remains on the mechanisms supporting this association. In this study we aimed to assess neurogenic inflammation in a model of diet-induced obesity and allergen-challenged mice. METHODS High fat diet-induced (HFD) obese Balb/c mice were sensitized and challenged with ovalbumin (OVA). Glucose, insulin, OVA-specific IgE and substance P (SP), and the main tachykinin involved in neurogenic inflammation, were quantified in sera. Cell counts were performed in bronchoalveolar lavage fluid (BALF). The extent of peribronchial infiltrates was estimated on lung tissue sections and inflammation was score based on inflammatory cell counts surrounding the bronchi. RESULTS Obesity per se and allergen-sensitization per se increased serum SP (P = .027, P = .004, respectively). Further increased was observed in obese-sensitized mice (P = .007). Obese-sensitized mice also showed higher insulin (P = .0016), OVA-specific IgE (P = .016), peribronchial inflammatory score (P = .045), and tendency for higher glycemia. The interaction of obesity and asthma on SP levels was confirmed (P = .005, R(2) = 0.710). SP was positively correlated with metabolic (glycemia, r = 0.539, P = .007) and allergic inflammation parameters (BALF eosinophils, r = 0.445, P = 0.033; BALF mast cells, r = 0.574, P = .004; peribronchial inflammation score, r = 0.661, P < .001; and OVA-specific IgE, r = 0.714, P < .001). CONCLUSIONS Our findings provide support to the neurogenic inflammation link between obesity and asthma in mice. These two conditions independently increased SP and the presence of both pathologies further increased this level. Neurogenic inflammation may be a previously unrecognized mechanism beyond the obese-asthma phenotype. Further studies are need to confirm this role of SP in human obesity-asthma association.
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Affiliation(s)
- Renata Ramalho
- Department of Immunology, Faculty of Medicine, University of Porto, Porto, Portugal.
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