Psychological stress, vascular inflammation, and atherogenesis: potential roles of circulating cytokines

Alopecia and Periodontitis: Exploring the connecting dots

Alopecia areata is a systemic disease with nonscarring hair loss from the scalp, face, or any part of the body. The disease with undetermined etiology and pathogenesis has a considerable impact on the social life of patients which gradually builds up stress and expedites further deterioration of their condition. Interestingly, in such patients, besides stress-relieving exercises and immunomodulators, well-timed dental assessment and prompt treatment have contributed to improving the prognosis of alopecia. This depicts an interrelationship between alopecia and oral foci of infections. Over the past few decades, periodontitis has remained to be one of the predominant forms of oral focus of infection for systemic diseases. The present review throws light on the role of stress and autoimmunity in establishing a possible correlation between alopecia and periodontitis. It is augmented with documented case reports, demanding a complete oral examination in patients with the unexplained origin of alopecia. An interdisciplinary approach is the need of the hour which can prevent the progression of both the diseases as well as other oral infections.

Understanding the relationships between physiological and psychosocial stress, cortisol and cognition

Stress is viewed as a state of real or perceived threat to homeostasis, the management of which involves the endocrine, nervous, and immune systems. These systems work independently and interactively as part of the stress response. The scientific stress literature, which spans both animal and human studies, contains heterogeneous findings about the effects of stress on the brain and the body. This review seeks to summarise and integrate literature on the relationships between these systems, examining particularly the roles of physiological and psychosocial stress, the stress hormone cortisol, as controlled by the hypothalamic-pituitary-adrenal (HPA) axis, and the effects of stress on cognitive functioning. Health conditions related to impaired HPA axis functioning and their associated neuropsychiatric symptoms will also be considered. Lastly, this review will provide suggestions of clinical applicability for endocrinologists who are uniquely placed to measure outcomes related to endocrine, nervous and immune system functioning and identify areas of intervention.

An integrated cytokine and kynurenine network as the basis of neuroimmune communication

Two of the molecular families closely associated with mediating communication between the brain and immune system are cytokines and the kynurenine metabolites of tryptophan. Both groups regulate neuron and glial activity in the central nervous system (CNS) and leukocyte function in the immune system, although neither group alone completely explains neuroimmune function, disease occurrence or severity. This essay suggests that the two families perform complementary functions generating an integrated network. The kynurenine pathway determines overall neuronal excitability and plasticity by modulating glutamate receptors and GPR35 activity across the CNS, and regulates general features of immune cell status, surveillance and tolerance which often involves the Aryl Hydrocarbon Receptor (AHR). Equally, cytokines and chemokines define and regulate specific populations of neurons, glia or immune system leukocytes, generating more specific responses within restricted CNS regions or leukocyte populations. In addition, as there is a much larger variety of these compounds, their homing properties enable the superimposition of dynamic variations of cell activity upon local, spatially limited, cell populations. This would in principle allow the targeting of potential treatments to restricted regions of the CNS. The proposed synergistic interface of 'tonic' kynurenine pathway affecting baseline activity and the superimposed 'phasic' cytokine system would constitute an integrated network explaining some features of neuroimmune communication. The concept would broaden the scope for the development of new treatments for disorders involving both the CNS and immune systems, with safer and more effective agents targeted to specific CNS regions.

Profile of IL-6 and TNF in Foam Cell Formation: An Improved Method Using Fluorescein Isothiocyanate (FITC) Probe

BACKGROUND

The formation of foam cells occurs due to the increase in low-density plasma lipoprotein (LDL) and dysregulation of inflammation, which is important for the development of atherosclerosis.

OBJECTIVE

To evaluate the profile of tumor necrosis factor-alpha (TNF-α) and Interleukin-6 (IL-6) in the existing foam cell formation method, optimizing this protocol.

METHODS

The LDL was isolated, oxidized, and labeled with a Fluorescein isothiocyanate (FITC) probe. Foam cells were generated from THP-1 human monocyte-derived cells and incubated in the absence (control) or presence of FITC-ox-LDL (10, 50, 100, 150, or 200 μg/mL), for 12, 24, 48, or 72 hours. The accumulated FITC-ox-LDL in the cell was quantified by microscopy. The enzyme-linked immunosorbent assay was evaluated to quantify the IL-6 and TNF-α, with p < 0.05 considered significant.

RESULTS

All the FITC-ox-LDL concentrations tested showed a higher fluorescence when compared to the control, showing a greater accumulation of lipoprotein in cells. The higher the concentration of FITC-ox-LDL, the greater the production of TNF-α and IL-6. The production of IL-6 by foam cells was detected up to the value of 150 µg/mL of the maximum stimulus for LDL. Concentrations above 50 μg/mL LDL stimulated greater release of TNF-α compared to control.

CONCLUSIONS

Our model contributes to the understanding of the release of IL-6 and TNF-α in response to different concentrations of ox-LDL, using an optimized method for the formation of foam cells.

Racial Disparities in Ion Channelopathies and Inherited Cardiovascular Diseases Associated With Sudden Cardiac Death

Cardiovascular disease (CVD) continues to be the most common cause of death worldwide, and cardiac arrhythmias account for approximately one half of these deaths. The morbidity and mortality from CVD have been reduced significantly over the past few decades; however, disparities in racial or ethnic populations still exist. This review is based on available literature to date and focuses on known cardiac channelopathies and other inherited disorders associated with sudden cardiac death in African American/Black subjects and the role of epigenetics in phenotypic manifestations of CVD, and illustrates existing disparities in treatment and outcomes. The review also highlights the knowledge gaps that limit understanding of the manifestation of phenotypic abnormalities across racial or ethnic groups and discusses disparities associated with device underuse in the management of patients at risk for sudden cardiac death. We discuss factors related to reports in the United States, that the overall mortality attributed to CVD and the number of out‐of‐hospital cardiac arrests are higher among African American/Black subjects when compared with other racial or ethnic groups. African American/Black subjects are disproportionally affected by CVD, including cardiac arrhythmias and sudden cardiac death, thus highlighting a major concern in this population that remains underrepresented in clinical trials with limited genetic testing and device underuse. The proposed solutions include (1) early identification of genetic variants, which is crucial in tailoring a preventive management strategy; (2) inclusion of diverse racial or ethnic groups in clinical trials; (3) compliance with guideline‐directed medical treatment and referral to cardiovascular subspecialists; and (4) training and mentoring of underrepresented junior faculty in cardiovascular health disparities research.

The Role of Mental Stress in Ischaemia with No Obstructive Coronary Artery Disease and Coronary Vasomotor Disorders

Ischaemic heart disease has been estimated to affect 126.5 million people globally. Approximately 70% of patients with angina and suspected myocardial ischaemia show no signs of obstructed coronary arteries after coronary angiography, but may still demonstrate ischaemia. Ischaemia with no obstructive coronary artery disease (INOCA) is increasingly acknowledged as a serious condition because of its association with poor quality of life and elevated risk for cardiovascular events. The negative effects of psychological stress on INOCA are gaining more attention. Psychological stress is associated with adverse cardiovascular outcomes such as mental stress-induced myocardial ischaemia. Psychological stress includes anxiety, depression, anger and personality disturbances. Coronary microvascular dysfunction and coronary arterial spasm are phenotypes of coronary vasomotor disorders that are triggered by psychological distress and depression, thereby increasing cardiovascular disease risk. Coronary vasomotor disorders are often co-existent in INOCA patients and might be considered as a contributing factor to mental stress-associated adverse cardiovascular outcomes. Additionally, psychological stress induces endothelial dysfunction more often in (young) women with INOCA than in men. Overall, many studies demonstrate an association between mental stress, coronary microvascular dysfunction and coronary vasospasm in patients with INOCA - especially women. Future research on stress-reducing therapies that target coronary vasomotor disorders in patients with INOCA is needed. This is particularly the case in young adolescents, in whom this type of ischaemic heart disease is increasing.

Effect of long work hours and shift work on high-sensitivity C-reactive protein levels among Korean workers

Objective We aimed to investigate the association between low-grade inflammation as indicated by high-sensitivity C-reactive protein (hsCRP) level and organizational factors, such as work hours and shift work. Methods We evaluated 7470 young and middle-aged workers who participated in the Korea National Health and Nutrition Examination Surveys from 2015-2018. Work hours were determined from self-reported questionnaires. Shift work was defined as a non-daytime fixed work schedule. An interaction effect between shift work and long work hours on the hsCRP level was estimated using relative excess risk due to interaction (RERI) and attributable proportion (AP) with 95% confidence intervals (CI). Results Increased hsCRP levels were prevalent in 25.2% of the study population. There was a significant association between long work hours and increased hsCRP, especially among middle-aged men [odds ratio (OR) 1.50 (95% CI 1.20-1.87) for moderately increased hsCRP and OR 1.62 (95% CI 1.14-2.30) for highly increased hsCRP]. There was a significant interaction effect between long work hours and shift work on increased hsCRP among middle-aged workers. The RERI were 0.03 (95% CI 0.02-0.04) and 0.56 (95% CI 0.45-0.68) among middle-aged men and women, respectively. The AP were 0.02 (95% CI 0.01-0.03) and 0.36 (95% CI 0.31-0.40) among middle-aged men and women, respectively. Conclusion There was no significant association between shift work and the level of hsCRP. Long work hours were related to low-grade inflammatory processes, but only in middle-aged workers. There was an interaction effect between long work hours and shift work for increased hsCRP, especially in middle-aged women.

Sex differences in the inflammatory response to stress and risk of adverse cardiovascular outcomes among patients with coronary heart disease

Stress may contribute to progression of coronary heart disease (CHD) through inflammation, especially among women. Thus, we sought to examine whether increased inflammatory response to stress among patients with CHD is associated with a greater risk of cardiovascular events and whether this risk is higher in women. We examined inflammatory biomarkers known to increase with mental stress (speech task), including interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), and matrix metallopeptidase-9 (MMP-9) among 562 patients with stable CHD. Inflammatory response, the difference between post-stress and resting values, was examined as a predictor of major adverse cardiovascular events (MACE) using subdistribution hazards models for competing risks adjusting for demographics, cardiovascular risk factors, and medications. MACE was defined as a composite endpoint of cardiovascular death, myocardial infarction, unstable angina with revascularization, and heart failure. All biomarkers were standardized. The mean age was 63 years (range 34-79) and 24% were women. During a median follow-up of 3 years, 71 patients experienced MACE. Overall, there was no significant association between inflammatory response to stress and risk of MACE, but there were sex-based interactions for IL-6 (p = 0.001) and MCP-1 (p = 0.01). The risk of MACE increased 56% (HR: 1.56; 95% CI: 1.21, 2.01; p = 0.001) and 30% (HR: 1.30; 95% 1.09, 1.55; p = 0.004) for each standard deviation increase in IL-6 and MCP-1 response to mental stress for women, respectively, while there was no association among men. Increased inflammation in response to stress is associated with future adverse cardiovascular outcomes among women with CHD.

A Paradoxical Vasodilatory Nutraceutical Intervention for Prevention and Attenuation of Migraine-A Hypothetical Review

Studies suggest that migraine pain has a vascular component. The prevailing dogma is that peripheral vasoconstriction activates baroreceptors in central, large arteries. Dilatation of central vessels stimulates nociceptors and induces cortical spreading depression. Studies investigating nitric oxide (NO) donors support the indicated hypothesis that pain is amplified when acutely administered. In this review, we provide an alternate hypothesis which, if substantiated, may provide therapeutic opportunities for attenuating migraine frequency and severity. We suggest that in migraines, heightened sympathetic tone results in progressive central microvascular constriction. Suboptimal parenchymal blood flow, we suggest, activates nociceptors and triggers headache pain onset. Administration of NO donors could paradoxically promote constriction of the microvasculature as a consequence of larger upstream central artery vasodilatation. Inhibitors of NO production are reported to alleviate migraine pain. We describe how constriction of larger upstream arteries, induced by NO synthesis inhibitors, may result in a compensatory dilatory response of the microvasculature. The restoration of central capillary blood flow may be the primary mechanism for pain relief. Attenuating the propensity for central capillary constriction and promoting a more dilatory phenotype may reduce frequency and severity of migraines. Here, we propose consideration of two dietary nutraceuticals for reducing migraine risk: L-arginine and aged garlic extracts.

An evidence of brain-heart disorder: mental stress-induced myocardial ischemia regulated by inflammatory cytokines

OBJECTIVE

Underlying Coronary Artery Disease (CAD) complicated by Mental Stress-Induced Myocardial Ischemia (MSIMI) has been linked with an increased risk for adverse cardiovascular events and even sudden death. However, the underlying mechanisms of MSIMI remain unknown. In this study, we investigated cytokine levels at baseline inflammation status and during acute inflammatory responses to mental stress in patients with known CAD who presented with MSIMI.

METHOD

77 patients with known CAD were recruited and all underwent echocardiography before and during arithmetic stress task. MSIMI was diagnosed by new or worsening wall motion abnormalities greater than or equal to a 5% reduction of left ventricle ejection fraction. Inflammatory markers were measured both before and immediately after the Mental Stress (MS) by ELISA kits. Repeated measures models were used to report the responses and mixed linear regression models were used to report the differences between MSIMI negative and positive patients.

RESULT

MS induced a significant increase in Stromal Cell-Derived Factor-1α (SDF-1α) and Monocyte Chemoattractant Protein-1 (MCP-1) in all subjects; 20.78% of the patients with known CAD developed MSIMI during the arithmetic task. MSIMI positive patients had significantly lower baseline levels of Interleukin-1β (IL-1β) and Tumor Necrosis Factor-α (TNF-α), but a higher response in levels of SDF-1α than MSIMI negative patients.

CONCLUSION

MS can induce acute inflammatory responses. MSIMI is associated with lower levels of IL-1β and TNF-α at baseline and higher levels of SDF-1α in response to MS.

Evidence-Informed strategies for promoting equitability in brownfields redevelopment

Brownfields redevelopment creates opportunities for enhanced environmental conditions, improved physical and mental health, community cohesion, and economic prosperity. However, brownfields cleanup and recycling projects sometimes fail due to a lack of community engagement. Recent research suggests that such failures can stem from a lack of equitability in the planning process, especially when it comes to decision making. This paper examines issues of equitability in a recent brownfields redevelopment project in Tampa, Florida funded by the U.S. Environmental Protection Agency. The project focused on an underserved and under-resourced community with long-term environmental burdens and health disparities. Our ethnographic research shows that, while the project engaged in multiple and intersecting efforts to include a diversity of community voices in the decision-making process, ultimately structural and organizational power imbalances in sustainability transitions influenced participation in redevelopment initiatives. This study suggests that attending to issues of power articulated through expressions of local and authoritative knowledge about environmental cleanup and redevelopment can lead to deeper levels of community engagement.

Associations between community well-being and hospitalisation rates: results from a cross-sectional study within six US states

OBJECTIVE

To evaluate the association between community well-being, a positively framed, multidimensional assessment of the health and quality of life of a geographic community, and hospitalisation rates.

DESIGN

Cross-sectional study SETTING: Zip codes within six US states (Florida, Iowa, Nebraska, New York, Pennsylvania and Utah) MAIN OUTCOME MEASURES: Our primary outcome was age-adjusted, all-cause hospitalisation rates in 2010; secondary outcomes included potentially preventable disease-specific hospitalisation rates, including cardiovascular-related, respiratory-related and cancer-related admissions. Our main independent variable was the Gallup-Sharecare Well-Being Index (WBI) and its domains (life evaluation, emotional health, work environment, physical health, healthy behaviours and basic access).

RESULTS

Zip codes with the highest quintile of well-being had 223 fewer hospitalisations per 100 000 (100k) residents than zip codes with the lowest well-being. In our final model, adjusted for WBI respondent age, sex, race/ethnicity and income, and zip code number of hospital beds, primary care physician density, hospital density and admission rates for two low-variation conditions, a 1 SD increase in WBI was associated with 5 fewer admissions/100k (95% CI 4.0 to 5.8; p<0.001). Results were similar for cardiovascular-related and respiratory-related admissions, but no association remained for cancer-related hospitalisation after adjustment. Patterns were similar for each of the WBI domains and all-cause hospitalisations.

CONCLUSION AND RELEVANCE

Community well-being is inversely associated with local hospitalisation rates. In addition to health and quality-of-life benefits, higher community well-being may also result in fewer unnecessary hospitalisations.

Relationships between indicators of cardiovascular disease and intensity of oil and natural gas activity in Northeastern Colorado

BACKGROUND

Oil and natural gas (O&G) extraction emits pollutants that are associated with cardiovascular disease, the leading cause of mortality in the United States.

OBJECTIVE

We evaluated associations between intensity of O&G activity and cardiovascular disease indicators.

METHODS

Between October 2015 and May 2016, we conducted a cross-sectional study of 97 adults living in Northeastern Colorado. For each participant, we collected 1-3 measurements of augmentation index, systolic and diastolic blood pressure (SBP and DBP), and plasma concentrations of interleukin (IL)- 1β, IL-6, IL-8 and tumor necrosis factor alpha (TNF-α). We modelled the intensity of O&G activity by weighting O&G well counts within 16 km of a participant's home by intensity and distance. We used linear models accounting for repeated measures within person to evaluate associations.

RESULTS

Adjusted mean augmentation index differed by 6.0% (95% CI: 0.6, 11.4%) and 5.1% (95%CI: -0.1, 10.4%) between high and medium, respectively, and low exposure tertiles. The greatest mean IL-1β, and α-TNF plasma concentrations were observed for participants in the highest exposure tertile. IL-6 and IL-8 results were consistent with a null result. For participants not taking prescription medications, the adjusted mean SBP differed by 6 and 1 mm Hg (95% CIs: 0.1, 13 mm Hg and -6, 8 mm Hg) between the high and medium, respectively, and low exposure tertiles. DBP results were similar. For participants taking prescription medications, SBP and DBP results were consistent with a null result.

CONCLUSIONS

Despite limitations, our results support associations between O&G activity and augmentation index, SBP, DBP, IL-1β, and TNF-α. Our study was not able to elucidate possible mechanisms or environmental stressors, such as air pollution and noise.

Chronic stress: a critical risk factor for atherosclerosis

Chronic stress refers to the non-specific systemic reaction that occurs when the body is stimulated by various internal and external negative factors over a long time. The physiological response to chronic stress exposure has long been recognized as a potent modulator in the occurrence of atherosclerosis. Furthermore, research has confirmed the correlation between atherosclerosis and cardiovascular events. Chronic stress is pervasive during negative life events and may lead to the formation of plaque. Several epidemiological studies have shown that chronic stress is an independent risk factor for the development of vascular disease and for increased morbidity and mortality in patients with pre-existing coronary artery disease. One possible mechanism for this process is that chronic stress causes endothelial injury, directly activating macrophages, promoting foam cell formation and generating the formation of atherosclerotic plaque. This mechanism involves numerous variables, including inflammation, signal pathways, lipid metabolism and endothelial function. The mechanism of chronic stress in atherosclerosis should be further investigated to provide a theoretical basis for efforts to eliminate the effect of chronic stress on the cardiocerebral vascular system.

Psychosocial Stressors at Work and Ambulatory Blood Pressure

PURPOSE OF REVIEW

Psychosocial stressors at work from the demand-latitude and effort-reward imbalance models are adverse exposures affecting about 20-25% of workers in industrialized countries. This review aims to summarize evidence on the effect of these stressors on blood pressure (BP).

RECENT FINDINGS

Three systematic reviews have recently documented the effect of these psychosocial stressors at work on BP. Among exposed workers, statistically significant BP increases ranging from 1.5 to 11 mmHg have been observed in prospective studies using ambulatory BP (ABP). Recent studies using ABP have shown a deleterious effect of these psychosocial stressors at work on masked hypertension as well as on blood pressure control in pharmacologically treated patients. Evidence on the effect of these psychosocial stressors on BP supports the relevance to tackle these upstream factors for primary prevention and to reduce the burden of poor BP control. There is a need for increased public health and clinical awareness of the occupational etiology of high BP, hypertension, and poor BP control.

Depression induced by chronic stress leads to penile cavernosal dysfunction: protective effect of anti-TNF-α treatment

Psychological stress may lead to erectile dysfunction (ED), and inflammation has been evaluated as a major contributing factor. The goal of this study was to investigate the effects of etanercept (ETN), an anti-tumor necrosis factor α (TNF-α) protein, on cavernosal function in the unpredictable chronic mild stress (UCMS) rat model of depression. Animals were divided into 4 groups: animals not exposed to UCMS, animals not exposed to UCMS and treated with ETN, animals exposed to UCMS, and animals treated with ETN while exposed to UCMS. UCMS significantly impaired the neurogenic and endothelium-dependent relaxation responses; reduced cavernosal endothelial nitric oxide (NO) synthase (eNOS) and neuronal NO synthase (nNOS) expressions; decreased testosterone levels; enhanced systemic levels of corticosterone, TNF-α, interleukin 1β (IL-1β), interleukin 6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), and intercellular adhesion molecule 1 (ICAM-1); and also increased cavernosal levels of TNF-α, IL-1β, and IL-6 in rats. ETN administration restored NO-mediated neurogenic and endothelium-dependent relaxation responses of the corpus cavernosum, increased cavernosal eNOS and nNOS expressions, enhanced testosterone levels, and decreased corticosterone levels in UCMS-exposed rats. Also, systemic inflammatory markers and cavernosal proinflammatory cytokine levels were reduced by ETN. Our results demonstrate the role of TNF-α-mediated inflammation in the development of depression and ED in rats exposed to chronic stress.

Inflammatory response to mental stress and mental stress induced myocardial ischemia

BACKGROUND

Mental stress-induced myocardial ischemia (MSIMI) is associated with increased risk of adverse cardiovascular outcomes, yet the underlying mechanisms are not well understood. We measured the inflammatory response to acute laboratory mental stress in patients with coronary artery disease (CAD) and its association with MSIMI. We hypothesized that patients with MSIMI would have a higher inflammatory response to mental stress in comparison to those without ischemia.

METHODS

Patients with stable CAD underwent 99mTc sestamibi myocardial perfusion imaging during mental stress testing using a public speaking stressor. MSIMI was determined as impaired myocardial perfusion using a 17-segment model. Inflammatory markers including interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), matrix metallopeptidase 9 (MMP-9) and high-sensitivity C reactive protein (hsCRP) were measured at rest and 90 min after mental stress. Results were validated in an independent sample of 228 post-myocardial infarction patients.

RESULTS

Of 607 patients analyzed in this study, (mean age 63 ± 9 years, 76% male), 99 (16.3%) developed MSIMI. Mental stress resulted in a significant increase in IL-6, MCP-1, and MMP-9 (all p <0.0001), but not hsCRP. However, the changes in these markers were similar in those with and without MSIMI. Neither resting levels of these biomarkers, nor their changes with mental stress were significantly associated with MSIMI. Results in the replication sample were similar.

CONCLUSION

Mental stress is associated with acute increases in several inflammatory markers. However, neither the baseline inflammatory status nor the magnitude of the inflammatory response to mental stress over 90 min were significantly associated with MSIMI.

TNF-α antagonism with etanercept enhances penile NOS expression, cavernosal reactivity, and testosterone levels in aged rats

Erectile dysfunction (ED) has been reported to be associated with inflammation. This study investigated the effects of tumor necrosis factor alpha (TNF-α) inhibitor etanercept on penile neuronal nitric oxide synthase (nNOS) and endothelial nitric oxide synthase (eNOS) expressions, testosterone concentrations, neurogenic and endothelium-dependent relaxations of corpus cavernosum (CC), and circulating and cavernosal levels of inflammatory markers in aged rats. Animals were separated into control, aged, and etanercept-treated aged groups. Aged rats displayed significantly increased serum and cavernosal TNF-α, C-reactive protein (CRP), monocyte chemoattractant protein-1 (MCP-1) and intercellular adhesion molecule (ICAM-1) levels, and decreased penile nNOS and eNOS expressions and serum testosterone levels compared with controls. In etanercept-treated aged group, NOS expressions were similar to that of the control group. The circulating and cavernosal concentrations of TNF-α, CRP, MCP-1, ICAM-1, and testosterone were also normalized by etanercept. Neurogenic and endothelium-dependent relaxant responses significantly decreased in aged rats and etanercept treatment markedly improved these relaxation responses. Our findings indicate that aging decreases penile NOS expression, neurogenic and endothelium-dependent relaxations of CC, and also suppresses serum testosterone levels by inducing inflammatory response that may contribute to the development of ED. TNF-α antagonism may be a novel strategy to treat aging-associated ED.

Psychological stress as a measure for treatment response prediction in idiopathic sudden hearing loss

OBJECTIVE

Early prediction of therapeutic outcomes could reduce exposure to ineffective treatments and optimize clinical outcomes. However, none of the known otologic predictors is amenable to therapeutic intervention for idiopathic sudden sensorineural hearing loss (ISSNHL). The aims of this study were to investigate psychological stress as a potential predictor to discriminate outcomes in ISSNHL.

METHODS

Various psychological measures were conducted including structured interview assessment tools in patients with recently diagnosed ISSNHL before initiating treatment. Using logistic regression analysis, we identified the predictors of treatment response and estimated the probability of treatment response in 50 ISSNHL patients who participated in a clinical trial.

RESULTS

Treatment non-responders were significantly differentiated from responders by various psychological problems. The depression subscore of Modified form of Stress Response Inventory (SRI-MF) (p=0.007) and duration of hearing loss (p=0.045) significantly predicted treatment response after controlling other clinical correlates. The same predictors were identified from different treatment response measured using Siegel's criteria. The most discriminative measure for treatment response was SRI-MF depression score with an overall classification accuracy of 73%.

CONCLUSIONS

We found depressive stress response to be the strong predictor of treatment response in patients with ISSNHL. Our results highlight the potential use of the psychiatric approach as a tool for enhancing therapeutic outcomes. Future stress intervention studies with larger number of ISSNHL patients are needed.

Urban natural environments as nature-based solutions for improved public health - A systematic review of reviews

Increasing urbanisation, changing disease scenarios, and current predictions of climate change impacts require innovative strategies for providing healthy and sustainable cities, now and in the future. The recently coined concept, Nature-based solutions (NBS), is one such strategy referring to actions that are inspired by, supported by, or copied from nature, designed to address a range of environmental challenges. The objective with this article is to evaluate the evidence on public health benefits of exposure to natural environments and explore how this knowledge could be framed within the NBS concept. We conducted a systematic review of reviews following established methodology, including keyword search in several databases, predefined inclusion criteria, and a data extraction in accordance with the PICOS structure. We reviewed literature on associations between public health and natural environments in relation to pathways - sociobehavioural/cultural ecosystem services (e.g. stress and physical activity) and regulating ecosystem services (e.g. heat reduction) - or defined health outcomes (e.g. cardiovascular mortality). The results show that there is strong evidence for improved affect as well as on heat reduction from urban natural environments. These conditions may mediate the effect seen on cardiovascular disease (CVD)-related mortality by exposure to natural environments. By also reviewing existing literature on NBS and health, we phrase the results within the NBS context, providing guidelines on how public health and well-being could be integrated into implementation of NBS for resilient and liveable urban landscapes and health in a changing climate.

Brain Under Stress and Alzheimer's Disease

Modern society is characterized by the ubiquity of stressors that affect every individual to different extents. Furthermore, experimental, clinical, and epidemiological data have shown that chronic activation of the stress response may participate in the development of various somatic as well as neuropsychiatric diseases. Surprisingly, the role that stress plays in the etiopathogenesis of Alzheimer's disease (AD) has not yet been studied in detail and is therefore not well understood. However, accumulated data have shown that neuroendocrine and behavioral changes accompanying the stress response affect neuronal homeostasis and compromise several key neuronal processes. Mediators of the neuroendocrine stress response, if elevated repeatedly or chronically, exert direct detrimental effects on the brain by impairing neuronal metabolism, plasticity, and survival. Stress-induced hormonal and behavioral reactions may also participate in the development of hypertension, atherosclerosis, insulin resistance, and other peripheral disturbances that may indirectly induce neuropathological processes participating in the development and progression of AD. Importantly, stress-induced detrimental effects as etiological factors of AD are attractive because they can be reduced by several approaches including behavioral and pharmacological interventions. These interventions may therefore represent an important strategy for prevention or attenuation of the progression of AD.

Panic Disorder Comorbidity with Medical Conditions and Treatment Implications

Panic disorder (PD) is unique among the anxiety disorders in that panic symptoms are primarily of a physical nature. Consequently, comorbidity with medical illness is significant. This review examines the association between PD and medical illness. We identify shared pathophysiological and psychological correlates and illustrate how physiological activation in panic sufferers underlies their symptom experience in the context of the fight-or-flight response and beyond a situation-specific response pattern. We then review evidence for bodily symptom perception accuracy in PD. Prevalence of comorbidity for PD and medical illness is presented, with a focus on respiratory and cardiovascular illness, irritable bowel syndrome, and diabetes, followed by an outline for potential pathways of a bidirectional association. We conclude by illustrating commonalities in mediating mechanistic pathways and moderating risk factors across medical illnesses, and we discuss implications for diagnosis and treatment of both types of conditions.

Relationship of childhood adversity and neighborhood violence to a proinflammatory phenotype in emerging adult African American men: An epigenetic link

African American men (AAM) who are exposed to trauma and adversity during their early life are at greater risk for poor health over their lifespan. Exposure to adversity during critical developmental windows may embed an epigenetic signature that alters expression of genes that regulate stress response systems, including those genes that regulate the inflammatory response to stress. Such an epigenetic signature may increase risk for diseases exacerbated by inflammation, and may contribute to health disparity. The purpose of this study was to evaluate the extent to which exposure to early life adversity influences the psychological, cortisol, and proinflammatory response to acute stress (Trier Social Stress Test - TSST) in emerging adult AAM, ages 18-25years (N=34). Hierarchical linear modeling was used to examine the cortisol and IL-6 pattern of response to the TSST with respect to childhood adversity factors and DNA methylation of the IL-6 promoter. Findings revealed that in response to the TSST, greater levels of childhood trauma and indirect exposure to neighborhood violence were associated with a greater TSST-induced IL-6 response, and a blunted cortisol response. Reduced methylation of the IL6 promoter was related to increased exposure to childhood trauma and greater TSST-induced IL-6 levels. These results support the concept that exposure to childhood adversity amplifies the adult proinflammatory response to stress, which is related to epigenetic signature.

Family Member Deaths in Childhood Predict Systemic Inflammation in Late Life

Biological and epidemiological evidence has linked early-life psychosocial stress with late-life health, with inflammation as a potential mechanism. We report here the association between familial death in childhood and adulthood and increased levels of high-sensitivity C-reactive protein (CRP), a marker of systemic inflammation. The Cache County Memory Study is a prospective study of persons initially aged 65 and older in 1995. In 2002, there were 1,955 persons in the study with data on CRP (42.3 percent male, mean [SD] age = 81.2 [5.8] years), linked with objective data on family member deaths. Using logistic regression, high (> 10 mg/L) versus low (≤ 10 mg/L) CRP was regressed on cumulative parental, sibling, spouse, and offspring deaths during childhood and during early adulthood, adjusted for family size in each period (percentage family depletion; PFD). Findings revealed PFD during childhood to be significantly associated with CRP (OR = 1.02, 95% CI [1.01, 1.04]). Individuals with two or more family deaths were 79 percent more likely to have elevated CRP than those with zero family deaths (OR = 1.79, 95% CI [1.07, 2.99]). Early adulthood PFD was not related to CRP. This study demonstrates a link between significant psychosocial stress in early life and immune-inflammatory functioning in late life, and suggests a mechanism explaining the link between early-life adversity and late-life health.

Associations of socioeconomic position in childhood and young adulthood with cardiometabolic risk factors: the Jerusalem Perinatal Family Follow-Up Study

BACKGROUND

Several stages in the life course have been identified as important to the development of cardiovascular disease. This study aimed to assess the associations of childhood and adulthood socioeconomic position (SEP) and social mobility with cardiometabolic risk factors (CMRs) later in life.

METHODS

We conducted follow-up examinations of 1132 offspring, aged 32, within a population-based cohort of all births in Jerusalem from 1974 to 1976. SEP was indicated by parents' occupation and education, and adulthood SEP was based on offspring's occupation and education recorded at age 32. Linear regression models were used to investigate the associations of SEP and social mobility with CMRs.

RESULTS

Childhood-occupational SEP was negatively associated with body mass index (BMI; β=-0.29, p=0.031), fat percentage (fat%; β=-0.58, p=0.005), insulin (β=-0.01, p=0.031), triglycerides (β=-0.02, p=0.024) and low-density lipoprotein cholesterol (LDL-C; β=-1.91, p=0.015), independent of adulthood SEP. Adulthood-occupational SEP was negatively associated with waist-to-hip ratio (WHR; β=-0.01, p=0.002), and positively with high-density lipoprotein cholesterol (HDL-C; β=0.87, p=0.030). Results remained similar after adjustment for smoking and inactivity. Childhood-educational SEP was associated with decreased WHR and LDL-C level (p=0.0002), and adulthood-educational SEP was inversely associated with BMI (p=0.001), waist circumference (p=0.008), WHR (p=0.001) and fat% (p=0.0002) and positively associated with HDL-C (p=0.030). Additionally, social mobility (mainly upward) was shown to have adverse cardiometabolic outcomes.

CONCLUSIONS

Both childhood and adulthood SEP contribute independently to CMR. The match-mismatch hypothesis may explain the elevated CMRs among participants experiencing social mobility. Identification of life-course SEP-related aspects that translate into social inequality in cardiovascular risk may facilitate efforts for improving health and for reducing disparities in cardiovascular disease.

The Implicit Positive and Negative Affect Test: Validity and Relationship with Cardiovascular Stress-Responses

Self-report, i.e., explicit, measures of affect cannot fully explain the cardiovascular (CV) responses to stressors. Measuring affect beyond self-report, i.e., using implicit measures, could add to our understanding of stress-related CV activity. The Implicit Positive and Negative Affect Test (IPANAT) was administered in two studies to test its ecological validity and relation with CV responses and self-report measures of affect. In Study 1 students (N = 34) viewed four film clips inducing anger, happiness, fear, or no emotion, and completed the IPANAT and the Positive And Negative Affect Scale at baseline and after each clip. Implicit negative affect (INA) was higher and implicit positive affect (IPA) was lower after the anger inducing clip and vice versa after the happiness inducing clip. In Study 2 students performed a stressful math task with (n = 14) or without anger harassment (n = 15) and completed the IPANAT and a Visual Analog Scale as an explicit measure afterwards. Systolic (SBP), diastolic (DBP) blood pressure, heart rate (HR), heart rate variability (HRV), and total peripheral resistance (TPR) were recorded throughout. SBP and DBP were higher and TPR was lower in the harassment condition during the task with a prolonged effect on SBP and DBP during recovery. As expected, explicit negative affect (ENA) was higher and explicit positive affect (EPA) lower after harassment, but ENA and EPA were not related to CV activity. Although neither INA nor IPA differed between the tasks, during both tasks higher INA was related to higher SBP, lower HRV and lower TPR and to slower recovery of DBP after both tasks. Low IPA was related to slower recovery of SBP and DBP after the tasks. Implicit affect was not related to recovery of HR, HRV, and TPR. In conclusion, the IPANAT seems to respond to film clip-induced negative and positive affect and was related to CV activity during and after stressful tasks. These findings support the theory that implicitly measured affect can add to the explanation of prolonged stress-related CV responses that influence CV health.

Catecholamine metabolites in urine, as chronic stress biomarkers, are associated with higher risk of chronic periodontitis in adults

BACKGROUND

The purpose of this case-control study is to investigate the association between stress and periodontitis by determining stress biomarkers in saliva and urine and to determine whether oral hygiene, gingival inflammation, and tooth loss are correlated with stress biomarkers in patients with periodontitis.

METHODS

A total of 77 patients (41 cases [with periodontitis] and 36 controls) participated in this study. Periodontal examination findings included probing depth, clinical attachment loss, bleeding on probing (BOP), plaque index (PI), and tooth loss. Secretory immunoglobulin (sIg)A and cortisol were determined in saliva. Cortisol, creatinine-adjusted cortisol, metanephrine, normetanephrine, and total metanephrines were measured in urine.

RESULTS

Urinary metanephrine (P = 0.013) and total metanephrine (P = 0.023) levels were higher in the case group. In cases, salivary cortisol was correlated with PI (r = 0.464, P <0.01), BOP (r = 0.401, P <0.05), and tooth loss (r = 0.245, P <0.05). Urinary metanephrine levels above the median were associated with a 3.4-fold higher risk of periodontitis (95% confidence interval [CI] = 1.1 to 10.2; P = 0.029), with an 82% increase in risk for each increment of 0.05 µg/24 hours. Urinary total metanephrine levels above the median were associated with a five-fold higher risk of periodontitis (95% CI = 1.6 to 15.7; P = 0.006).

CONCLUSIONS

The present results offer new evidence of the association between urinary concentrations of catecholamine metabolites (metanephrine and total metanephrines) and chronic periodontitis. Salivary IgA level showed no statistical difference between the cases and controls. Salivary cortisol levels in the patients with periodontitis were correlated with worse PI, higher gingival inflammation, and greater tooth loss.

Role of chronic stress and depression in periodontal diseases

An extensive body of experimental and clinical evidence documents the negative impact of chronic psychological stress and depression on the immune system and health. Chronic stress and depression can result in general dysregulation of the immune system, of both cellular and humoral pathways, which may contribute to pathogenic infection and concomitant periodontal tissue destruction. In general, the evidence is consistent with the hypothesis that stress can modify the host defense and progression of periodontal infections in patients susceptible to periodontitis. However, substantial evidence also indicates that these conditions can mediate risk for disease, including periodontitis, through changes in health-related behaviors, such as oral hygiene, smoking and diet. The unequivocal interpretation of studies has also been hampered, in part, by issues related to conceptualization of stress and depression, as well as commonly associated comorbidities, such as diabetes, that can modify the onset and progression of periodontal disease. In addition, stress and depression appear to fall into a spectrum, ranging from mild to severe, involving a complex interaction of genetic background, coping strategies and environment. Differences in the conceptualization of stress and depression are probably important in assessing associations with other biologic and clinical measures. Future studies are necessary to clarify the complex interactions of chronic stress and depression in periodontal diseases.

Chronic stress impacts the cardiovascular system: animal models and clinical outcomes

Psychological stresses are associated with cardiovascular diseases to the extent that cardiovascular diseases are among the most important group of psychosomatic diseases. The longstanding association between stress and cardiovascular disease exists despite a large ambiguity about the underlying mechanisms. An array of possibilities have been proposed including overactivity of the autonomic nervous system and humoral changes, which then converge on endothelial dysfunction that initiates unwanted cardiovascular consequences. We review some of the features of the two most important stress-activated systems, i.e., the humoral and nervous systems, and focus on alterations in endothelial function that could ensue as a result of these changes. Cardiac and hematologic consequences of stress are also addressed briefly. It is likely that activation of the inflammatory cascade in association with oxidative imbalance represents key pathophysiological components of stress-induced cardiovascular changes. We also review some of the commonly used animal models of stress and discuss the cardiovascular outcomes reported in these models of stress. The unique ability of animals for adaptation under stressful conditions lessens the extrapolation of laboratory findings to conditions of human stress. An animal model of unpredictable chronic stress, which applies various stress modules in a random fashion, might be a useful solution to this predicament. The use of stress markers as indicators of stress intensity is also discussed in various models of animal stress and in clinical studies.

TLR4/NF-κB signaling contributes to chronic unpredictable mild stress-induced atherosclerosis in ApoE-/- mice

Objective

Chronic stress is an important risk factor for atherosclerotic diseases. Our previous studies have shown that chronic unpredictable mild stress (CUMS) accelerates atherosclerosis and up-regulates TLR4/NF-κB expression in apoE^-/- mice. However, TLR4/NF-κB signaling whether directly contributes to the development of atherosclerosis in CUMS mice is unclear. We hypothesized that the interference of TLR4/NF-κB can ameliorate CUMS-induced inflammation and atherosclerosis in apoE^-/- mice.

Methods

ApoE^-/- mice were exposed to 12 weeks CUMS. Ad-siRNA TLR4 was given by tail vein injection (10 μl/mouse, every 5 days), and PDTC (an inhibitor of NF-κB) was given by intraperitoneal injection (60 mg/kg, once a day). Plasma corticosterone concentrations were determined by solid-phase ¹²⁵I radioimmunoassay. Atherosclerosis lesions in aortic sinuses were evaluated and quantified by IMAGEPRO PLUS. Western blotting was used to detect the expression of TLR4, NF-κB, and IL-1β in aortas of the mice. Plasma lipid profiles, IL-1β, TNF-α, and MCP-1 were measured by ELISA.

Results

Our results indicated that CUMS apoE^-/- mice treatment with siRNA TLR4 significantly decreased atherosclerosis and down-regulated TLR4, NF-κB, and inflammatory cytokines. PDTC also remarkably reduced atherosclerosis and the levels of IL-1β, TNF-α and MCP-1 in plasma. However, Treatment with siRNA TLR4 or PDTC had no effect on plasma corticosterone levels, and lipid profiles.

Conclusions

TLR4/NF-κB pathway may participate in CUMS-induced atherosclerosis through activation of proinflammatory cytokines in apoE^-/- mice. Our data may provide a new potential therapeutic target for prevention of CUMS -induced atherosclerosis.

The Man I Once Knew

Grief, although traditionally conceptualized as a bereavement-related reaction, is also experienced by significant others in response to the profound cognitive and personality changes associated with a traumatic brain injury (TBI) in a loved one. Grief associated with the death of a loved one is related to increases in proinflammatory cytokines, yet it is not clear whether this is the case for grief experienced by individuals caring for a significant other with TBI. The purpose of this cross-sectional, exploratory study was to examine grief and its association with a proinflammatory cytokine, tumor necrosis factor α (TNF-α), in wives/partners caring for veterans with TBI. Participants completed written measures of grief, perceived stress, and depressive symptoms and provided morning saliva samples for TNF-α analysis. Participants reported levels of grief comparable to those reported in studies evaluating individuals grieving the death of a loved one. Path analysis revealed that grief was not associated with TNF-α; however, participants reporting high levels of blame/anger, a subscale of the grief scale, had higher levels of TNF-α. In addition, both grief and blame/anger were related to increased perceived stress and depressive symptoms; however, path analysis demonstrated that perceived stress and depressive symptoms did not mediate the influence of blame/anger on TNF-α. These findings suggest that blame/anger associated with grief may be related to the elevations in TNF-α exhibited by individuals caring for a loved one with TBI.

Epigenetics and social context: implications for disparity in cardiovascular disease

BACKGROUND

Although it is well established that African Americans (AA) experience greater social stressors than non-Hispanic Whites (NHW), the extent to which early life adversity and cumulative social stressors such as perceived discrimination, neighborhood violence, subjective social status, and socioeconomic status contribute to disparity in coronary heart disease (CHD) and stroke between AA and NHW are not well understood.

PURPOSE

The purpose of this paper is to propose a conceptual model based upon McEwen's Allostatic Load Model suggesting how the relationships among social context, early life adversity, psychological stress, inflammation, adaptation, and epigenetic signature may contribute to the development of CHD and ischemic stroke. We hypothesize that social context and prior life adversity are associated with genome-wide as well as gene-specific epigenetic modifications that confer a proinflammatory epigenetic signature that mediates an enhanced proinflammatory state. Exposure to early life adversity, coupled with an increased allostatic load places individuals at greater risk for inflammatory based diseases, such as CHD and ischemic stroke.

RESULTS

Based on a review of the literature, we propose a novel model in which social context and psychological stress, particularly during early life, engenders a proinflammatory epigenetic signature, which drives a heightened inflammatory state that increases risk for CHD and stroke. In the proposed model, a proinflammatory epigenetic signature and adaptation serve as mediator variables.

CONCLUSIONS

Understanding the extent to which epigenetic signature bridges the psycho-social environment with inflammation and risk for CHD may yield novel biomarkers that can be used to assess risk, development, and progression of CHD/stroke. Epigenetic biomarkers may be used to inform preventive and treatment strategies that can be targeted to those most vulnerable, or to those with early signs of CHD, such as endothelial dysfunction. Furthermore, epigenetic approaches, including lifestyle modification and stress reduction programs, such as mindfulness-based stress reduction, offer promise to reduce health inequity linked to social disadvantage, as emerging evidence demonstrates that adverse epigenetic marks can be reversed.

Cyclin-dependent kinase 9 may as a novel target in downregulating the atherosclerosis inflammation (Review)

Inflammation is a key component of atherosclerosis. Genes coding for inflammatory or anti-inflammatory molecules are considered good candidates for estimating the risk of developing atherosclerosis. Cyclin-dependent kinase 9 (CDK9), the kinase of positive transcription elongation factor b (P-TEFb), is crucial in the cell cycle and apoptosis. Previous studies have focused on its inhibition of immune cells for the resolution of inflammation. Considering the effects of inflammation in the pathogenicity of atherosclerosis, decreasing inflammation through the inhibition of CDK9 may be useful for the prognosis of atherosclerosis. The aim of this review was to examine whether inhibition of the CDK9 monocyte may affect the process of inflammation by acting on the cytokine secretion and interacting with endothelial cells (ECs). Thus, CDK9 may be a novel target for the diagnosis and therapy of atherosclerosis.

Docosahexaenoic acid decreases TNF-α-induced lectin-like oxidized low-density lipoprotein receptor-1 expression in THP-1 cells

Docosahexaenoic acid (DHA) prevents atherosclerosis and may decrease monocyte/macrophage activation by tumor necrosis factor (TNF)-α. Here, we sought to determine the protective effects of DHA against TNF-α-induced stimulation of lectin-like oxidized low-density lipoprotein (LDL) receptor-1 (LOX-1) expression, which is associated with atherosclerosis. Using reverse transcription polymerase chain reaction, we found that TNF-α induced the expression of LOX-1 (OLR1), NADPH oxidase 2 (Nox2), p47phox (NCF1), very late antigen-4 (ITGA4), and lymphocyte function-associated antigen (ITGAL) genes. Additionally, DHA attenuated TNF-α-induced acetylated (Ac)-LDL uptake and reactive oxygen species (ROS) production, as measured using fluorescently labeled LDL and H2DCFDA, respectively, and reduced the expression levels of these genes. Moreover, the PI3 kinase inhibitor LY294002 blocked these effects of DHA. These results indicated that DHA inhibited several events associated with redox regulation in a PI3K-dependent manner, thereby mediating the expression of LOX-1 in monocytes/macrophages.

Dysfunctional brain-bone marrow communication: a paradigm shift in the pathophysiology of hypertension

It is widely accepted that the pathophysiology of hypertension involves autonomic nervous system dysfunction, as well as a multitude of immune responses. However, the close interplay of these systems in the development and establishment of high blood pressure and its associated pathophysiology remains elusive and is the subject of extensive investigation. It has been proposed that an imbalance of the neuro-immune systems is a result of an enhancement of the "proinflammatory sympathetic" arm in conjunction with dampening of the "anti-inflammatory parasympathetic" arm of the autonomic nervous system. In addition to the neuronal modulation of the immune system, it is proposed that key inflammatory responses are relayed back to the central nervous system and alter the neuronal communication to the periphery. The overall objective of this review is to critically discuss recent advances in the understanding of autonomic immune modulation, and propose a unifying hypothesis underlying the mechanisms leading to the development and maintenance of hypertension, with particular emphasis on the bone marrow, as it is a crucial meeting point for neural, immune, and vascular networks.