Central sympathetic modulation of tissue cytokine response to hemorrhage

Catecholamines-crafty weapons in the inflammatory arsenal of immune/inflammatory cells or opening pandora's box?

It is well established that catecholamines (CAs), which regulate immune and inflammatory responses, derive from the adrenal medulla and from presynaptic neurons. Recent studies reveal that T cells also can synthesize and release catecholamines which then can regulate T cell function. We have shown recently that macrophages and neutrophils, when stimulated, can generate and release catecholamines de novo which, then, in an autocrine/paracrine manner, regulate mediator release from these phagocytes via engagement of adrenergic receptors. Moreover, regulation of catecholamine-generating enzymes as well as degrading enzymes clearly alter the inflammatory response of phagocytes, such as the release of proinflammatory mediators. Accordingly, it appears that phagocytic cells and lymphocytes may represent a major, newly recognized source of catecholamines that regulate inflammatory responses.

Opioids and opiates: analgesia with cardiovascular, haemodynamic and immune implications in critical illness

Traumatic injury, surgical interventions and sepsis are amongst some of the clinical conditions that result in marked activation of neuroendocrine and opiate responses aimed at restoring haemodynamic and metabolic homeostasis. The central activation of the neuroendocrine and opiate systems, known collectively as the stress response, is elicited by diverse physical stressor conditions, including ischaemia, glucopenia and inflammation. The role of the hypothalamic-pituitary-adrenal axis and sympathetic nervous system in counterregulation of haemodynamic and metabolic alterations has been studied extensively. However, that of the endogenous opiates/opioid system is still unclear. In addition to activation of the opiate receptor through the endogenous release of opioids, pharmacotherapy with opiate receptor agonists is frequently used for sedation and analgesia of injured, septic and critically ill patients. How this affects the haemodynamic, cardiovascular, metabolic and immune responses is poorly understood. The variety of opiate receptor types, their specificity and ubiquitous location both in the central nervous system and in the periphery adds additional complicating factors to the clear understanding of their contribution to the stress response to the various physical perturbations. This review aims at discussing scientific evidence gathered from preclinical studies on the role of endogenous opioids as well as those administered as pharmacological agents on the host cardiovascular, neuroendocrine, metabolic and immune response mechanisms critical for survival from injury in perspective with clinical observations that provide parallel assessment of relevant outcome measures. When possible, the clinical relevance and corresponding scenarios where this evidence can be integrated into our understanding of the clinical implications of opiate effects will be examined. Overall, the scientific basis to enhance clinical judgment and expectations when using opioid sedation and analgesia in the management of the injured, septic or postsurgical patient will be discussed.

IL-1 alpha and TNF-alpha expression in rat periapical lesions and dental pulp after unilateral sympathectomy

OBJECTIVES

Apical periodontitis is an inflammatory disease characterized by bone resorption, and sympathetic nerves are known to modulate bone resorption and bone remodeling. Higher numbers of osteoclasts and larger periapical lesions have been observed after sympathectomy in rats, but the mechanisms underlying the inhibitory effect of sympathetic nerves on osteoclasts are unknown. This study aimed to test the hypothesis that sympathetic nerves inhibit the production of the bone-resorbing pro-inflammatory cytokines IL-1 alpha and TNF-alpha in rat periapical lesions.

METHODS

Rats were unilaterally sympathectomized and apical lesions were induced by exposing the dental pulp of molar teeth to the oral microflora. We quantified the cytokines IL-1 alpha and TNF-alpha by enzyme-linked immunosorbent assay, and immunohistochemical analysis was done for qualitative localization. Pulp from intact incisor teeth was tested as a control.

RESULTS

We showed that IL-1 alpha was increased, but not TNF-alpha, in the periapical lesions on the sympathectomized side. Both IL-1 alpha and TNF-alpha were expressed in unexposed pulp. TNF-alpha was significantly decreased in the denervated incisor pulp, whereas the level of IL-1 alpha remained unchanged.

CONCLUSIONS

This study suggests that sympathetic nerves have an inhibitory effect on IL-1 alpha in periapical lesions and a stimulatory effect on TNF-alpha in the intact rat pulp.

Stress-specific opioid modulation of haemodynamic counter-regulation

1. The haemodynamic and cardiovascular responses to stress, in addition to being under control of the autonomic nervous system, are also under opiate modulation. Our studies have provided evidence for activation of the endogenous opioid system in haemorrhagic shock, sepsis and trauma. Furthermore, we have demonstrated that both central and systemic opiate administration to naïve rats result in marked alterations in haemodynamic responses, which are associated with activation of the sympathetic nervous system. 2. Because of the ubiquitous presence of opiate receptors in both the central nervous system and peripheral tissues, as well as their production and release centrally and peripherally, this facilitates an endocrine as well as a paracrine contribution to modulating vascular responses to stress, either directly or indirectly. Results from previous studies suggest that endogenous opioids are not involved in mediating the lipopolysacharide-induced hypotensive response. 3. In more recent studies, we have examined the role of opiate receptor activation in modulating the haemodynamic and neuroendocrine responses to fixed pressure haemorrhagic shock in conscious unrestrained rats. Using systemic opiate blockade (naltrexone, 15 mg/kg, i.p.) prior to haemorrhage, we have observed that blood loss required to achieve mean arterial blood pressure of 40 mmHg was higher in naltrexone-treated animals than in time-matched saline controls. Interestingly, the haemodynamic modulation exerted by naltrexone cannot be attributed to differences in circulating catecholamine levels. Haemorrhage produced an immediate and progressive increase in circulating adrenaline and noradrenaline levels, reaching values that were 50- and 20-fold higher than basal, respectively. Naltrexone pretreatment did not alter the time-course or magnitude of the rise in circulating levels of catecholamines. 4. These results indicate that endogenous opioid activation contributes to the haemodynamic dishomeostasis associated with blood loss. Our findings suggest stress-specific roles for opiate-sensitive haemodynamic counter-regulatory responses.

A low level of TNF-alpha mediates hemorrhage-induced acute lung injury via p55 TNF receptor

Acute lung injury after hemorrhagic shock (HS) is associated with the expression of tumor necrosis factor (TNF)-alpha in the lung. However, the role of TNF-alpha and its receptors in this pulmonary disorder remains obscure. This study examined the temporal relationship of pulmonary TNF-alpha production to neutrophil accumulation during HS and determined the role of TNF-alpha in neutrophil accumulation and lung leak. HS was induced in mice by removal of 30% of total blood volume. Lung TNF-alpha was measured by ELISA. Neutrophil accumulation was detected by immunofluorescent staining, and microvascular permeability was assessed using Evans blue dye. Although HS induced a slight and transient increase in lung TNF-alpha, neutrophil accumulation preceded the increase in TNF-alpha. However, lung neutrophil accumulation and lung leak were abrogated in TNF-alpha knockout mice, and both were restored by administration of recombinant TNF-alpha to TNF-alpha knockout mice before HS. Neutrophil accumulation and lung leak were abrogated in mice lacking the p55 TNF-alpha receptor, but neither was influenced by p75 TNF-alpha receptor knockout. This study demonstrates that a low level of pulmonary TNF-alpha is sufficient to mediate HS-induced acute lung injury during HS and that the p55 TNF-alpha receptor plays a dominant role in regulating the pulmonary inflammatory response to HS.