The hypothalamic-pituitary-adrenal axis and immune-mediated inflammation

Impact of left ventricular dysfunction on cytokines, hemodynamics, and outcome in bypass grafting

BACKGROUND

Although patients with reduced left ventricular ejection fraction undergoing cardiac operation experience a higher rate of perioperative complications, the contribution of proinflammatory cytokines released during extracorporeal circulation is not well defined.

METHODS

We compared arterial and mixed venous levels of interleukin-6, tumor necrosis factor-alpha, soluble interleukin-2 receptor, and interleukin-2 at 10 points in time (24 hours before until 48 hours after extracorporeal circulation) in 21 patients with an ejection fraction of less than 0.45 (study group) to 15 patients with an ejection fraction of more than 0.55 (control group) undergoing elective coronary artery bypass grafting. The study and control group differed with regard to left ventricular ejection fraction (0.37 +/- 0.05 versus 0.66 +/- 0.11, p < 0.05) and reperfusion time (35 +/- 42 minutes versus 18 +/- 4 minutes, p = 0.07), but not age, sex, vessel involvement, number of grafts performed, cross-clamp time, extracorporeal circulation time, core temperature, and duration of ventilation.

RESULTS

Six patients in the study group required mechanical support and 1 died. There were no complications in the control group. In the study group, there were higher preoperative interleukin-2 and tumor necrosis factor-alpha levels and a higher maximum cytokine response to extracorporeal circulation for interleukin-2, soluble interleukin-2 receptor, interleukin-6, and tumor necrosis factor-alpha (all p < 0.05). Interleukin-6 correlated with duration of extracorporeal circulation, dose of norepinephrine and epinephrine support, pulmonary capillary wedge pressure, mean pulmonary arterial pressure, right atrial pressure, heart rate, cardiac index, and inversely with systemic vascular resistance. Interleukin-6 was highest in patients with complications. Arterial and venous cytokine levels correlated closely.

CONCLUSIONS

Preoperative left ventricular dysfunction is associated with a higher degree of proinflammatory cytokine release during elective coronary artery bypass grafting. This response is associated with impaired hemodynamics and a higher incidence of perioperative complications.

[D-Pro5]Corticotropin-releasing factor analogs as selective agonists at corticotropin-releasing factor receptors

Corticotropin-releasing factor (CRF) acts on at least two types of CRF receptors. To search for selective CRF receptor agonists, 37 ovine CRF analogs, systematically substituted with D-amino acids, were tested for inhibitory activity on edema induced in the pentobarbital-anesthetized rat paw by heat (immersion in 58 degrees C water for 1 min). The activity of each analog, administered 21 nmol/kg i.v. 10 min before heat, was compared to published data on the analog's potency in stimulating adrenocorticotropin (ACTH) release from cultured rat pituitary cells. In general, a positive rank correlation was found between the anti-edema and neuroendocrine activities of these analogs, however, one outlier, [D-Pro5]ovine CRF, exhibited greater selectivity for anti-edema activity. The human/rat analog of [D-Pro5]CRF was synthesized and found to be equipotent to human/rat CRF for suppression of heat-edema. In cells transfected with two types of cloned CRF receptors, the intracellular cAMP response to [D-Pro5]human/rat CRF was equipotent to human/rat CRF in the heart-muscle CRF (CRF2 beta) receptor assay but was five times less potent than human/rat CRF in the pituitary-central nervous system CRF (CRF1) receptor assay. We conclude that changing residue Pro5 in the CRF molecule from a L- to a D-configuration confers selectivity by decreasing second messenger activation at the CRF1 receptor whilst retaining full potency at the CRF2 beta receptor.

The three-way interactions between the hypothalamic-pituitary-adrenal and gonadal axes and the immune system

The stress system is controlled by brain nuclei at the hypothalamus and brainstem. These nuclei interact with each other and control the HPA axis and sympathetic nervous systems, respectively. Major inputs to the stress system arise from the cerebral cortex and subcortical systems, the sensory organs and nerves, and the endocrine and immune systems. The major peripheral effectors of the stress system are glucocorticoids and the catecholamines. Pathological hypoactivity of the stress system has been associated with atypical depression, the chronic fatigue/fibromyalgia syndromes and autoimmune inflammatory disease; hyperactivity with melancholic depression and anxiety disorders. The stress system responds in a quantitatively and qualitatively specific fashion to different stressors. A major role of the HPA axis is to restrain the immune system and prevent tissue damage. Reciprocal interactions between the HPA axis and immune system constitutes a new endocrine feedback loop that has given rise to the field of neuroendocrine immunology. Gonadal axis hormones directly, and indirectly via the HPA axis, alter the tone of the immune system and the quality and quantity of the inflammatory responses. Effects of the HPA axis on the gonadal axis are consistent with conservation and redirection of valuable resources towards homeostasis during times of stress. These complex interactions between the HPA axis, immune and the gonadal systems may prove to be fundamental in the genesis and perpetuation of autoimmune disease.

Leukemia inhibitory factor (LIF) stimulates proopiomelanocortin (POMC) expression in a corticotroph cell line. Role of STAT pathway

We recently described the expression of leukemia inhibitory factor (LIF) in human fetal and murine corticotrophs. LIF and the related cytokine oncostatin M induced basal, and corticotropin-releasing hormone (CRH) induced proopiomelanocortin (POMC) mRNA and ACTH secretion in AtT20 cells. LIF signaling and regulation of POMC gene transcription were therefore tested. Dexamethasone inhibited both basal- and LIF-induced ACTH secretion (P<0.05) and LIF induction of ACTH was also attenuated by immuneutralization of either the LIF receptor (35%, P<0.05) or the gp130 affinity converter (41%, P<0.05). These antisera also attenuated basal ACTH secretion in the absence of added ligand (P<0.05). To examine intrapituitary LIF signaling, phosphorylation of post-receptor substrates was measured. 1 nM LIF rapidly induced tyrosyl phosphorylation of STAT 1 and STAT 3 proteins, as well as tyrosyl phosphorylation of a 115-kD protein, coimmunoprecipitated with STAT 1. The transfected rat POMC promoter -706/+64, fused to the luciferase reporter gene, was induced by LIF, which exerted strong (18-fold) synergy with CRH. Deletion of the major CRH responsive region in POMC (-323/-166) abolished CRH induction of transcription and severely limited LIF synergy. Although 8 bromo cAMP or forskolin modestly enhanced POMC transcription (2.8-fold), LIF markedly potentiated (7.4-fold) these cAMP activators. These results demonstrate that corticotroph LIF action is receptor mediated and involves activation of STAT signaling pathways. LIF potently synergizes with both CRH and cAMP induction of POMC transcription. This novel intrapituitary signaling mechanism may mediate a neuroimmune pituitary interface.

Influence of endotoxin on daytime sleep in humans

Administration of endotoxin in the evening has been shown to transiently suppress rapid eye movement (REM) and to promote non-REM sleep in humans. In a single-blind placebo-controlled crossover design, we assessed the effects of Salmonella abortus equi endotoxin administered intravenously in the morning on the primary host response and on daytime sleep by use of a multiple napping protocol in healthy volunteers. The extent of the host response achieved by 0.8 ng of endotoxin per kg of body weight given at 0900 h was comparable to that previously reported to result from the administration of 0.4 ng/kg at 1900 h. However, sleep was only slightly influenced. Endotoxin reduced the amount of REM sleep and increased REM latency. Non-REM sleep amount in the first nap, although not significantly changed, correlated negatively with the individual peak levels of interleukin-6 (r = -0.73, P < 0.05). Subjective tiredness, sleep onset latency, total sleep time, and the amounts of slow-wave and non-REM sleep were not affected by endotoxin throughout the entire experiment. Spectral analysis of the electroencephalogram obtained during non-REM sleep yielded no condition differences. We conclude that endotoxin administration in the morning to healthy volunteers, while activating the host defense to the same extent as a lower dose that has been reported to promote non-REM sleep when given in the evening, does not affect non-REM sleep. REM sleep suppression is, to date, the most consistently reported effect of endotoxin on human sleep.

A glucocorticoid receptor-independent mechanism for neurosteroid inhibition of tumor necrosis factor production

We investigated the effect of two neurosteroids, pregnenolone and dehydroepiandrosterone sulfate on lipopolysaccharide-induced tumor necrosis factor (TNF) production in vivo and in vitro. Dehydroepiandrosterone sulfate (0.3-30 mg/kg, i.p.) inhibited serum TNF induced by lipopolysaccharide (2.5 micrograms/mouse, i.p.), without affecting the induction of serum corticosterone. Intracerebroventricular (i.c.v.) administration of dehydroepiandrosterone sulfate (0.2-5 micrograms/mouse) also inhibited brain TNF induced by i.c.v. lipopolysaccharide (2.5 micrograms/mouse). Dehydroepiandrosterone sulfate and pregnenolone (10(-6)-10(-4) M) inhibited TNF production in vitro by lipopolysaccharide-stimulated human peripheral blood mononuclear cells or by the human THP-1 cell line, suggesting that this action might also be relevant in humans. We obtained two lines of evidence that neurosteroids do not inhibit TNF via the glucocorticoid receptor. (1) Dehydroepiandrosterone sulfate and pregnenolone did not activate the alpha 1-acid glycoprotein promoter, a typical effect of glucocorticoids mediated by the glucocorticoid receptor, while strong activation of this promoter was observed with dexamethasone. (2) The inhibitory effect of dehydroepiandrosterone sulfate and pregnenolone on TNF production was not reversed by the glucocorticoid receptor antagonist, mifepristone (RU38486). On the contrary the inhibitory effect of dexamethasone, a classical glucocorticoid and inhibitor of TNF synthesis, was completely reversed by RU38486.

Mind-body medicine in primary care. Implications and applications

A growing body of research in basic and clinical science confirms that psychological states and interventions affect physiologic and pathophysiologic processes and the outcome of clinical illness. This evidence is reviewed in detail, with special attention paid to those findings that have particular relevance for primary care physicians. Specific guidelines are offered for incorporating mind-body principles and techniques into primary care practice.

Environmental and experimental procedures leading to variations in the incidence of diabetes in the nonobese diabetic (NOD) mouse

Environmental factors appear to be nongenetic risks of importance in the progression of insulin-dependent diabetes mellitus (IDDM) or type 1 diabetes, whose mechanisms are not yet well understood. Stressful life events, in particular, have been linked to the expression of overt diabetes in humans. However, in rodent models of IDDM, contradictory data exist concerning the effects of stress on the disease. Here, we show that a stressor, such as long-term repeated injections of vehicle (0.9% saline), was able to delay the appearance and/or decrease the incidence of diabetes in both sexes of NOD mice. Short-term chronic stress applied from the 6th to the 8th week of age by a combination of multiple stressors (overcrowding + immobilization + cold exposure + anesthesia) protected NOD mice from diabetes, particularly males. In contrast, prenatal stress, induced by immobilization of the mothers during the third part of pregnancy, accelerated the onset and increased the prevalence of diabetes at 30 weeks of age in NOD females, while it had no effect in males. Finally, adrenalectomy appears to aggravate the development of diabetes in NOD mice, particularly in males. In conclusion, these data demonstrate that the appearance of diabetes in NOD mice is extremely sensitive to various experimental and environmental conditions. These results are discussed in the context of the complex neuroendocrine-immune interactions which occur during the progression of IDDM, with a particular focus on glucocorticoids and cytokines.

Cytokines and thyroid function

Cytokines play a crucial role in autoimmune thyroid disease (ATD) through various mechanisms. They are produced in the thyroid by intrathyroidal inflammatory cells, in particular lymphocytes, as well as by the thyroid follicular cells (TFC) themselves and may thus act in a cascade to enhance the autoimmune process (Fig. 1). Cytokines upregulate the inflammatory reaction through stimulation of both T and B cells, resulting in antibody production and tissue injury. In addition, intrathyroidal cytokines induce immunological changes in TFC including enhancement of both major histocompatibility complex (MHC) class I and class II molecule expression, and upregulation of adhesion and complement regulatory molecule expression. Cytokines can also modulate both growth and function of TFC and have a role in extrathyroidal complications of ATD, most importantly thyroid-associated ophthalmopathy (TAO), where they induce fibroblast proliferation and enhance the production of glycosaminoglycans (GAG), resulting in proptosis and the other clinical features of the disease. In addition to these effects, exogenous administration of cytokines has been associated with impairment of thyroid function ranging from the appearance of autoantibodies alone to the development of frank thyroid dysfunction. Cytokines have also been implicated in subacute thyroiditis (SAT) and amiodarone-induced thyroid dysfunction, as well as in thyroid function abnormalities occurring in patients with non-thyroidal illnesses (NTI). Genetic variations in cytokine genes represent potential risk factors for ATD, and disease associations have been described for polymorphisms in IL-1ra and TNF beta genes. Recent experimental evidence suggests the possibility of novel cytokine-based therapeutic approaches for ATD and its complications, in particular TAO.

Cytokines in the ovary: pathophysiology and potential for pharmacological intervention

The ovary and testis are sites for interaction between the endocrine and immune system via leukocytes and their secreted products, the cytokines. There are convincing data available to show that the gonads are sites of cytokine action and production. In the ovary, cytokines and leukocytes are intimately involved in follicular development, ovulation, and luteal function. A variety of clinical situations may be due to cytokine action in the gonads, and therapeutic manipulation of the immune system may affect reproductive function.

Neuroimmunologic implications in coronary artery disease

In this review, the role of the macrophage in the pathophysiology of coronary artery disease (CAD) is examined. The central interaction of macrophage, endothelial cell and smooth muscle cell in the context of hyperlipidemia is considered. The macrophage appears to be at the beginning of a chain of events that starts with elevated low density lipoprotein (LDL). Stress, particularly in those with a core hostility, may be associated not only with higher catecholamine levels but also with higher serum lipid levels. These lipids will in turn be processed to oxidized LDL by macrophage and endothelial cells. Oxidized LDL molecules will contribute to atherosclerotic plaquing. A side effect of such plaque formation may be a diminished vasodilatory response to the nitric oxide (NO) produced by macrophages and endothelium. Indeed, paradoxical vasoconstriction occurs in atherosclerosis in response to neurotransmitters such as serotonin and acetylcholine, which under normal circumstances cause vasodilation. There also is evidence that both macrophages and endothelial cells can regulate NO production through a specific mu 3 morphine receptor, an effect that can be blocked by naloxone. The clinical effectiveness of morphine and nitroglycerin in CAD patients may relate to these mechanisms. More research will be needed to elucidate the neuroimmunologic basis for atherosclerosis with prospects for better treatment and management in future.

The protective role of the hypothalamic-pituitary-adrenal axis against lethality produced by immune, infectious, and inflammatory stress

We have shown that ADX and HYPOX rats exhibit a markedly increased sensitivity to the lethal effects of IL-1-beta and LPS compared to sham controls with an intact HPAA. These results indicated that the reports of lethal effects of cytokines and LPS which generates cytokines in mice with a compromised HPAA were not idiosyncratic or specific to mice but represented a general response that would have been expected in any organism with a compromised HPAA. We further demonstrated that protection against lethal effects due to IL-1-beta or LPS could be produced by treating ADX rats with glucocorticoid in a quantity estimated to be equivalent to corticosterone secretion provoked during stress. In contrast, we found that acutely stalk-sectioned rats with pituitaries disconnected from hypothalamic regulation did not show a markedly increased susceptibility to lethal effects of LPS as did ADX or HYPOX rats. Although a minority of stalk-sectioned rats were killed by LPS, the majority of rats were protected from lethal actions of LPS. This response suggested that an intact pituitary-adrenal axis without the normal hypothalamic control could still provide significant protection presumably due to generation of cytokines which stimulated the pituitary over several hours. The results from our lethality studies clearly underscore the importance of activating the stress axis and increasing glucocorticoid secretion to protect against potentially lethal effects of cytokines that can be induced by immune, infectious, or inflammatory stimuli. Cytokine-stimulated effects can initially result in beneficial actions to the host by promoting immune/inflammatory responses that are protective in nature and help defend against a variety of invading stimuli (infectious, immune, inflammatory, traumatic, neoplastic). Normally the HPAA responds to cytokine stimulation by ultimately increasing glucocorticoid secretion in order to counterregulate cytokine actions, modulate the host response, and protect the host from excessively catabolic effects of unregulated cytokine generation and actions. For many years, clinicians have recognized that patients with deficient glucocorticoid secretion (e.g., Addison's disease or pituitary ACTH deficiency) require increased glucocorticoid replacement during episodes of fever, infection, or inflammatory stress. However, the reasons why stress-equivalent glucocorticoid replacement were required were not entirely clear. Now, we understand that glucocorticoids are critically important for protecting the host against its own defense mechanisms so that the stimulation of cytokines can facilitate a protective response against an invading insult without also killing the host.

Hormonal and pregnancy relationships to rheumatoid arthritis: convergent effects with immunologic and microvascular systems

OBJECTIVE

To review sex hormones and rheumatoid arthritis (RA) and the interrelationships between hormonal, immunological, and vascular systems.

DATA SOURCES

Publications detailing serum sex hormone levels and their HLA interactions, steroidogenesis, pregnancy, and therapeutic uses of sex hormones in RA.

STUDY SELECTION

Controlled studies of sex hormone levels in RA patients not previously treated with glucocorticoids.

DATA EXTRACTION

Mean (+/- SD) serum levels of dehydroepiandrosterone sulfate (DHEAS), testosterone (T), and estradiol (E2).

DATA SYNTHESIS

Mean (+/- SD) levels were collated into tables for women with pre-versus postmenopausal onsets of disease and men. Data were also ordered across all study groups by increasing mean levels of the control subjects. Pooled data were summarized statistically, and major sources of variation between the studies were identified.

CONCLUSIONS

Serum DHEAS, an adrenal androgen, was impressively decreased among women with premenopausal onset of RA. One study showed such deficiency years before disease onset. Serum T was somewhat decreased in the premenopausal onset group, but could be explained by decreased peripheral conversion of the lower levels of adrenal androgens. Women with postmenopausal onset of RA had modestly decreased serum DHEAS levels overall, but no difference in serum T, compared with controls. Male RA cases had consistently decreased serum levels of T, but not of DHEAS. Serum E2 was comparable in all RA versus control groups. The complex biology of pregnancy was interpreted as an example of vital interactions between hormonal, immunological, and vascular systems, as they may relate to the physiopathology of RA. The major age, sex, and hereditable determinants of RA were compared within a composite table of estimated relative risks. Elucidation of the interacting risk factors offers promising avenues of research in this complex disease.

Glucocorticoids and immune function: physiological relevance and pathogenic potential of hormonal dysfunction

The more knowledge accumulates on the molecular action of glucocorticoids, the less appears to be known about the physiological relevance of these data. Mechanisms that determine bioactivity of glucocorticoids are largely neglected in studies on their molecular actions in immunoregulation. However, alterations of these mechanisms may contribute to the pathogenesis of acute of chronic inflammation, ranging from septic shock to autoimmune disease, or even acquired immuno deficiency syndrome. In this article, Thomas Wilckens attempts to challenge the long-standing dogma of glucocorticoids being only immunosuppressive in their action, and suggests a physiological role in which they are a prerequisite for a coordinated immune response.