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The effects of aging on hydromorphone-induced thermal antinociception in healthy female cats. Pain Rep 2019; 4:e722. [PMID: 31041422 PMCID: PMC6455684 DOI: 10.1097/pr9.0000000000000722] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/18/2018] [Accepted: 01/17/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction: This study aimed to evaluate the effects of aging on hydromorphone-induced thermal antinociception in cats. Methods: In a prospective, randomized, blinded, controlled design, 10 healthy female cats received each of the following treatments intramuscularly: hydromorphone (0.1 mg/kg) and 0.9% saline (0.05 mL/kg) with a 1-week washout between treatments at 6, 9, and 12 months of age. Skin temperature and thermal thresholds (TTs) were recorded before and up to 12 hours after injection. Data were analyzed using a repeated-measures linear mixed model (α = 0.05). Results: After saline treatment, TT was not significantly different from baseline at any time point for any age group. After hydromorphone treatment, TT was significantly higher than baseline at 6 months for up to 1 hour, and at 9 and 12 months for up to 4 hours. Peak TT at 6, 9, and 12 months were 50.4 ± 2.7, 50.9 ± 2.0, and 53.6 ± 2.0°C at 0.5, 1, and 1 hours, respectively. Mean TT was significantly higher after hydromorphone treatment when compared with saline treatment at 9 and 12 months for up to 4 hours but not at 6 months. Magnitude of antinociception was consistently larger at 12 months when compared with 6 months of age. Hydromorphone provided a shorter duration and smaller magnitude of antinociception at 6 months when compared with 9 and 12 months. Conclusion: Pediatric cats may require more frequent dosing of hydromorphone than adults.
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2
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A history of chronic morphine exposure during adolescence increases despair-like behaviour and strain-dependently promotes sociability in abstinent adult mice. Behav Brain Res 2013; 243:44-52. [PMID: 23295400 DOI: 10.1016/j.bbr.2012.12.049] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 12/20/2012] [Accepted: 12/27/2012] [Indexed: 11/22/2022]
Abstract
A crucial issue in treating opiate addiction, a chronic relapsing disorder, is to maintain a drug-free abstinent state. Prolonged abstinence associates with mood disorders, strongly contributing to relapse. In particular, substance use disorders occurring during adolescence predispose to depression later in adulthood. Using our established mouse model of opiate abstinence, we characterized emotional consequences into adulthood of morphine exposure during adolescence. Our results indicate that morphine treatment in adolescent mice has no effect on anxiety-like behaviours in adult mice, after abstinence. In contrast, morphine treatment during adolescence increases behavioural despair in adult mice. We also show that morphine exposure strain-dependently enhances sociability in adult mice. Additional research will be required to understand where and how morphine acts during brain maturation to affect emotional and social behaviours into adulthood.
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Abstract
It is not known if the fetus can actually feel pain, but noxious stimulation during fetal life does cause detectable stress responses. These responses cause both short and long-term changes in the central nervous system, which can affect subsequent pain behaviour. Reducing the stress response is known to be beneficial in children and adults and recent evidence suggests this is also true for the fetus. However, the optimal amount of suppression required and the best method of achieving this (opioid or regional anaesthesia techniques) remain unknown. Prevention and treatment of pain is a basic human right, regardless of age, and if the technique of fetal surgery is to progress then a greater understanding of nociception and the stress response is required.
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Affiliation(s)
- Michelle C White
- Department of Anaesthesia, Bristol School of Anaesthesia, Southmead Hospital, Southmead Road, Bristol BS10 5NB, UK
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4
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Kivell BM, Day DJ, McDonald FJ, Miller JH. Developmental expression of mu and delta opioid receptors in the rat brainstem: evidence for a postnatal switch in mu isoform expression. BRAIN RESEARCH. DEVELOPMENTAL BRAIN RESEARCH 2004; 148:185-96. [PMID: 14766196 DOI: 10.1016/j.devbrainres.2003.12.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/16/2003] [Indexed: 11/22/2022]
Abstract
Opioid receptors are expressed in the brain during fetal and postnatal development, and the expression patterns vary with developmental age. To investigate the role of opioids in brain development, immunoblotting and immunohistochemical techniques were used to determine mu (MOR) and delta (DOR) opioid receptor expression levels and regional distributions in fetal, early postnatal and adult rat brainstem. Two immunoreactive bands were seen on Western blots of brainstem lysates for both MOR (50 and 70 kDa) and DOR (30 and 60 kDa). The expression levels of the isoforms changed dramatically between 6 and 15 days after birth. Total MOR protein was expressed at low levels in fetal and early postnatal animals with the 50-kDa band predominating. MOR expression then increased in the older animals and the 70-kDa isoform became dominant. Total DOR protein showed the opposite pattern, being high in the fetal and neonatal brainstem and low in the juvenile and adult. A postnatal switch in isoform expression for DOR was not evident in our study. In general, regional brainstem distributions in developing and adult animals were comparable to those reported in the literature, and both receptors were localized in the same areas where opioid receptor expression was high. It was concluded that MOR and DOR are developmentally regulated in the brainstem of the rat, that the isoform ratio switches postnatally from a fetal-neonatal pattern to a juvenile-adult pattern and that both receptors are generally expressed in the same brainstem regions from E16 to adult.
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MESH Headings
- Animals
- Animals, Newborn
- Blotting, Western/methods
- Brain Stem/embryology
- Brain Stem/growth & development
- Brain Stem/metabolism
- Cell Line, Tumor
- Embryo, Mammalian
- Female
- Gene Expression Regulation, Developmental
- Immunohistochemistry/methods
- Male
- Neuroblastoma
- Pregnancy
- Rats
- Rats, Wistar
- Receptors, Opioid, delta/genetics
- Receptors, Opioid, delta/metabolism
- Receptors, Opioid, mu/genetics
- Receptors, Opioid, mu/metabolism
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Affiliation(s)
- Bronwyn M Kivell
- School of Biological Sciences, Victoria University of Wellington, P.O. Box 600, Wellington, New Zealand
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5
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Tong Y, Chabot JG, Shen SH, O'Dowd BF, George SR, Quirion R. Ontogenic profile of the expression of the mu opioid receptor gene in the rat telencephalon and diencephalon: an in situ hybridization study. J Chem Neuroanat 2000; 18:209-22. [PMID: 10781737 DOI: 10.1016/s0891-0618(00)00043-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The developmental profile of mu (mu) opioid receptor gene expression has been characterized in the embryonic, postnatal and adult rat brain by in situ hybridization histochemistry. By ED12, mu opioid receptor mRNA was detectable in the deep neuroepithelium of the cortical plate. In the developing rat central nervous system (ED13-PD40), transcripts were seen over numerous telencephalic and diencephalic structures, such as the olfactory bulb, caudate-putamen, nucleus accumbens, amygdaloid complex, hippocampal formation, hypothalamus and thalamus. In the vast majority of brain regions examined, the developmental profile of the mu opioid receptor gene expression is similar to that of its translated protein as established using receptor autoradiography. Once a hybridization signal is detected in the prenatal period, it gradually increased to reach maximal levels during the second and third postnatal weeks. By the end of the third postnatal week, mu opioid receptor mRNA levels decreased to reach amounts seen in adulthood. Our study demonstrates that mu opioid receptor gene expression is seen very early on in the embryonic rat brain with transient increases observed during the critical period of neurogenesis, neuronal migration and synaptogenesis, suggesting a role of this opioid receptor subtype in brain developmental processes.
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Affiliation(s)
- Y Tong
- Douglas Hospital Research Centre, Department of Psychiatry, McGill University, 6875 LaSalle Blvd, Verdun, Canada
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6
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Sanchez MD, Milanés MV, Pazos A, Diaz A, Laorden ML. Autoradiographic evidence of delta-opioid receptor downregulation after prenatal stress in offspring rat brain. Pharmacology 2000; 60:13-8. [PMID: 10629438 DOI: 10.1159/000028341] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In order to visualize neuroanatomical alterations in specific brain regions, light microscopy autoradiography was carried out on offsprings (postnatal day 10) from female rats stressed in different periods of gestation and controls. Group 1 was subjected to restraint stress from day 2 to 6; group 2, from day 7 to 11; group 3, from day 12 to 16; group 4 from day 2 to 16. Group 2 showed decreases in delta-opioid receptor density in different hypothalamic regions. The decrease in delta-opioid receptor density was less marked in groups 1 and 3 whereas there was no modification in group 4. Present data suggest that the prenatal stress induces a downregulation of delta-receptors in different hypothalamic regions.
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Affiliation(s)
- M D Sanchez
- Department of Physiology and Pharmacology, University School of Medicine, Murcia, Spain
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7
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Sanchez MD, Milanés MV, Pazos A, Diaz A, Laorden ML. Autoradiographic evidence of mu-opioid receptors down-regulation after prenatal stress in offspring rat brain. BRAIN RESEARCH. DEVELOPMENTAL BRAIN RESEARCH 1996; 94:14-21. [PMID: 8816272 DOI: 10.1016/0165-3806(96)00032-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In order to visualize neuroanatomical alterations in specific brain regions, light microscopy autoradiography was carried out on offspring (postnatal day 10) from female rats stressed in different periods of gestation and controls. Group 1 was subjected to restraint stress from day 2 to 6; group 2, from day 7 to 11; group 3, from day 12 to 16; group 4, from day 2 to 16. Group 2 showed pronounce decreases in mu-opioid receptor density in different brain regions. The decrease in mu-opioid receptor density was less marked in the group 1, 3 and 4. Present data suggest that the prenatal stress induce down-regulation of mu-receptors in different brain regions.
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Affiliation(s)
- M D Sanchez
- Department of Physiology and Pharmacology, University School of Medicine, Murcia, Spain
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8
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Ebbesson LO, Deviche P, Ebbesson SO. Distribution and changes in mu- and kappa-opiate receptors during the midlife neurodevelopmental period of Coho salmon, Oncorhynchus kisutch. J Comp Neurol 1996; 366:448-64. [PMID: 8907358 DOI: 10.1002/(sici)1096-9861(19960311)366:3<448::aid-cne6>3.0.co;2-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Parr-smolt transformation (PST) in coho salmon is associated with a plasma thyroid hormone (PT4) surge and a critical period of neural development that includes axonal sprouting, neurogenesis, and surges of select neurotransmitters. Here we provide a description of the selectivity, distribution, and the changes in the density of mu- and kappa-opiate receptors during PST, as revealed by quantitative in vitro autoradiography of [3H]Tyr-D-Ala-Gly-NMe-Phe-Gly-ol ([3H]DAMGO) and [3H]ethylketocyclazocine ([3H]EKC), respectively. The concentration of mu-receptors increased significantly in select cell groups in the early stages of parr-smolt transformation, until a peak was reached at the time coinciding with the peak of the PT4 surge. In other cell groups, the peaks occurred 1 or 2 weeks later. With one exception, this increase was followed by a decrease in concentration. The brain areas showing the highest concentrations are the dorsal nucleus of the ventral telencephalic area, the glomerular region, the granular layer of the valvula cerebelli, the nucleus diffuses of the inferior lobe, and the nucleus diffuses of the torus lateralis. Other regions with distinctly elevated mu-receptor concentrations are the stratum griseum centrale of the optic tectum and the preoptic area. The distribution of kappa-receptors is more diffuse, and the densities are considerably lower. The overlap in distribution of mu- and kappa-receptors is considerable, but significant exceptions are noted. For example, the dorsomedial nucleus of the dorsal telencephalic area, the habenular nucleus, and the dorsomedial nucleus of the thalamus exhibit a surge in density of kappa-receptors at the time of the PT4 surge, while the density of mu-receptors in these nuclei remain very low throughout parr-smolt transformation. The kappa-receptor containing cell groups are not identifiable until 3 weeks before the PT4 surge because of low densities. The most prominently labeled kappa-receptor regions are the ventral and dorsal nuclei of the ventral telencephalic area, the medial and dorsal zones of the dorsal telencephalic area, the optic tectum (all layers), the dorsomedial nucleus of the thalamus, the torus lateralis of the ventral hypothalamus, and the preoptic area. An increase of mu- and kappa-opiate receptor densities in specific brain regions may reflect roles in the alteration of brain organization, olfactory imprinting, neuroendocrine activity or other physiological activities. The overall distribution of these receptors are relatively more extensive in salmon than in other vertebrates so far studied.
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MESH Headings
- 3,4-Dichloro-N-methyl-N-(2-(1-pyrrolidinyl)-cyclohexyl)-benzeneacetamide, (trans)-Isomer
- Analgesics/pharmacology
- Animals
- Autoradiography
- Binding, Competitive/physiology
- Brain/physiology
- Brain Chemistry
- Enkephalin, Ala(2)-MePhe(4)-Gly(5)-
- Enkephalin, D-Penicillamine (2,5)-
- Enkephalins/pharmacology
- Oncorhynchus kisutch/growth & development
- Pyrrolidines/pharmacology
- Receptors, Opioid, kappa/agonists
- Receptors, Opioid, kappa/analysis
- Receptors, Opioid, kappa/metabolism
- Receptors, Opioid, mu/agonists
- Receptors, Opioid, mu/analysis
- Receptors, Opioid, mu/metabolism
- Thyroxine/blood
- Tritium
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Affiliation(s)
- L O Ebbesson
- Institute of Marine Science, University of Alaska, Fairbanks 99775, USA
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Gorodinsky A, Barg J, Belcheva MM, Levy R, McHale RJ, Vogel Z, Coscia CJ. Dynorphins modulate DNA synthesis in fetal brain cell aggregates. J Neurochem 1995; 65:1481-6. [PMID: 7561841 PMCID: PMC2581519 DOI: 10.1046/j.1471-4159.1995.65041481.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Previously, opioid peptide analogues, beta-endorphin, and synthetic opiates were found to inhibit DNA synthesis in 7-day fetal rat brain cell aggregates via kappa- and mu-opioid receptors. Here dynorphins and other endogenous opioid peptides were investigated for their effect on DNA synthesis in rat and guinea pig brain cell aggregates. At 1 microM, all dynorphins tested and beta-endorphin inhibited [3H]thymidine incorporation into DNA by 20-38% in 7-day rat brain cell aggregates. The putative epsilon-antagonist beta-endorphin (1-27) did not prevent the effect of beta-endorphin, suggesting that the epsilon-receptor is not involved in opioid inhibition of DNA synthesis. The kappa-selective antagonist norbinaltorphimine blocked dynorphin A or B inhibition of DNA synthesis, implicating a kappa-opioid receptor. In dose-dependency studies, dynorphin B was three orders of magnitude more potent than dynorphin A in the attenuation of thymidine incorporation, indicative of the mediation of its action by a discrete kappa-receptor subtype. The IC50 value of 0.1 nM estimated for dynorphin B is in the physiological range for dynorphins in developing brain. In guinea pig brain cell aggregates, the kappa-receptor agonists U50488, U69593, and dynorphin B reduced thymidine incorporation by 40%. When 21-day aggregates were treated with dynorphins, a 33-86% enhancement of thymidine incorporation was observed. Because both 7- and 21-day aggregates correspond to stages in development when glial cell proliferation is prevalent and glia preferentially express kappa-receptors in rat brain, these findings support the hypothesis that dynorphins modulate glial DNA synthesis during brain ontogeny.
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Affiliation(s)
- A Gorodinsky
- Department of Biochemistry and Molecular Biology, St. Louis University School of Medicine, MO 63104-1079, USA
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10
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Behar L, Marx R, Sadot E, Barg J, Ginzburg I. cis-acting signals and trans-acting proteins are involved in tau mRNA targeting into neurites of differentiating neuronal cells. Int J Dev Neurosci 1995; 13:113-27. [PMID: 7639096 DOI: 10.1016/0736-5748(95)00001-w] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Tau microtubule-associated protein is a neuron specific protein found primarily in axons and is developmentally regulated. The function of tau is in stabilization of microtubules, which is important in establishing and maintaining neuronal morphology. Axonal localization of tau involves a multistep process which is studied in differentiating primary neuronal culture. The initial step involves sorting and subcellular localization of its encoding mRNA into the proximal portion of the axon. Using the transfection assay into neuronal cells, we have demonstrated that sequences located in the 3'-untranslated region include a cis-acting signal which is involved in tau mRNA targeting. In addition, using ultraviolet cross-linking assay, two RNA-binding proteins of 43 and 38 kDa were identified, that exhibit specific binding to a minimal sequence of 91 nucleotides located within the same functional region, which is involved in targeting. The 43 and 38-kDa RNA-binding proteins are present in cytoplasmic extracts, prepared from neuronal cells, and in isolated microtubule preparations. Our results support a novel model in which cis-acting signals, together with RNA-binding proteins are involved in the targeting of tau mRNA, that may ultimately lead to its axonal localization.
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Affiliation(s)
- L Behar
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
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Barg J, Belcheva M, Rowinski J, Ho A, Burke WJ, Chung HD, Schmidt CA, Coscia CJ. Opioid receptor density changes in Alzheimer amygdala and putamen. Brain Res 1993; 632:209-15. [PMID: 8149229 DOI: 10.1016/0006-8993(93)91155-l] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Since opioids can influence the release of acetylcholine, substance P and a number of other neurotransmitters that have been implicated in the pathogenesis of Alzheimer's disease (AD), it is of interest to assess opioid receptor levels in AD. We have examined mu, delta and kappa opioid receptor binding parameters, binding sensitivity to a GTP analog and distribution in amygdala, frontal cortex and putamen of AD brain. Control brains were matched according to age, sex, post-mortem interval and storage time. Kd values and GTP analog binding sensitivity did not differ in AD and control brains. Bmax values for mu ([3H]DAMGE) sites also appeared unaffected by in vitro binding assays. In contrast, kappa ([3H]U69593) and delta ([3H]DSLET) opioid receptor levels, were significantly changed. In AD amygdala kappa Bmax values increased from control levels of 123 +/- 12 to 168 +/- 13 fmol/mg protein, whereas densities of kappa and delta sites were decreased from 94 +/- 8 to 48 +/- 8 and 102 +/- 3.6 to 69 +/- 8.5 fmol/mg protein, respectively, in putamen. Autoradiography revealed corresponding differences in the distribution of kappa opioid receptors. The findings indicate that the kappa binding site, which is quantitatively the major opioid receptor class in human brain, undergoes marked changes in AD amygdala and putamen.
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MESH Headings
- Aged
- Aged, 80 and over
- Alzheimer Disease/metabolism
- Alzheimer Disease/pathology
- Amygdala/metabolism
- Amygdala/pathology
- Analgesics/metabolism
- Autoradiography
- Benzeneacetamides
- Enkephalin, Ala(2)-MePhe(4)-Gly(5)-
- Enkephalin, Leucine/analogs & derivatives
- Enkephalin, Leucine/metabolism
- Enkephalins/metabolism
- Female
- Frontal Lobe/metabolism
- Frontal Lobe/pathology
- Humans
- Kinetics
- Male
- Putamen/metabolism
- Putamen/pathology
- Pyrrolidines/metabolism
- Receptors, Opioid, delta/analysis
- Receptors, Opioid, delta/metabolism
- Receptors, Opioid, kappa/analysis
- Receptors, Opioid, kappa/metabolism
- Receptors, Opioid, mu/analysis
- Receptors, Opioid, mu/metabolism
- Reference Values
- Tritium
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Affiliation(s)
- J Barg
- Department of Biochemistry and Molecular Biology, St. Louis University, MO 63104-1079
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12
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Abstract
This paper is the fifteenth installment of our annual review of research concerning the opiate system. It includes papers published during 1992 involving the behavioral, non-analgesic, effects of the endogenous opiate peptides. The specific topics this year include stress; tolerance and dependence; eating; drinking; gastrointestinal and renal function; mental illness and mood; learning, memory, and reward; cardiovascular responses; respiration and thermoregulation; seizures and other neurological disorders; electrical-related activity; general activity and locomotion; sex, pregnancy, and development; immunological responses; and other behaviors.
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Affiliation(s)
- G A Olson
- Department of Psychology, University of New Orleans, LA 70148
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13
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Barg J, Belcheva M, McHale R, Levy R, Vogel Z, Coscia CJ. Beta-endorphin is a potent inhibitor of thymidine incorporation into DNA via mu- and kappa-opioid receptors in fetal rat brain cell aggregates in culture. J Neurochem 1993; 60:765-7. [PMID: 8380443 PMCID: PMC2571952 DOI: 10.1111/j.1471-4159.1993.tb03214.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Thymidine incorporation into DNA was inhibited dose-dependently by beta-endorphin in rat fetal brain cell aggregate cultures. The inhibition was reversed partially by mu (cyclic D-Phe-Cys-Tyr-D-Trp-Orn-Thr- Pen-Thr amide) or kappa (norbinaltorphimine) antagonists. Complete blockade of the beta-endorphin inhibitory effect was achieved only on concomitant exposure to both antagonists. Eadie-Hofstee analysis revealed that beta-endorphin inhibited thymidine incorporation noncompetitively. In the presence of protease inhibitors, beta-endorphin decreased thymidine incorporation with an IC50 of 0.7 nM. Truncated and N-acetylated beta-endorphin derivatives, which bind with low affinity to opioid receptors, did not affect thymidine incorporation. These findings indicate that beta-endorphin at physiological concentrations can regulate thymidine incorporation in cultured brain cells.
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MESH Headings
- Animals
- Brain/drug effects
- Brain/metabolism
- Cell Aggregation
- Cells, Cultured
- DNA/biosynthesis
- Enkephalin, D-Penicillamine (2,5)-
- Enkephalin, Leucine-2-Alanine/pharmacology
- Enkephalins/pharmacology
- Fetus
- Kinetics
- Rats
- Receptors, Opioid, kappa/drug effects
- Receptors, Opioid, kappa/physiology
- Receptors, Opioid, mu/drug effects
- Receptors, Opioid, mu/physiology
- Thymidine/metabolism
- Tritium
- beta-Endorphin/analogs & derivatives
- beta-Endorphin/pharmacology
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Affiliation(s)
- J Barg
- E. A. Doisy Department of Biochemistry and Molecular Biology, St. Louis University School of Medicine, MO 63104-1079
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