ACTH Response Research Articles

ODP045 Implantation of Steroidogenic Cells Derived from Human Adipose-derived Stem Cells Extends Survival in a Mouse Model of Adrenal Insufficiency

Abstract Cell therapy has an advantage of compensating hormone in response to physiological stimuli. We have previously shown that mouse mesenchymal stem cells (MSCs) were transformed into steroidogenic cells by forced expression of NR5A1 (a master regulator of steroidogenesis, also known as SF-1/Ad4BP) and that the syngeneic implantation of NR5A1-induced steroidogenic cells extended survival of bilateral adrenoectomised (bAdx) mice. However, ACTH receptor is not induced by NR5A1 in mouse MSCs, and ACTH responsiveness was not detected in recipient mice. In contrast to mice, in human MSCs, ACTH receptor is induced by NR5A1 and ACTH enhances steroid production in NR5A1 induced-steroidogenic cells in vitro studies. In the present study, we implanted human ADSCs-derived steroidogenic cells into immunodeficient mice with adrenal insufficiency. Human adipose tissue-derived stem cells (ADSCs) were inoculated with recombinant adenovirus containing human NR5A1 or LacZ cDNA (MOI=50) and cultured for 7 days. NR5A1 induced-steroidogenic cells secreted both adrenal and gonadal steroids and responded to ACTH. Before xenotransplantation studies, adrenal glands of SCID/Beige mice were surgically removed and implanted into under capsule of the kidney. bAdx mice were dead within 9 days (N=11), bAdx mice (N=12) transplanted with adrenal glands survived to the endpoint of 30 days, and died within 9 days after removal of the kidney containing the graft. We next implanted NR5A1-induced steroidogenic cells or control cells into bAdx mice. The overall survival rate (endpoint of 30 days) of NR5A1 implanted mice was 16.7%, (N=12) while control cell implanted mice died within 13 days (N=10). Median survival time of bAdx mice implanted with NR5A1 induced-steroidogenic cells and control ADSCs was 16. 0 and 11. 0 days, respectively (log-rank test, p < 0. 0001). In the NR5A1 induced-steroidogenic cells implanted mice, serum aldosterone was undetectable, whereas serum corticosterone and cortisol were detectable. Although we performed ACTH loading test on bAdx mice implanted with NR5A1-induced steroidogenic cells, no ACTH responsiveness was detected. The expression of Pomc mRNA in the pituitary gland was increased by bAdx, whereas this increase was not suppressed by implantation of steroid-producing cells (N=3), suggesting that the amount of steroids in the graft complemented survival but was insufficient for negative feedback. These results indicate that human ADSCs are transformed into steroidogenic cells by NR5A1 and are responsive to ACTH in vitro but not in vivo. Xenotransplantation of the induced steroidogenic cells into immunodeficient bAdx mice prolonged the survival, which was supported by the significant detection of basal serum corticosterone and cortisol levels. In particular, serum cortisol indicated hormone secretion from the grafts, suggesting that human ADSCs may also be useful as a regenerative source of steroid-producing cells. Presentation: No date and time listed

LBODP006 Clinical Usefulness Of The Growth Hormone-releasing Peptide-2 Test For Hypothalamic-pituitary Disorder

Abstract Purpose Growth hormone deficiency (GHD) develops early in patients with hypothalamic-pituitary disorder and is frequently accompanied by other anterior pituitary hormone deficiencies including secondary adrenal insufficiency (AI). A growth hormone-releasing peptide-2 (GHRP2), which is wildly used for the diagnosis of patients with GHD, has been considered to induce not only growth hormone (GH) release but also ACTH release. However, its clinical usefulness in hypothalamic-pituitary disorder is unclear. Methods The GHRP2 test, a cosyntropin stimulation test, corticotropin-releasing hormone (CRH) tests and/or insulin tolerance tests (ITTs) were performed on 36 patients having hypothalamic-pituitary disorder. Results Twenty-two (61%) had severe GHD, and 3 (8%) had moderate GHD by GHRP2. There was no difference in baseline ACTH and cortisol between non-GHD, moderate GHD and severe GHD participants. However, a cosyntropin stimulation test and subsequent CRH tests and/or ITTs revealed that 17 (47%) had secondary AI and 16/17 (94%) cases of secondary AI were concomitant with severe GHD. ROC curve analysis demonstrated that the ACTH response in the GHRP2 test was useful for screening pituitary-AI, with a cut-off value of 1.55-fold (83% sensitivity and 88% specificity). Notably, the combination of ACTH response and the peak cortisol level in the GHRP2 test using each cut-off value (1.55-fold and 10 µg/dl, respectively) showed high specificity (100%) with high accuracy (0.94) for diagnosis of pituitary-AI. Conclusion We recommend measuring ACTH as well as GH during the GHRP2 test to avoid overlooking and delays in diagnosis of secondary AI that frequently accompanies GHD. Presentation: No date and time listed

RF09 | PSAT88 Pro-opiomelanocortin (POMC), ACTH and Cortisol Responses to Pediatric Cardiac Surgery

Abstract Introduction In critically ill adults, high plasma free cortisol in face of suppressed plasma ACTH coincides with high plasma pro-opiomelanocortin (POMC), the ACTH precursor (1). Further augmenting the systemic glucocorticoid availability with hydrocortisone treatment further lowered plasma ACTH, while plasma POMC remained unaffected (2). The dynamics of POMC in relation to ACTH and free cortisol prior to intensive care unit (ICU) admission are unknown, as well as the impact hereon of glucocorticoid treatment. Also, elevated plasma POMC concentrations have not yet been confirmed in pediatric ICU (PICU) patients. In pediatric cardiac surgery-induced critical illness, we hypothesized that plasma POMC is elevated and that plasma ACTH transiently rises per-operatively and becomes suppressed once free cortisol has risen on PICU day 1 and 2. In addition, we hypothesized that in patients receiving glucocorticoids per-operatively, plasma ACTH is further suppressed while plasma POMC is unaffected. Methods From 53 children aged 0-36 months, who underwent cardiac surgery and were admitted to the PICU, blood samples were taken prior to surgery (pre-operatively, available samples N=51), during surgery (per-operatively, N=47), on the following morning (PICU day 1, N=40) and the day hereafter (PICU day 2, N=24). Blood samples were also collected from 24 age- and gender-matched healthy children. To investigate the impact of synthetic glucocorticoid treatment on the endogenous plasma hormone concentrations, patients were categorized into steroid-naive (total N=38) and steroid-treated patients (total N=15). Plasma hormone concentrations were quantified with highly-specific ELISA (POMC), RIA (ACTH, cortisol, CBG) or colorimetric assays (albumin). Cross reactivity with synthetic glucocorticoids within the used cortisol RIA is minimal (<0.27% for methylprednisolone, <0.1% for dexamethasone). Free cortisol was estimated with the adapted Coolens’ formula. Results Plasma POMC was increased pre-operatively (p<0.0001) but no longer thereafter (p>0.05), irrespective of steroid treatment. Plasma ACTH in patients was never higher than in healthy children. While in steroid-naive patients, plasma ACTH became suppressed only by PICU day 1 (p<0.0001), steroid-treated patients had already suppressed plasma ACTH per-operatively (p≤0.0001). In steroid-naive patients, plasma free cortisol was increased from per-operatively onwards (p≤0.002), while in steroid-treated patients, plasma free cortisol (endogenous) concentrations always remained comparable to those of healthy children (p>0.05). Conclusion Pre-operatively high plasma POMC, not followed by increased ACTH, suggests a centrally-activated HPA-axis already prior to surgery and an immature pituitary processing of POMC into ACTH. Systemic glucocorticoid availability is elevated from surgery onwards, likely driven by ACTH-independent mechanisms. Further increasing systemic glucocorticoid availability exogenously with glucocorticoid administration accelerates the suppression of plasma ACTH. The long-term impact of early glucocorticoid treatment in critically ill children remains to be investigated. References (1) Téblick A. et al. Critical Care 2021. (2) Téblick A. et al. Endocrinology 2022. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:42 p.m. - 1:47 p.m.

PMON17 Impaired cortisol regulation in Myotonic dystrophy

Abstract Introduction - Myotonic dystrophy (MD) is the most common cause of adult-onset muscular dystrophy. It has impaired HPA axis regulation with exaggerated ACTH response to CRH mediated stimuli and abnormal cortisol metabolism. We present a case of myotonic dystrophy in a male with elevated cortisol levels. Case report - 54-year-old male with a past medical history of type 1 myotonic dystrophy (MD1) presented for evaluation of hypogonadism with complaints of feeling fatigued, progressive weakness of muscles. During the workup, he was noted to have elevated cortisol levels 30.2 mcg/dL (6-18.4) with elevated ACTH 220 pg/mL (10-48). Other notable lab results included low total testosterone levels of 231, 185 with elevated LH of 17.3 m IU/ml (2-9) and FSH 37.7 m IU/ml (1-12). Prolactin levels were minimally elevated to 21.4 ng/mL (4-15.2). On further inquiry, the patient did not have headaches or vision changes. The patient did not report weight gain, easy bruising, change in facial appearance. Physical exam was significant for bilateral gynecomastia and small testes. No cushingoid facies, abdominal stria, proximal myopathy was noted. Given elevated ACTH and cortisol levels, further laboratory data showed a lack of suppression of cortisol levels with 1 mg dexamethasone - cortisol 2.9 micro g/dL (<1.8), elevated midnight salivary cortisol - 0.130, 0.102 ug/dl (0.010-0.090), and normal 24-hour urine cortisol levels -15 mcg/24 hours. Discussion – Even though Cushing's disease is one of the differential diagnoses for the above case, high cortisol levels have been reported in MD. Few mechanisms suggested causing this abnormality are increased ACTH responsiveness to CRH-mediated stimuli and abnormal cortisol metabolism. Patients with MD have high pro-inflammatory (IL-1 and TNF-a) markers, which mediate the increased ACTH responsiveness to CRH-mediated stimuli centrally by stimulating the HPA axis.1 In addition, IL-6 chronically stimulates steroidogenesis from the adrenal gland, whereas TNF-α inhibits ACTH-induced adrenal steroid synthesis and increases 11BHSD1 activity. Along with the impaired HP axis, abnormal metabolism of cortisol also contributes to elevated cortisol levels. Increased activity of 11 BHSD1 has been hypothesized to cause impaired clearance of cortisol.2 Impaired diurnal variation for cortisol is also seen in MD with elevated 24-hour cortisol levels. Elevated cortisol levels as in our case can be a diagnostic dilemma given impaired cortisol regulation as seen in MD. References Åsa Johansson et.al. Abnormal Cytokine and Adrenocortical Hormone Regulation in Myotonic Dystrophy, The Journal of Clinical Endocrinology & Metabolism, Volume 85, Issue 9, 1 September 2000, Pages 3169–76.Åsa Johansson et.al. Glucocorticoid Metabolism and Adrenocortical Reactivity to ACTH in Myotonic Dystrophy, The Journal of Clinical Endocrinology & Metabolism, Volume 86, Issue 9, 1 September 2001, Pages 4276–83 Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Recurrent suicide attempts affect normalization of HPA axis dysregulation after recovery from major depression.

More than 700,000 people worldwide die by suicide every year, and the number of suicide attempts is estimated as 20 times higher, most of them being associated with psychiatric disorders, especially major depression. Knowledge about effective methods for preventing suicide attempts in individuals at high risk for suicide is still scarce. Dysregulation of the neuroendocrine stress response system, i.e., the hypothalamic-pituitary-adrenocortical (HPA) axis, is one of the most consistent neurobiological findings in both major depression and suicidality. While the HPA axis is mostly overactive in depression, individuals with a history of suicide attempts exhibit an attenuated hormonal response to stress. It is unknown, however, whether the HPA axis is constantly attenuated in repeated suicide attempters or whether it regains normal responsivity after recovery from depression. Using the combined dexamethasone suppression/corticotropin-releasing hormone (dex/CRH) test, we assessed HPA axis regulation in acute depression (N = 237) and after recovery with respect to previous suicide attempts. Patients without previous suicide attempts show normalization of the stress hormone response to the second dex/CRH (basal ACTH response and cortisol response) after recovery from acute depression, while patients with multiple previous SA show an increased ACTH response. The change in HPA axis responsivity in patients with only one previous SA lies between the response patterns of the other groups with no change in HPA axis reactivity. Our findings suggest that patients with a history of suicide attempts belong to a subgroup of individuals that exhibit a distinct pattern of stress hormone response during acute depression and after recovery. Future studies may extend our approach by investigating additional psychological stress tasks to gain a broader understanding of the stress pathology of recurrent suicide attempters.

Ectopic ACTH-producing neuroendocrine tumor occurring with large recurrent metastatic pheochromocytoma: a case report

BackgroundEctopic ACTH-dependent Cushing syndrome is rarely caused by pheochromocytoma (PCC). Glucocorticoid-regulated positive feedback loops in ACTH and catecholamines were proposed in some similar cases.Case presentationWe present here an 80-year-old man who had previously undergone surgery for a left adrenal PCC and newly developed severe hypertension, hypokalemia, and typical Cushingoid manifestations. Investigations revealed hyperglycemia, hypokalemia, and extremely high catecholamines and their metabolites, ACTH and cortisol. Imaging modalities showed a recurrent large left adrenal mass positively visualized with 123I-metaiodobenzylguanidine as well as somatostatin receptor scintigraphy. Surgical interventions were not indicated; thus, metyrapone, phentolamine, and doxazocin were initiated, which successfully controlled his symptoms and biochemical conditions. With the evidence that metyrapone administration decreased ACTH and catecholamine levels, the existence of positive feedback loops was speculated. During the terminal stages of the disease, additional metyrosine treatment successfully stabilized his physiological and biochemical conditions. Upon the patient’s death, pathological autopsy was performed. Immunohistochemical analysis indicated that the tumor appeared to be co-positive with tyrosine hydroxylase (TH) as well as ACTH in most tumor cells in both PCC and liver metastasis. Most cells were clearly positive for somatostatin receptor 2 staining in the membrane compartment. The dense immunostaining of ACTH, TH, dopamine-β-hydroxylase and the large tumor size with positive feedback loops may be correlated with high levels of ACTH and catecholamines in the circulation.ConclusionsWe experienced a case of severe ectopic ACTH producing the largest reported recurrent malignant left PCC with liver metastases that presented positive feedback loops in the ACTH/cortisol and catecholamine/cortisol axes. Clinicians should be aware of the paradoxical response of ACTH on metyrapone treatment and possible steroid-induced catecholamine crisis.

Clinical Usefulness of the Growth Hormone-Releasing Peptide-2 Test for Hypothalamic-Pituitary Disorder.

ContextGrowth hormone deficiency (GHD) develops early in patients with hypothalamic-pituitary disorder and is frequently accompanied by other anterior pituitary hormone deficiencies, including secondary adrenal insufficiency (AI). A growth hormone–releasing peptide-2 (GHRP2) test, which is widely used for the diagnosis of patients with GHD, is thought to induce release of not only growth hormone (GH) but also ACTH. However, its clinical usefulness in hypothalamic-pituitary disorder is unclear.ObjectiveWe aimed to determine the clinical utility of the GHRP2 test in patients with hypothalamic-pituitary disorders, particularly for AI concomitant with GHD.MethodsThe GHRP2 test, a cosyntropin stimulation test, corticotropin-releasing hormone (CRH) tests, and/or insulin tolerance tests (ITTs) were performed on 36 patients with hypothalamic-pituitary disorder.ResultsTwenty-two (61%) had severe GHD, and 3 (8%) had moderate GHD by GHRP2. There was no difference in baseline ACTH and cortisol between non-GHD, moderate GHD, and severe GHD participants. However, a cosyntropin stimulation test and subsequent CRH tests and/or ITTs revealed that 17 (47%) had secondary AI and 16/17 (94%) cases of secondary AI were concomitant with severe GHD. ROC curve analysis demonstrated that the ACTH response in the GHRP2 test was useful for screening pituitary-AI, with a cutoff value of 1.55-fold (83% sensitivity and 88% specificity). Notably, the combination of ACTH response and the peak cortisol level in the GHRP2 test using each cutoff value (1.55-fold and 10 µg/dL, respectively) showed high specificity (100%) with high accuracy (0.94) for diagnosis of pituitary-AI.ConclusionWe recommend measuring ACTH as well as GH during the GHRP2 test to avoid overlooking or delaying diagnosis of secondary AI that frequently accompanies GHD.

Responsiveness to DDAVP in Cushing's disease is associated with USP8 mutations through enhancing AVPR1B promoter activity.

To clarify the characteristics of Cushing's disease (CD) patients who respond to the desmopressin (DDAVP) test and its underlying mechanisms. Forty-seven patients with CD who underwent DDAVP testing were included. Patients were divided into two groups: DDAVP test (+) (adrenocorticotropic hormone [ACTH] levels increased by ≥ 1.5-fold during the DDAVP test) and DDAVP test (-) (ACTH levels increased by < 1.5-fold). AVP receptor expression levels in these tumors were quantified using quantitative RT-PCR and immunohistochemistry. AVP receptor promoter activity was analyzed using a dual-luciferase reporter assay system. Females (96.9%) and USP8 mutants (85.7%) were more prevalent in the DDAVP test (+) than in the DDAVP test (-). Indeed, the ACTH and cortisol responsiveness to DDAVP was greater in USP8 mutation positive tumors than that in USP8 wild type tumors (3.0-fold vs. 1.3-fold, 1.6-fold vs. 1.1-fold, respectively). Responsiveness to DDAVP was correlated with the expression levels of AVPR1B, but not with those of AVPR2. Comparably, Avpr1b promoter activity was enhanced by the overexpression of mutant USP8 compared to the wild type. We found that the responsiveness of ACTH to DDAVP in CD was greater in tumors with USP8 mutations. The present data suggest that USP8 mutations upregulate the AVPR1B promoter activity. Additionally, we showed that the DDAVP test can predict the presence of USP8 mutations.

Dexamethasone, Interleukin 6, and the Adrenal Gland are the Real Battles for COVID-19: Our Molecular Docking, Physiological, and Immunological Explanations of Why the Clinical Benefit of Dexamethasone is More Evident in Males

More than two years have passed since the pandemic and despite all the efforts of researchers, the pathogenesis of the SARS-CoV-2 has not yet been resolved. The SARS-CoV-2 coronavirus that causes COVID-19 has high ability of mutation resulting in different variants of the virus. This mutation helps the virus bypass the body's immune defenses such as innate and adaptive immunity. Interleukin (Il-6), neutrophils, high ferritin, and high D dimer are crucial markers for all sorts of cells on the lengthy path to treatment of COVID-19. IL-6 is one of the key mediators of inflammation and viral cytokine storm in COVID-19 patients. In humans, interleukin (IL)-6 is a strong stimulator of the hypothalamic-pituitary-adrenal (HPA) axis at all levels, and it appears to have a pathogenic role in chronic stress and physiological aging. The adrenal glands have earned further recognition as key modulators of immune function, because secretory products of the adrenal glands. Dexamethasone inhibits TNF-α–induced IL-6 mRNA expression and protein secretion by reducing IL-6 mRNA stability. Although Dexamethasone provides benefits in patients with coronavirus disease but there is sex linked difference between male and female at response to this drug. It was showed that this drug might indeed have an effect in treating covid-19 but the clinical benefit of dexamethasone is more evident in males. Here we propose a testable hypothesis that dexamethasone may be effective in men better than female owing to two factors the first is the ability of males to induce high secretion of adrenal hormone under stress vs female. In males both stressors induced a significant increase, whereas in female adrenal e excretion remained on the same level under the two stress conditions. Both Adrenal e hormones and dexamethasone are hypothesized to promote blood neutrophil levels by increasing neutrophil exit from bone marrow, delaying neutrophil outflow from circulation, and lengthening the half-life of circulating neutrophils. Neutrophils a type of white blood cells that can downregulate interferon-stimulated genes, i.e., suppress their activity. When male patients received the steroid treatment, the dysregulated interferon signals went away quickly. But in female patients, the proportions of neutrophils were not as high and they did not react to the steroids in the same way. The second factor is that ACTH response to il-6 is stronger in males than females and ACTH was found to induce il-6. Therefore, male interact with dexamethasone better than females. Additionally, dexamethasone does not affect Il-6 secreted from the adrenal cortex, which allows Il-6 to be produced during stress and increase neutrophil ratio leading to stronger response in males. We need a new classification of IL-6 at physiological and pathological aspects, as the stimulatory factors are different. it was found that ACTH is h Endocrine Il-6 is stimulated by ACTH, but immune Il-6 is stimulated by il-1β and angiotensin II. Of note, dexamethasone critically saves COVID-19 patients but has no effect on Il-6 of endocrine (ACTH stimulated) origin, either basal or stimulated. We studied the molecular docking of dexamethasone with interleukin-6 and showed that the binding interaction of dexamethasone with interleukin-6 was with high binding affinity (-6.7 Kcal/mol)

DHEA-S production capacity in relation to perceived prolonged stress

We and other research groups have previously described that levels of the anabolic hormone dehydroepiandrosterone sulfate (DHEA-S) are lowered in individuals who report prolonged stress. We have also shown that the DHEA-S production capacity during acute stress is attenuated in individuals reporting high prolonged stress. This study aimed to further investigate the DHEA and DHEA-S production capacity in relation to prolonged stress. Eighty-one healthy participants in the age 20–50 years old were included in the study and divided into a low stress (n = 45) and a high stress group (n = 36) according their response to a single question regarding perceived stress during the preceding month. They underwent the Trier Social Stress Test while blood samples were drawn before, during and after the stress test. The concentration of DHEA, DHEA-S, cortisol and ACTH was measured. The results showed that the high stress group exhibited a significantly lower response of DHEA-S (40% lower) than the low stress group, while DHEA, cortisol and ACTH responses did not differ between the groups. Reduced DHEA-S production may constitute one of the links between stress and poor health.

Repeated restraint stress induced neurobehavioral and sexual hormone disorders in male rats.

Several studies have demonstrated that depression include disruptions not only for mental human disorders but also their healthy living. Rodent-based behavioral tests and models are widely used to understand the mechanisms by which stress triggers anxiety-related behaviors.This present study examined the evidence of a chronic restraint stress (CRS) paradigm in male Wistar rats for the progressive nature of depression alongside with related changes in behavior and functions. The body weight was determined, and the behavior tests, including sucrose preference and the open field test were performed. Theses parameters confirme the presence of anxiety-like and depression-like behaviors beside that we will focus on the response of ACTH and testosterone concentrations in rats.The results obtained during the experiment show that CRS led to decrease the time spent in the field center, a decrease of total distance travelled, in the stressed group compared with the control group. A significant increased of ACTH levels and decreased in testosterone hormone levels in the CRS. According to these results the CRS rodent model has value to validating the development for depression.

Cellular and serotonergic correlates of habituated neuroendocrine responses in male and female rats.

Male and females appear equally capable of showing habituated hypothalamic-pituitary-adrenal (HPA) axis output responses to repeated exposures of the same challenge. Whether this reflects, within males and females, common mechanisms of decreased neuronal activity within stress responding, afferents to the paraventricular hypothalamic nucleus (PVH), the final common pathway to the HPA axis, has not been examined. Here we compared in adult male and female rats the extent to which declines in HPA axis responses to repeated restraint are met by habituated cellular (Fos) responses, in addition to changes in serotonin (5-hydroxytryptamine; 5-HT) expression and signaling, which normally stimulates the HPA axis. Thus, alterations in this component of HPA axis drive could provide an underlying basis for sex differences in adaptive responses. Males and females showed reliable declines in ACTH and corticosterone responses after 10 daily episodes of repeated restraint, recapitulated, in largest part, by similar regional patterns of Fos habituation, including within the PVH, several stress sensitive cell groups of the limbic forebrain, as well as within the raphe nucleus. Serotonin staining in the dorsal raphe and terminal profiles in the forebrain continued to reflect a higher pre-synaptic capacity for the 5-HT system in females. The sexual dimorphism encountered within the lateral septum and medial preoptic area of control animals was less distinguished in the repeat condition, however, whereas 5-HT varicosities in the PVH increased after repeated restraint only in females. Relative to their singly restrained counterparts, males displayed an increase in 5-HT 1 A receptor expression in the raphe nucleus after repeated restraint, whereas females showed a decrease in 5-HT 1 A mRNA levels in the hippocampus and in the zona incerta, representing the most proximal of cell groups expressing the 5-HT 1 A receptor in the vicinity of the PVH. In conclusion, similar regional profiles of cellular habituation in males and females suggest common CNS substrates of neuroendocrine adaptation. However, this process may be met by underlying sex differences in serotonergic control, given the respective roles for pre- and postsynaptic 5-HT 1 A receptors in mediating serotonin availability and signal transfer.

Associations of Childhood Neglect With the ACTH and Plasma Cortisol Stress Response in Patients With Type 2 Diabetes.

Background: Cross-sectional as well as longitudinal studies have linked childhood maltreatment to type 2 diabetes in adulthood with childhood neglect showing the strongest effect on type 2 diabetes risk. However, the mechanisms that link childhood maltreatment to type 2 diabetes are still unclear. Alterations in the psychological and physiological stress response system, specifically the hypothalamus-pituitary-adrenal (HPA) axis are a common finding in samples with a background of childhood neglect and are associated with type 2 diabetes. In the present study, we investigated the association between childhood neglect and the physiological and psychological stress response in patients with type 2 diabetes and healthy control participants.Method: We assessed emotional and physical childhood neglect in a sample of n = 74 patients with type 2 diabetes and n = 50 healthy control participants. We used the trier social stress test (TSST) to induce a stress response. Blood ACTH and cortisol levels were measured before (T0), directly after (T1) as well as 30 (T2) and 60 (T3) min after the TSST. Participants' subjective experience was assessed via visual analog scales before, directly after as well as at 45 min after the TSST. We used multiple regression analyses to predict the change in self-reported tension between T0 and T1. Multilevel models were applied to predict cortisol and ACTH levels across all measurement points.Results: We found a significant association between moderate to severe childhood neglect and a stronger psychological stress response in patients with type 2 diabetes, that was not present in healthy controls. In type 2 diabetes patients, but not in healthy controls, higher ACTH levels across all measurement points were significantly associated with higher severity of emotional neglect and higher severity of physical neglect was significantly associated with a stronger increase in plasma cortisol from T0 to T1.Conclusions: This is the first study to investigate whether childhood maltreatment in patients with type 2 diabetes could be associated with a dysregulated stress response. Our results show a link between the psychological and physiological stress response and childhood neglect in type 2 diabetes patients. This pathway is thus a possible mechanism connecting type 2 diabetes and childhood neglect.

Male long-Evans rats: An outbred model of marked hypothalamic-pituitary-adrenal hyperactivity

Rat and mouse strains differ in behavioral and physiological characteristics, and such differences can contribute to explain discrepant results between laboratories and better select the most appropriate strain for a particular purpose. Differences in the activity of the hypothalamic-pituitary-adrenal (HPA) axis are particularly important given the pivotal role of this system in determining consequences of exposure to stressors. In this regard, Long-Evans (LE) rats are widely used in stress research, but there is no specific study aiming at thoroughly characterizing HPA activity in LE versus other extensively used strains. In a first experiment, LE showed higher resting ACTH and corticosterone levels only at certain points of the circadian rhythm, but much greater ACTH responsiveness to stressors (novel environment and forced swim) than Sprague-Dawley (SD) rats. Accordingly, enhanced corticotropin-releasing hormone (CRH) expression in the paraventricular nucleus of the hypothalamus and reduced expression of glucocorticoid receptors were observed in the hippocampal formation. Additionally, they are hyperactive in novel environments, and prone to adopt passive-like behavior when compared to SD rats. Supporting that altered HPA function has a marked physiological impact, we observed in another set of animals much lower thymus weight in LE than SD rats. Finally, to demonstrate that LE rats are likely to have higher HPA responsiveness to stressors than most strains, we studied resting and stress levels of HPA hormones in LE versus Wistar and Fischer rats, the latter considered an example of high HPA responsiveness. Again, LE showed higher resting and stress levels of ACTH than both Wistar and Fischer rats. As ACTH responsiveness to stressors in LE rats is stronger than that previously reported when comparing other rat strains and they are commercially available, they could be an appropriate model for studying the behavioral and physiological implications of a hyper-active HPA axis under normal and pathological conditions.

The Cortisol and ACTH Response to Dex/CRH Testing in Women With and Without Perimenopausal Depression.

Abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis are frequent accompaniments of depression, and studies have documented the role of stress and stressful life events in the ontogeny of perimenopausal depressions (PMD). Because HPA axis function in women is further modulated both by aging and ovarian steroids, it is possible that a dysregulated HPA axis contributes to the increased risk of PMD. We examined HPA axis function in perimenopausal women with and without depression using the combined dexamethasone-corticotropin-releasing hormone (Dex/CRH) test. Dex/CRH tests were performed on 20 women with PMD and 20 women who were also perimenopausal but without current or past depression (control women). Main outcome measures were plasma levels of cortisol and adrenocorticotropin (ACTH) and 24-hour urinary free cortisol (UFC). Five women took chronic stable medications, otherwise all women were medically healthy, and both groups were comparable with respect to reproductive stage and age. Standardized symptom rating scales were administered to each woman prior to Dex/CRH testing. No group differences were present in either baseline or stimulated ACTH and cortisol secretion. Baseline plasma measures of estradiol, progesterone, and 24-hour UFC levels similarly did not differ in PMD and control women. Despite reports of increased stress responsiveness in PMD, we observed no abnormalities of HPA axis activity associated with PMD compared with women without depression. These findings suggest that PMD is not uniformly associated with HPA dysregulation and could reflect underlying pathophysiologic processes that are distinct from women with nonreproductive-related depressions.

Effects of weariness of life, suicide ideations and suicide attempt on HPA axis regulation in depression

The neuropathological mechanisms leading to suicidality are still unknown, which, in view of an annual toll of around 1 million completed suicides constitutes an urgent clinical and societal problem. Alterations of stress hormone (ACTH and cortisol, representing the activity of the hypothalamic-pituitary-adrenocortical, HPA axis) regulation has been repeatedly studied in context of suicidality. Following a suicide attempt, stress hormone activity seems to be blunted, while depressed patients with suicidal ideation often present with elevated HPA axis activity. MethodsWe investigated the effects of different forms of suicidality on HPA axis regulation in 568 hospitalized patients of the Munich Antidepressant Response Signature (MARS) project. All patients had a diagnosis of a depressive disorder; 62 patients reported a recent suicide attempt, 192 patients suicide ideation, and 171 patients expressed weariness of life as the weakest form of suicidality, the latter not being analyzed in studies so far. All patients participated in the combined dexamethasone/corticotropin releasing hormone (dex/CRH) test for assessing HPA axis regulation shortly after admission to the hospital. ResultsWe found an increased ACTH and cortisol response following the dex/CRH-test in patients that were weary of life. In contrast, stress hormone response in suicide attempters and suicide ideators did not differ from non-suicidal patients. Further, repeated suicide attempts in patients’ history were associated with more pronounced stress hormone attenuation. ConclusionIn this so far largest study analyzing the HPA axis with respect to suicidality, we could not confirm the assumption of a general attenuation of HPA axis response in depressed suicide ideators and attempters. Conversely, HPA axis appears to be influenced by divergent effects of a specific suicidal psychopathology as well as outlasting effects of previous suicide attempts. We discuss these findings in the light of recent concepts of suicidality, pointing to multifactorial effects of acute and predisposing conditions on HPA axis reactivity in depressed patients.

A Re-Examination of the oCRH Stimulation Test for the Diagnosis of Ectopic ACTH Secretion

Background: Previous studies of the oCRH test for the differential diagnosis of ACTH-dependent Cushing’s syndrome gave imprecise point estimates of specificity because of small numbers (n<20) of patients with ectopic ACTH secretion (EAS). We examined a large EAS population to re-assess the test’s performance and whether benign tumors were associated with a positive response (i.e. Cushing’s disease (CD). Methods: We evaluated 103 EAS patients, including 58 females, with median age of 38 years (range 10 - 83); 99 had surgically-proven tumors and four had biochemical testing consistent with EAS. ACTH and cortisol were measured 5 and 0 minutes before and 15, 30 and 45 minutes after administration of oCRH, 1 ug/kg up to 100 ug, iv. Previous criteria were used to determine EAS responses: mean ACTH increase of <34% at 15 and 30 min or mean cortisol increase of <20% at 30 and 45 min. Mean responses and UFC (expressed as fold increase above upper limit of normal, ULN) were compared with t-tests; a p-value of < 0.05 was considered significant. Results: Tumor types included NET (pulmonary n=67; with 4 spindle type and 5 tumorlets, thymic n=9, pancreas n=7, appendix n=1, prostate n=1), SCLC (N=3), pheochromocytoma/paraganglioma (n=3/1), metastatic without known primary (n=3), teratoma with corticotroph elements (n=1) and occult (n=4). 23 patients had “CD” responses that were significantly higher than those of non-responders: 11 with ACTH (mean+SD: 83.7 + 49.8% vs 1.2 + 18.8%, p=00025), 15 with cortisol (mean+SD: 34.7 + 8.9% vs -1.7 + 14.2%, p< 0.00001). Three patients responded to both ACTH and cortisol. Among the ACTH (only) responders, 6 had cortisol increases of < 10% (range 0-2-8.5%); a similar discordant response was seen among cortisol (only) responders, of whom 7 had ACTH increases of <20% (range -18 - 13.4%). 70% of responders, including 3 with both ACTH and cortisol responses, had pulmonary NET (n=13), spindle cell NET (n=2) or tumorlets (n=4). Other responders had thymic NET (n=3), appendiceal NET n=1, teratoma (n=1) or were occult (n=2). The patient with corticotroph elements in a teratoma had an ACTH response only. UFC fold-increases above ULN were similar in responders and non-responders (20.20 + 26.9 xULN vs 31.4 + 38.4 xULN, p =0.21). Four of 10 patients with UFC cyclicity responded to CRH. Conclusions: Among patients with EAS the rate of false positive responses to CRH was similar to that of initial reports, 11–15%, and was associated with hormonal cyclicity and presence of a thymic carcinoid. The marked discordance of ACTH and cortisol responses may result from reduced sensitivity to ACTH, less biologically active ACTH, or autonomous cortisol release.

Testing of Adrenal Axis Function in Patients With Combined Pituitary Hormone Deficiency Caused by PROP1 Mutation

Background: The mechanism of adrenal axis deterioration in PROP1 mutation remains uncertain and challenging. Aim: The aim of the project was to investigate the adrenal axis function in patients with combined pituitary function deficiency and PROP1 mutation. Methods: We performed the corticotrophin (CRH) stimulation test in 15 patients ((8W/7M) with confirmed CPHD due to the PROP1 mutation. 9/15 were familial cases from four families. Time of observation (ToO) was calculated since the first pituitary axis/ACTH insufficiency has occurred. The results were reported in the group with confirmed Adrenal Insufficiency (AI) and without AI defined as cortisol >18 ug/dl at any point during CRH test. ACTH is reported in pg/ml and cortisol in ug/dl, time of test is given in minutes (0‘, 15’,30’,45’,60’,120’). Results: The mean age of the group was 40,6 ± 12,1 years with mean 34,7 ± 10,3 years of CPHD observation (range 18 – 54 years). The In 5/15 the cortisol response met the criteria excluding AI. Among siblings there were patients both with/without AI. Both subgroups had similar ToO (without AI 35,6 ± 10,0 years vs 34,2 ± 10,3 years with AI). Mean time of AI duration was 15,0 ± 9,3 years. In the group of 5 patients without AI the mean morning cortisol was 12,48 ± 4,31 and ACTH was 31,26 ± 5,43. The mean maximal concentration of cortisol and ACTH were 24,94 ± 3,6 and 123,6 ± 39,9 respectively; Mean increase of cortisol was 12,46 ±4,04 and 92,34±34,48 for ACTH. In 10 patients with AI the mean morning cortisol was 3,33±1,39 and ACTH 22,71±6,75. The mean maximal concentration of cortisol and ACTH were 10,15±4,47 and 97,05 ± 59,15 respectively; Mean increase of cortisol was 6,83 ± 3,41 and 74,35 ± 53,72 for ACTH. For two patients high ACTH increase from 36,7 to 260 and from 28,65 to 112,0 was observed. Analysis of cortisol and ACTH response in both groups revealed that in group without AI the time of peak of ACTH was observed in 15’ (2/5) and 30’ (3/5) vs. in 15’(3/10), 30’(6/10) and 45’ in group with AI. The peak cortisol was observed in 30’, 45’ and 60’ (3/5) in group without AI vs 60’(6/10) or 120’ (4/10) in AI group. The mean maximal increase of ACTH was by 4,09±1,46 and 4,12±1,58 in AI group vs no AI group respectively. Conclusions: In patients with PROP1 mutation the adrenal axis can deteriorate long after other axis insufficiencies, however there are patients with no adrenal insufficiency even during lifelong observation. There is no specific order of deterioration even among affected siblings. In the vast majority of patients independently of cortisol increase there is ACTH response after CRH. Further studies on the pituitary function deterioration in patients with PROP1 mutation should be carried out to understand better the underlying mechanism and to set up the diagnostic timing and procedures.

Concordant pattern of the HPA axis response to visceral stimulation and CRH administration

The physiological and psychological mechanisms explaining the individual variability in the stress response are poorly understood. We tested the hypothesis that hypothalamic-pituitary- adrenal (HPA) axis responses to colorectal stimulation affect HPA axis reactivity to corticotropin-releasing hormone (CRH), the visceral pain threshold, and perceived stress. We examined 31 healthy volunteers and 27 individuals with irritable bowel syndrome. According to the ACTH response to colorectal stimulation, the participants were classified into three groups: flattened, decreased, and increased. We found significant differences in the abdominal pain threshold, discomfort threshold, and sensitivity to anxiety among the groups. There were significant differences in the ACTH change and peak level after CRH administration among the groups. The area under the curve of the cortisol response to CRH was significantly different among the groups. The increased group showed a higher basal ACTH level, earlier peak level in the CRH administration test, and higher stress rating during the experiment. The increased group had an exaggerated psychological and physiological stress response, whereas the decreased group had a higher anticipatory endocrine response, stress, and sensitivity to anxiety. Further studies are needed to determine factors including gut microbiota on the individual difference in HPA response.

Glucagon, insulin, adrenocorticotropic hormone, and cortisol in response to carbohydrates and fasting in healthy neonatal foals.

BackgroundThe endocrine pancreas and hypothalamic‐pituitary‐adrenal axis (HPAA) are central to energy homeostasis, but information on their dynamics in response to energy challenges in healthy newborn foals is lacking.ObjectivesTo evaluate glucagon, insulin, ACTH, and cortisol response to fasting and carbohydrate administration in healthy foals.AnimalsTwenty‐two healthy Standardbred foals ≤4 days of age.MethodsFoals were assigned to fasted (n = 6), IV glucose (IVGT; n = 5), PO glucose (OGT; n = 5), and PO lactose (OLT; n = 6) test groups. Blood samples were collected frequently for 210 minutes. Nursing was allowed from 180 to 210 minutes. Plasma glucagon, ACTH, serum insulin, and cortisol concentrations were measured using immunoassays.ResultsPlasma glucagon concentration decreased relative to baseline at 45, 90, and 180 minutes during the OLT (P = .03), but no differences occurred in other test groups. Nursing stimulated marked increases in plasma glucagon, serum insulin, and glucose concentrations in all test groups (P < .001). Plasma ACTH concentration increased relative to baseline at 180 minutes (P < .05) during fasting and OLT, but no differences occurred in other test groups. Serum cortisol concentration increased relative to baseline during OLT at 180 minutes (P = .04), but no differences occurred in other test groups. Nursing resulted in decreased plasma ACTH and serum cortisol concentrations in all test groups (P < .01).Conclusions and Clinical ImportanceThe endocrine response to enterally and parenterally administered carbohydrates, including the major endocrine response to nursing, suggests that factors in milk other than carbohydrates are strong stimulators (directly or indirectly) of the endocrine pancreas and HPAA.