In search of a dose-response relationship in SSRIs-a systematic review, meta-analysis, and network meta-analysis.

OBJECTIVE: Recent meta-analyses on dose-response relationships of SSRIs are largely based on indirect evidence. We analyzed RCTs directly comparing different SSRI doses. METHOD: Systematic literature search for RCTs. Two raters independently screened articles and extracted data. Across SSRIs, doses defined as low, medium, and high doses, based on drug manufacturers' product monographs, were analyzed in pairwise random-effects meta-analyses and in a sensitivity network meta-analysis with regard to differences in antidepressive efficacy (primary outcome). We also analyzed all direct comparisons of different dosages of specific SSRIs. (Prospero CRD42018081031). RESULTS: Out of 5333 articles screened, we included 33. Comparisons of dosage groups (low, medium, and high) resulted in only small and clinically non-significant differences for SSRIs as a group, the strongest relating to medium vs low doses (SMD: -0.15 [95%-CI: -0.28; -0.01) and not sustained in a sensitivity analysis. Among different doses of specific SSRIs, no statistically significant trend emerged for efficacy at higher doses, but 60 mg/day fluoxetine are statistically significantly inferior to 20 mg/day. Paroxetine results are inconclusive: 10 mg/day are inferior to higher doses, but 30 and 40 mg/day are inferior to 20 mg/day. Meaningful effects cannot be ruled out for certain drugs and dosages, often investigated in only one trial. Dropout rates increase with dose-particularly due to side effects. Network meta-analyses supported our findings. CONCLUSIONS: There is no conclusive level I or level II evidence of a clinically meaningful dose-response relationship of SSRIs as a group or of single substances. High SSRI doses are not recommended as routine treatment.

Main biomarkers associated with age-related plasma zinc decrease and copper/zinc ratio in healthy elderly from ZincAge study.

PURPOSE: Zinc (Zn) plays an essential role in many biological processes including immune response. Impaired Zn status promotes immune dysfunction, and it has been associated with enhanced chronic inflammation during aging. It has been suggested that the measurement of circulating Zn by itself could not reflect the real Zn status of an individual. It is therefore necessary to identify other determinants associated with plasma Zn to better understanding how physiopathological conditions during aging may affect the concentration of this metal. METHODS: We have investigated the association between Zn levels and some biomarkers in 1090 healthy elderly from five European countries to increase the accuracy in the assessment of the Zn status. Stepwise multivariate linear regression models were used to analyze the influence of factors such as age, dietary intake, inflammatory mediators, laboratory parameters and polymorphisms previously associated with Zn homeostasis. RESULTS: Plasma Zn decrement was most strongly predicted by age, while positive correlations were found with albumin, RANTES and Zn intake after adjustment for multiple confounders. HSP70 +1267 AA genotype was an independent factor associated with Zn plasma concentrations. Cu/Zn ratio was positively associated with markers of systemic inflammation and age and negatively associated with albumin serum levels. CONCLUSIONS: Our findings show the most important independent determinants of plasma Zn concentration and Cu/Zn ratio variability in elderly population and suggest that the decline with age of Zn circulating levels is more dependent on physiopathological changes occurring with aging rather than to its nutritional intake.

Effects of a short-term reduction in brain serotonin synthesis on the availability of the soluble leptin receptor in healthy women.

Serotonin (5-HT) and the hormone leptin have been linked to the underlying neurobiology of appetite regulation with evidence coming from animal and cellular research, but direct evidence linking these two pathways in humans is lacking. We examined the effects of reduced brain 5-HT synthesis due to acute tryptophan depletion (ATD) on levels of soluble leptin receptor (sOb-R), the main high-affinity leptin binding protein, in healthy adults using an exploratory approach. Women, but not men, showed reduced sOb-R concentrations after ATD administration. With females showing reduced baseline levels of central 5-HT synthesis compared to males diminished brain 5-HT synthesis affected the leptin axis through the sOb-R in females, thereby potentially influencing their vulnerability to dysfunctional appetite regulation and co-morbid mood symptoms.

Association among 1267 A/G HSP70-2, -308 G/A TNF-α polymorphisms and pro-inflammatory plasma mediators in old ZincAge population.

Proinflammatory cytokines and heat shock proteins play relevant roles in the pathogenesis of inflammatory diseases. We investigated whether Hsp70 1267 A/G and TNF-α -308 G/A polymorphisms are associated with proinflammatory mediators, zinc status and laboratory parameters in 1,078 healthy elderly from ZincAge study. Hsp70 1267 A/G genotype and allele distribution were similar among various European countries, while a TNF-α genetic heterogeneity was observed between the Northern and the Southern European populations, with a major frequency of the -308 A variant in France, Germany and Poland. We used linear regression models to test additive, dominant or recessive associations of each SNP with proinflammatory mediators, laboratory parameters, metallothioneins and zinc status. Hsp70 1267 A/G SNP, but not TNF-α -308 G/A SNP, influences TNF-α and IL-6 plasma levels under additive, dominant and recessive models (for TNF-α only). An association between Hsp70 1267 A/G SNP and zinc plasma levels was observed in the dominant model. In particular, G allele carriers showed increased circulating pro-inflammatory cytokines and zinc. Moreover, both these SNPs affect creatinine levels suggesting a possible influence on renal function. In conclusion, Hsp70 1267 A/G SNP is associated with pro-inflammatory cytokine production in healthy elderly and might represent a possible determinant of individual susceptibility to inflammatory diseases.

Zinc deficiency adversely influences interleukin-4 and interleukin-6 signaling.

Zinc deficiency is accompanied by a severe impairment of the immune system, causing a high risk for infections and autoimmune diseases due to altered functionality of B- and T- cells. The influence of zinc deficiency on T- and B- cells via alteration of cytokine expression is well established. The aim of this study was to examine potential direct effects of zinc deficiency on the reactivity of B- and T- cells. Zinc deficient B- and T- cells revealed divergent reaction patterns compared to zinc sufficienT-cells. This was manifested by a stronger proliferative response following IL-6 and IL-2 stimulation on the one hand, but less proliferation following IL-4 stimulation on the other hand. Moreover, these results were supported by the finding that the B- and T-cell signaling cascades activated by IL-4 or IL-6, respectively, were affected directly by zinc deficiency, resulting in reduced Stat6 phosphorylation and increased Stat3 phosphorylation. Whereas the transcription factor Stat6 is involved in IL-4 signaling, Stat3 is activated by IL-6 signaling. Consequently, these results show opposing effects of zinc deficiency on IL-4 and IL-6/IL-2 signaling pathways, thus underlying the importance of zinc for proper immune function.

A nonrandom association of gastrointestinal stromal tumor (GIST) and desmoid tumor (deep fibromatosis): case series of 28 patients.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) and desmoid tumors (DTs) are two rare mesenchymal tumor. Anecdotal reports of individuals with both diseases led us to make the hypothesis that the association is a nonrandom event as the probability would be extremely low to observe such cases if they were independent events. PATIENTS AND METHODS: We evaluated the existence of patients with GIST and DT in a large multicenter cohort at 10 institutions in the United States, Australia and Europe. Data on gender, age at diagnosis, KIT, PDGFRA, CTNNB1 mutation status and follow-up time after diagnosis were collected. RESULTS: We identified 28 patients diagnosed with both tumors. DT was diagnosed after GIST in 75% of patients and concomitantly in 21%. In only one case (4%), GIST was diagnosed after DT. KIT or PDGFRA mutations were detected in 12 of 14 GIST, 9 in KIT exon 11, 2 in KIT exon 9 and 1 in PDGFRA. CONCLUSION: A statistical analysis of these 28 cases suggests a nonrandom association between GIST and DT. Further studies may be able to elucidate the underlying biology responsible for this association.

Experimental peri-implant mucositis around titanium and zirconia implants in comparison to a natural tooth: part 2-clinical and microbiological parameters.

The aim of this study was to assess the clinical and microbiological parameters around dental zirconia and titanium implants compared with natural teeth during experimental plaque accumulation. Clinical parameters were evaluated (gingival index, plaque index, bleeding on probing, and probing pocket depth). Microbiological samples were analyzed for total bacterial cell counts, as well as Tannerella forsythia and Prevotella intermedia counts. A statistically significant difference over time was observed in the groups in terms of the gingival index (P<0.001), plaque index (P<0.001), and bleeding on probing (P=0.039). The lowest mean total number of bacterial cells was measured around the teeth, followed by the zirconia implants; the highest values were found around the titanium implants. T. forsythia and P. intermedia values showed significant changes over time and sessions around the titanium implants. Compared to the soft tissues around zirconia implants and the teeth, those around titanium implants developed a stronger inflammatory response to experimental plaque accumulation in terms of the total number of bacterial cells and T. forsythia and P. intermedia values.

Effects of zinc supplementation on antioxidant enzyme activities in healthy old subjects.

A large body of experimental research indicates that oxidative stress contributes to the processes related to aging and age-related diseases. Trace elements, particularly zinc (Zn), are essential components of the endogenous enzymatic antioxidant defenses. The aim of this study was to determine the activity of three main antioxidant enzymes in plasma [i.e. superoxide dismutase (pSOD), catalase (CAT), glutathione peroxidase (GPx)] and of SOD in erythrocyte (eSOD) in a group of 1108 healthy elderly subjects from different European countries. The same enzymatic activities were evaluated in a subgroup of 108 subjects before and after Zn supplementation. We observed that eSOD activity increased with age, whereas plasma Zn decreased. Moreover, we found that women showed higher eSOD activity and lower plasma Zn compared to men. There were no age and gender-related differences in the activities of pSOD, CAT and GPx. After Zn supplementation, the activities of Zn-dependent enzymes (pSOD and eSOD), as well as plasma Zn concentration, were significantly higher than before supplementation. These results were not influenced by age, gender, plasma Zn variations (Delta Zn) and geographic area. These data suggest the potential beneficial effects of Zn supplementation on Zn-dependent antioxidant enzymes in healthy elderly subjects.

The significance of zinc for leukocyte biology.

Zinc is an essential element important for growth, the nervous system, and especially the immune system. Zinc deficiency as well as levels well above normal, due to high-dose treatment, showed an impaired immune function. This review summarizes the current status of zinc's significance for leukocyte biology and health. In detail, the physiology of zinc and the impaired immune functions in zinc deficiency syndromes are described. The regulation of innate immunity as well as the function and maturation of lymphocytes and monocytes is critically discussed as a system dependent on the zinc concentration in vivo and in vitro. Furthermore, the influence of zinc on experimental systems as well as on widely used immunostimulants is described, showing the importance of the knowledge of zinc concentration in in vitro leukocyte studies. The specific interactions of zinc with immunologically important serum proteins, signal transduction components, and membrane functions is summarized, showing the molecular basis of this interaction as known so far. Finally, the therapeutic use of zinc is critically discussed with new aspects also using the immunosuppressive effects of zinc. In conclusion, these data show that the zinc concentration should be taken into account whenever complex alterations of immune functions are observed.

Influence of serum on zinc, toxic shock syndrome toxin-1, and lipopolysaccharide-induced production of IFN-gamma and IL-1 beta by human mononuclear cells.

Measurement of cytokine secretion in vitro is usually performed in culture medium supplemented with human serum. We compared the secretion of interferon-gamma and interleukin-1 beta as a parameter for lymphocyte and monocyte activation in RPMI 1640 medium supplemented with fetal calf or autologous serum in serum-free medium and protein-free medium. Four different stimulatory mechanisms were tested: phytohemagglutinin, toxic shock syndrome toxin-1 (TSST-1), lipopolysaccharide (LPS), and zinc ions. We found that the optimal stimulatory zinc concentration depended on the total protein content of the medium, whereas the monokine levels were dependent on the concentration of transport proteins such as transferrin. Monokine induction by LPS or TSST-1 were each influenced by the protein and serum composition in a specific manner. Our results show that the differing mechanisms of cytokine induction are influenced by the medium and serum composition in a diverse but specific manner. Serum- or protein-free medium are especially suitable after superantigen challenge when LPS activity needs to be ruled out or after activation by agents with only a weak stimulatory capacity.

Induction of interleukin-8 in human neutrophils after MHC class II cross-linking with superantigens.

Neutrophils have been shown to express major histocompatibility complex class II (MHC II) after stimulation. However, reports concerning the functional effect of MCH II expression are still lacking. In our hands, granulocyte-monocyte colony-stimulating factor (GM-CSF) alone and in combination with interferon (IFN)-gamma, but not IFN-gamma or interleukin (IL)-3, induced a significant level of expression of human leukocyte antigen DR on neutrophils. The addition of staphylococcal enterotoxin E to neutrophils resulted in a significant increase in IL-8 production only after prestimulation with GM-CSF alone or in combination with IFN-gamma but had no effect on neutrophils preincubated with IFN-gamma alone or IL-3. Staphylococcal enterotoxin A, another bivalent superantigen, also stimulated production of IL-8 by preincubated polymorphonuclear neutrophils, whereas staphylococcal enterotoxin A mutants that are not able to cross-link MHC II molecules failed to induce IL-8 production. Taken together, our results clearly demonstrate that after induction of MHC II, neutrophils are able to respond to MHC II-specific stimulation. These findings support the ideas that the induced MHC II complex is completely functional and that neutrophils may be able to present antigens.

The biochemical effects of extracellular Zn(2+) and other metal ions are severely affected by their speciation in cell culture media.

Investigations of physiological and toxicological effects of metal ions are frequently based on in vitro cell culture systems, in which cells are incubated with these ions in specialized culture media, instead of their physiological environment. This allows for targeted examination on the cellular or even molecular level. However, it disregards one important aspect, the different metal ion speciation under these conditions. This study explores the role of culture conditions in investigations with zinc ions (Zn(2+)). Their concentration is buffered by several orders of magnitude by fetal calf serum. Due to the complexity of serum and its many zinc-binding components, zinc speciation in culture media cannot be completely predicted. Still, the primary effect is due to the main Zn(2+)-binding protein albumin. Buffering reduces the free Zn(2+) concentration, thereby diminishing its biological effects, such as cytotoxicity and the impact on protein phosphorylation. This is not limited to Zn(2+), but is also observed with Ag(+), Cu(2+), Pb(2+), Cd(2+), Hg(2+), and Ni(2+). Usually, the serum content of culture media, and thereby their metal buffering capacity, is only a fraction of that in the physiological cellular environment. This leads to systematic over-estimation of the effects of extracellular metal ions when standard cell culture conditions are used as model systems for assessing potential in vivo effects.

One-way synergistic effect of low superantigen concentrations on lipopolysaccharide-induced cytokine production.

Lipopolysaccharides (LPS) of gram-negative bacteria and superantigens of gram-positive bacteria are among the main causes of sepsis and septic shock. Symptoms are initiated primarily by the release of endogenous mediators, especially cytokines. In the last few years, increasing evidence for the clinical relevance of mixed sepsis caused by coinfections with both types of bacteria has been found. Therefore, we developed an in vitro mixed sepsis model investigating the effect of different superantigen doses, in combination with different LPS concentrations, on cytokine production in human PBMCs using ELISA and RT-PCR. Low, in vivo relevant concentrations of the superantigen toxic shock syndrome toxin-1 (TSST-1) synergistically enhance LPS-induced production of interferon-gamma (IFN-gamma) interleukin-1 beta (IL-1 beta), IL-6, and IL-10, but low LPS has no comparable effect. Signal transduction studies with different inhibitors suggest that this one-way synergism is caused by an interaction between the cAMP and the PIP2 signaling pathway. Furthermore, our findings support the idea that this interaction is one important crossover point of signal transduction pathways by LPS and superantigens, which seems to be predominantly regulated by IFN-gamma and PGE-2. The identification of additional crossover points in the genesis of a mixed sepsis and their selective influence could lead to identical treatment of both gram-negative and gram-positive sepsis.

Zinc supplementation reconstitutes the production of interferon-alpha by leukocytes from elderly persons.

The elderly are more prone to virus infections and neoplasias than are young adults. During a virus infection, interferon-alpha (IFN-alpha), proteins with antiviral, antiproliferative, and immunomodulatory properties, are transiently expressed. We here report that peripheral white blood cells from 16 subjects with a mean age of 72 years yielded less IFN when stimulated with a virus in vitro than those from 16 young adults with a mean age of 28 years. Monocytes are the main source of this IFN. However, yields of another monocyte product, interleukin-6 (IL-6), were greater in cells from the older subjects than from the young adults, so there is no general defect in monocytes from the former. Immunodeficiency in the elderly has been reported to be associated with a deficiency of zinc. When cultures of white blood cells from the elderly were supplemented with 15 microM zinc (the physiologic concentration), they produced IFN in amounts comparable to those from the younger subjects.

Induction of a cytokine network by superantigens with parallel TH1 and TH2 stimulation.

Superantigens cross-link the MHC class II molecule on accessory cells with the V beta region of the TCR outside the antigen binding sites. In this study, we compared the capacity of the staphylococcal entertoxins (SE) A, B, C1, C2, C3, D, and E, the toxic shock syndrome toxin (TSST) 1, the exfoliative toxin (ExFT) A, and the Streptococcus pyogenes erythrogenic exotoxins (SPE) B and C to induce cytokine release in human peripheral blood mononuclear cells. We showed that all toxins tested induced IL-1 alpha and beta, IL-2, IL-4, IL-6, IFN-gamma, and TNF-alpha, but not IFN-alpha. However, we found that SPEB differed from all other toxins tested, because its cytokine induction was significantly lower than that of the other toxins. This was not true of IL-6 and IL-10 induction, in which SPEB showed similar amounts of IL-6 compared with all other toxins and of IL-10 in comparison to SEC2. SPEB showed a specificity for TH2 cells, whereas the other toxins stimulated TH1 as well as TH2 cells very strongly. As a result, superantigens appear to be able to uncouple the TH1/TH2 antagonism. Collectively, our results indicate that SPEB seems not to be a superantigen or represents a different group of microbial superantigens. Furthermore, superantigens stimulate TH1 as well as TH2 cells without any preference and therefore they are able to induce humoral as well as cellular immunity. This could be one reason for the existence of autoantibodies and autoreactive T cells in autoimmune diseases and one major step in the beginning of the induction of autoreactivity.

Induction of a proinflammatory cytokine network by Mycoplasma arthritidis-derived superantigen (MAS).

Mycoplasma arthritidis is an arthritogenic organism for rodents, producing a superantigen (MAS). It has been postulated that mycoplasmas or superantigens thereof might play a role in human rheumatoid arthritis. Since M. arthritidis fulfills both, the present study was performed to investigate MAS-specific cytokine induction. Human or murine leukocytes were stimulated with MAS, staphylococcal enterotoxin E (SEE), or lipopolysaccharide (LPS). Cytokines were measured by ELISA, Bioassay, and RT-PCR. The response to MAS in humans was individually restricted, in contrast to the response to SEE or LPS. Furthermore, MAS showed the same capacity for inducing proinflammatory cytokines as interleukin (IL)-1 IL-6, and IL-8 as SEE and LPS. However, MAS showed a significantly decreased capacity to induce the anti-inflammatory cytokine IL-10 and IL-1RA. In mice, the reactivity to MAS was strictly MHC-II restricted, in contrast to that of SEE or LPS. The individual response to MAS in humans might be explained by the difference of the HLA-DR haplotype because H-2-differing mouse strains showed the same discrepancies. MAS induced an overproduction of proinflammatory cytokines, when its ability to induce proinflammatory and anti-inflammatory cytokines was compared with those of SEE and LPS. The individual response may explain an MHC linkage, and the failure to induce anti-inflammatory cytokines may be the reason for a chronic disease in contrast to acute inflammation.

Microbial superantigens stimulate T cells by the superantigen bridge and independently by a cytokine pathway.

Superantigens cross-link the MHC II molecule on accessory cells with the Vbeta region of the T cell receptor (TCR). In this study, we compared the capacity of established superantigens for inducing cytokine release. The experimental protocol was generated to answer the question whether all superantigen effects are transmitted by the MHC/TCR cross-linkage and induce mainly a T cell response. We found that TSST-1, ExFTA, and SEC3 differed from all other superantigens tested because they stimulated a stronger monokine release. T cell proliferation after challenge with these superantigens was mainly mediated by a cytokine pathway and not by the cross-linkage of MHC and TCR. For the other superantigens, we were able to demonstrate that major immunomodulatory effect is mediated by the superantigen bridge. With the exception of these three superantigens, the proliferative response of superantigens correlated with their Vbeta specificity. Interleukin-1 (IL-1) and IL-6 were induced in monocytes by all superantigens, whereas tumor necrosis factor-alpha (TNF-alpha) was induced in T cells and by some superantigens, also in monocytes. IL-2 was always induced by the superantigen bridge, whereas interferon-gamma (IFN-gamma) was also induced indirectly by monokines. Collectively, our results indicate that not all superantigens are suitable for investigating superantigen-specific effects, as they show indirect (mitogenic) side effects. Observations for an individual superantigen are, therefore, not transferable to all other superantigens.

Human neutrophils produce macrophage inhibitory protein-1beta but not type i interferons in response to viral stimulation.

Several cell types have been shown to produce type I interferons (IFN). Of human leukocytes, monocytes and especially type 2 dendritic cell precursors (pDC2) seem to be the main producers and also have a wide spectrum of cytokine production. However, neutrophils seem to have a limited capacity for cytokine production but possess efficient defense mechanisms vs. bacterial infection by phagocytosis and degranulation. To determine whether they also have antiviral functions, IFN-alpha and IFN-beta were measured in preparations of pure neutrophils. The capacity of neutrophils to produce type I IFN is controversial. Additionally, macrophage inflammatory protein-1alpha (MIP-1alpha) and MIP-1beta were measured, as they are described to have indirect or direct antiviral activity. As stimulants, active and inactivated Newcastle disease virus (NDV), Sendai virus, and granulocyte colony-stimulating factor (G-CSF) were used. Peripheral blood mononuclear cells (PBMC) from the same donors were highly reactive to viral stimulation, whereas neutrophils failed to produce IFN but produced MIP-1beta in response to NDV. We conclude that neutrophils fail to prevent viral infection by IFN production but probably possess alternative mechanisms, such as secreting MIP-1beta in response to viruses.

Interferon-gamma (IFN-gamma) levels finally become stable with increasing age as revealed by using an ELISA corresponding to the bioactivity.

The immune status is a parameter of the capacity of the immune system to fend off microorganisms. The use of leukocyte subtyping to define the immune status is clinically established. IFN-gamma is a key cytokine directing the immune response. In this study, we investigated whether IFN-gamma is a more sensitive parameter of the immune status. All persons tested showed stable quantities of white blood cell counts over the whole study. Analyses of the lymphocyte subpopulations of two time points resulted in a strong correlation with high statistical significance for the percentage of CD3, CD4, CD8, CD19, CD45 -subtypes and CD56/16 positive cells. IFN-gamma production by the individuals correlates between these time points also, but only if an ELISA strongly correlating to IFN-gamma bioactivity was used instead of other commercial IFN-gamma ELISAs. The IFN-gamma production by males was less variable than by females. Furthermore, intraindividual differences in IFN-gamma secretion were minimal after the age of 46. In conclusion, our data demonstrate that IFN-gamma is a more sensitive parameter for the actual status of the immune system, since its titer shows alterations faster than leukocyte subtyping. Furthermore, leukocyte subtypes do not correspond to the production capacity of the regulatory cytokine IFN-gamma in healthy individuals.

Altered cytokine production in the elderly.

Elderly persons are more susceptible to bacterial and virus infections and neoplasias than young adults. This is related to an impaired immune response. Lymphocytes of the elderly show a decreased proliferation after induction with mitogens. The decreased proliferation is correlated to a decreased release of interleukin (IL)-2 and soluble IL-2 receptor (sIL-2R). However, IL-2R expression on the cell surface is normal. Interferon (IFN)-gamma as the main T-helper-1 (TH1) cytokine is produced less by lymphocytes of the elderly, whereas the TH2 cytokines IL-4 and IL-10 are produced in higher amounts as compared to stimulated lymphocytes of young donors. The decreased production of IFN-gamma is correlated to a decreased number of CD45RO+/CD8+ T cells. Therefore in the elderly there seems to be a dysregulation in the TH1/TH2-system which is predominated by TH2-functions. Monocyte function seems to be increased in the elderly. Leukocytes of elderly persons produce higher amounts of IL-1, IL-6, IL-8 and tumor necrosis factor (TNF)-alpha after induction with lipopolysaccharide (LPS) than leukocytes from young donors. In contrast, in vitro induction of IFN-alpha by viruses is decreased in the elderly compared to the young. In conclusion, there are cellular defects and dysfunctions in the elderly resulting in an altered immune response.