A common polymorphism of the glucocorticoid-receptor gene is related to outcome of intensive care therapy
A common polymorphism of the glucocorticoid-receptor gene is related to traumatic
memories and post-traumatic stress disorder in patients after intensive care therapy
Daniela Hauera/# MD; Florian Weisa/# MD; Andreas Papassotiropoulosc,d MD; Michael
Schmoeckele MD; Julia Liekea MS; Ines Kaufmanna MD; Fabian Kirchhoffg; Michael Voge-
serg MD; Benno Roozendaalb PhD; Josef Briegela MD; Dominique de Quervainf MD and
Department of Anaesthesiologya, Cardiac Surgerye and Clinical Chemistryg, Ludwig-
Maximilians University, Munich, Germany; Department of Neuroscience, Section Anatomyb,
University Medical Center Groningen, University of Groningen, The Netherlands; Division of
Molecular Psychologyc, Life Sciences Training Facilityd, Biozentrum; University of Basel,
Switzerland; Division of Cognitive Neurosciencef, University of Basel, Switzerland
Florian Weis, MD Ludwig – Maximilians University Klinikum Grosshadern Department of Anaesthesiology 81377 Muenchen; Germany Phone: +49-89-7095-0 (operator) Fax: +49-89-7095-8886 e-mail: email@example.com
This study was supported by the Else Kröner-Fresenius Stiftung, the European Science Foun-
dation (BALANCE) and in part by the Swiss National Science Foundation (grants PP00B-
Key words: glucocorticoid receptor gene; genetic polymorphism; traumatic memories; stress;
post-traumatic stress disorder; outcome;
#both authors contributed equally to this work
Glucocorticoids play a major role in the consolidation and retrieval of traumatic
information. They act through the glucocorticoid receptor (GR) for which, in humans, several
polymorphisms have been described. In particular, the Bcl
I single-nucleotide polymorphism
(SNP) is associated with hypersensitivity to glucocorticoids and with susceptibility to devel-
opment of major depression. Furthermore, in patients with post-traumatic stress disorder
(PTSD) carrying the Bcl
I GG genotype, cortisol levels were lower and showed an inverse
relationship to PTSD-symptom intensity. Here, we studied the association of the Bcl
morphism with plasma cortisol levels, traumatic memories, PTSD symptoms and health-
related quality of life (HRQL) outcomes in 126 patients undergoing cardiac surgery (CS) and
Prospective observational study.
Cardiovascular intensive care unit in a university hospital.
126 patients undergoing CS and ICU treatment.
No intervention was performed.
Measurements and Main Results:
Validated questionnaires were used to quantify endpoints.
Measurements were taken 1 day before, 1 week and 6 months after CS. Homozygous carriers
of the Bcl
n=21) had significantly lower preoperative plasma cortisol lev-
els and more long-term traumatic memories from ICU-therapy at 6 months post-CS than het-
erozygous or non-carriers (1.9+1.4 vs. 1.0+1.2, p=0.01). Anxiety was significantly more
common as a long-term traumatic memory in homozygous Bcl
carriers than in heterozy-
gous or non-carriers (57% vs. 35%, p=0.03). PTSD-symptom scores were significantly higher
at discharge from ICU in homozygous Bcl
carriers than in heterozygous or non-carriers.
Only heterozygous or Bcl
non-carriers had a significant gain in HRQL physical function
at 6 months post-CS (p<0.01). Baseline values were not statistically different between carriers
carriers are at risk for traumatic memories, PTSD symp-
toms and lower HRQL after CS and ICU-therapy. The Bcl
I SNP may help to identify indi-
viduals at need for tailored medical care.
Animal and human studies have repeatedly shown that glucocorticoids influence memory in
situations of acute and chronic stress (1-3). Glucocorticoids are known to enhance memory
consolidation of emotionally arousing experiences (4, 5) but impair memory retrieval under
stressful conditions (6, 7). Persistent traumatic memories of highly stressful experiences are a
hallmark of stress-related disorders such as post-traumatic stress disorder (PTSD) and changes
in glucocorticoid signaling have consistently been demonstrated in humans with PTSD (8-10)
as well as in animal models of the disorder (11). In critically ill patients, traumatic memories
from treatment in an intensive care unit (ICU) can be associated with PTSD stress symptoms
and are influenced by the administered dosages of catecholamines and glucocorticoids in the
ICU (12-14). Glucocorticoids influence cognitive and emotional processes through the gluco-
corticoid receptor (GR) and changes in GR sensitivity have been shown in patients with
PTSD (10, 15) as well as other stress-related disorders such as depression (16). In humans,
several single nucleotide polymorphisms (SNPs) of the GR gene have been described which
influence GR sensitivity (17, 18). Among these SNPs, the Bcl
I polymorphism, which involves
a restriction site in intron 2, 646 base pairs downstream from exon 2, of the GR gene and con-
sists of a C to G nucleotide change (BCl
I GG), is associated with hypersensitivity to glucocor-
ticoids. This hypersensitivity has been documented by an increased suppression of adrenocor-
ticotropin and cortisol levels following a low-dose dexamethasone challenge (19, 20) and a
metabolic profile suggestive of GR hypersensitivity, including an increased risk for cardio-
We performed a hypothesis-driven study in patients with cardiovascular disease undergoing
CS to investigate whether patients homozygous for the Bcl
I G-allele (Bcl
I *G), which has
been associated with higher GR sensitivity, have more traumatic memories from ICU treat-
ment and more marked PTSD stress symptoms than heterozygous or non-carriers of this al-
Patients and Methods
Patient selection and study design
Between July 6, 2004 and July 1, 2005 we prospectively screened all adult patients (>18
years) scheduled for heart surgery at the Department of Cardiac Surgery of the University of
Munich for possible inclusion into our study. Inclusion criteria were planned coronary artery
bypass grafting or cardiac valve replacement. Exclusion criteria were combined coronary ar-
tery and valve disease, emergency procedures, severe alcohol or drug abuse, major pre-
existing neurologic disease or psychiatric illness (e.g. major depressive or bipolar disorder,
PTSD, somatoform disorder), current use of steroids and severe comorbidities such as chronic
organ dysfunction (renal, liver or pulmonale) or cancer. Patients not qualified for study inclu-
sion fulfilling the abovementioned exclusion criteria were identified by chart review, patient
interview, and direct communication with the attending cardiac surgeons or the private physi-
Eligible patients were evaluated for standardized traumatic memories and PTSD-symptom
scores at study inclusion and then followed prospectively. Plasma cortisol levels were meas-
ured pre- and postoperatively. Reevaluation for traumatic memories from ICU treatment and
the development of PTSD stress symptoms was performed 1 week after discharge from the
ICU and at 6 months thereafter. Plasma cortisol concentrations, traumatic memories and
PTSD stress-symptom intensities were then compared between homozygous and heterozy-
The study was approved by the Institutional Review Board of the Ludwig-Maximilians Uni-
versity of Munich (protocol #198/99 and #140/99) and data protection met the standard set by
German law. Written informed consent was obtained from all subjects (including an addition-
General patient assessment consisted of demographics, a detailed evaluation of type and se-
verity of cardiac disease, intraoperative data (e.g. duration of surgery and cardiopulmonary
bypass) and the prospective recording of predefined ICU treatment variables, including the
use and dosages of epinephrine, beta-adrenergic antagonists, glucocorticoids and the sedative
drugs midazolam and propofol. These drugs were selected for documentation and analyses
because possible effects of these substances on traumatic memory and PTSD symptoms after
ICU treatment have previously been described (12).
One day before their scheduled operation, the patients were approached by trained research
assistants and received a detailed explanation of the purpose of the study. The patients were
informed that we were interested in their present and postoperative state of physical and men-
tal health, without any direct referral to traumatic memories or PTSD symptoms. After in-
formed consent, the patients completed validated questionnaires evaluating standardized
traumatic memories and chronic stress symptoms including those of PTSD.
One week after discharge from the ICU, while in the normal cardiovascular ward, the patients
were approached again and asked to complete the same instruments on traumatic memories
from the ICU and PTSD-related symptoms as they did preoperatively. At 6 months after CS,
the patients were contacted by phone and, after repeated oral consent, received the same set of
Quantification of traumatic memories and PTSD symptoms
All patients completed a standardized and validated questionnaire evaluating different catego-
ries of traumatic memory and PTSD symptoms from ICU treatment (22). The questionnaire
consists of two parts: Part A evaluates four standardized categories of traumatic memory from
the ICU and Part B quantifies the presence and intensities of 10 PTSD-related symptoms. This
questionnaire has been validated in patients after ICU therapy (22) and used in several other
studies in patients after ICU therapy or CS (14, 23-26).
A category of traumatic memory as measured by Part A of the questionnaire was defined as
the patient’s subjective recollection of (1) nightmares, (2) respiratory distress/dyspnea, (3)
feelings of anxiety/panic or (4) pain at anytime between 1 week before CS and 1 week after
discharge from the ICU. When completing the questionnaire, the patients were asked to an-
swer each of these four items “yes” or “no,” independent of the number of occasions the ad-
verse experience occurred (only frequencies were scored). The number with which these four
items is answered “yes” by a subject is termed the number of categories of traumatic memory.
The intensity of traumatic memories was not specifically evaluated.
The severity and presence of PTSD symptoms was quantified by Part B of the questionnaire.
This part of the questionnaire resulted from a modification of the Post-Traumatic Stress
Symptom 10-Questions (PTSS-10) instrument (27) and evaluates the presence and intensity of
10 PTSD-related stress symptoms: (1) sleep disturbance, (2) nightmares, (3) depression, (4)
hyperalertness, (5) withdrawal (emotional numbing and inability to care for others), (6) gene-
ralized irritability, (7) frequent changes in mood, (8) guilt, (9) fear and avoidance reactions
with regard to the ICU, and (10) increased muscle tension. When evaluating these symptoms,
the patients were asked to think back to the last few days (“presently— that means in the past
few days—I suffer from. . .”), and then they were asked if they had symptoms expressed by
statements such as: “Jumpiness, I am easily frightened by sudden sounds or sudden move-
ments” (to evaluate hyperalertness), “fear of places and situations which remind me of the
intensive care unit” (to evaluate avoidance reactions), or “a bad conscience, blame myself,
have guilt feelings” (to evaluate guilt). Patients rated their symptoms using a scale from 1
(never) to 7 (always). A summary score could then be calculated that ranges from 10 to 70
points, with increasing scores indicating a higher prevalence and intensity of PTSD symp-
toms. The questionnaire has been specifically validated in patients after ICU therapy using a
double-blind interview performed by psychiatrists. The interviews were performed according
to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria to
diagnose PTSD. This validation process demonstrated a high internal consistency (Crohn-
bach´s α=0.93) and a high test-retest reliability (intraclass correlation coefficient r=0.89) of
the instrument. The specificity and sensitivity for diagnosis of PTSD after ICU treatment at a
cut-off value of 35 points of the questionnaire was 97.5% and 77%, respectively (22).
Health-related quality of life and chronic pain
Health-related quality of life (HRQL) was measured using the German version of the self-
administered Medical Outcomes Study Short Form Survey that consists of 36 questions (SF-
36) (28). Pain intensities were determined by using a visual analogue scale ranging from 0 to
10 where 0 indicated no pain and 10 the worst imaginable pain (VAS pain scores). Pain and
HRQL measurements were performed at the preoperative visit and at 6 months after surgery.
After enrollment into the study, 10 ml of blood was collected in EDTA-coated tubes from
each patient. Blood samples were kept frozen at -20 ºC. Genotyping was performed in those
patients who had a complete set of questionnaires across all 3 time points of measurements at
Genomic DNA was extracted using the QIAamp DNA blood maxi kit (Qiagen, Hilden, Ger-
many). Information on the Bcl
I polymorphic site of the GR was derived from the database of
single-nucleotide polymorphisms (dbSNP) established by the National Center for Biotechnol-
ogy Information (http://www.ncbi.nlm.nih.gov/SNP/ index.html). Genotyping was done with
Pyrosequencing on a PyroMark™ID System (Biotage, Uppsala, Sweden). Primers for the
I polymorphism were: 5’-CTT GCA GAA GAG GAT TCA CAT CA-3’ (forward, 5’-
biotinylated), 5’- GTG TGT CTG CCT GAA GGA ATG-3’ (reverse), 5’- GTG TAT CTC
AGA AAA GAC CT-3’ (sequencing). Primers for rs3781230 were: 5’-AGG TCT TGC TCA
CAG GGT TCT T-3’ (forward), 5’-TTT TGC ACC ATG TTG ACA CCA-3’ (reverse, 5' bio-
tinylated), 5’-ACA AGT TAT GTC TGC TGA T-3’ (sequencing primer). Genotype distribu-
tions were in Hardy-Weinberg equilibrium.
Measurement of plasma cortisol levels
Blood sampling for cortisol measurements were performed between 7 and 8 am at the preo-
perative time point and in the morning of the first postoperative day. Plasma cortisol levels
were measured by isotope dilution liquid chromatography tandem mass spectrometry (LC–
MS/MS) as previously described by our group (29).
Twenty-nine patients from the study sample received hydrocortisone after
time point at induction of anesthesia (Table 2). The use of hydrocortisone was not randomized
but left to the discretion of the attending anesthesiologists. Hydrocortisone was administered
starting with a loading dose (100 mg over 10 min), followed by a continuous infusion of 10
mg/h for 24 h (postoperative day 1 = POD 1), which was reduced to 5 mg/h on POD 2, and
then tapered to 3 x 20 mg, i.v. on POD 3, and 3 x 10 mg i.v. on POD 4. Stress doses of hydro-
cortisone given during the first 24 h were calculated to be approximately equivalent to the
endocrine secretion rate of the adrenal glands under maximal stimulation (30).
All variables were tested for normal distribution using the Kolmogorov-Smirnov test. For the
initial statistical analyses and in order to increase statistical power, heterozygous and non-
carriers of the Bcl
I *G SNP were combined into one group and compared to the second group
of homozygous Bcl
I *G carriers. Normally distributed continuous variables between homozy-
gous and heterozygous/non Bcl
I *G carriers were compared by t–tests. Nonparametric data
were compared by the Mann-Whitney U test. In order to delineate possible gene-dose effects,
additional comparisons between non-carriers, heterozygous and homozygous subgroups were
performed when the differences between combined groups were significant. For these com-
parisons, analysis of variance (ANOVA) in normally distributed data and Kruskal-Wallis One
Way Analysis of Variance on Ranks in nonparametric data with Fischer´s LSD post-hoc test
was used. Cortisol measurements were transformed to log10 before comparison because un-
transformed values were skewed. The log cortisol was normally distributed. Discrete variables
were analyzed with the Chi2- or Fisher’s exact test, when appropriate. All statistical calcula-
tions were performed using the SPSS 17.0 statistical package (SPSS Inc., Chicago, Il, USA).
Results are expressed as mean ± standard deviation (SD). In graphs, mean ± SEM is shown to
improve clarity. A p value <0.05 was considered as statistically significant for all compari-
One-hundred-and-fifty patients were initially included into the study. Of these patients, 13
(8.7%) had died during post-operative ICU treatment, 137 individuals had complete question-
naires at 1 week after discharge from the ICU. A further 11 (8.0%) patients died during the
follow-up period and 126 patients returned complete questionnaires at 6 months after CS.
These 126 individuals represent the final study population and were subjected to genotyping.
Fifty-one patients (40.5%) were non-carriers of the Bcl
I *G, 54 (42.9%) were heterozygous
I *G carriers and 21 (14%) were homozygous. Heterozygous and non-carriers were com-
bined into one group (n=105) and compared to the homozygous group (n=21). Baseline and
treatment variables did not differ significantly between both groups and are shown in detail in
Differences between homozygous and heterozygous/non-carriers of the BclI *G
I *G carriers had lower basal plasma concentrations and showed no
increase in plasma cortisol when receiving stress doses of hydrocortisone
At the preoperative time point, homozygous carriers of the Bcl
I *G had significantly lower
log10 transformed plasma cortisol levels than heterozygous/non-carriers with no significant
postoperative differences in plasma cortisol concentrations (Figure 1). A subgroup analysis
with regard to the Bcl
I *G alleles using ANOVA with Fischer´s LSD post-hoc test revealed
no significant difference in preoperative log10 transformed plasma cortisol levels between
heterozygous and non-carriers (mean difference=-0.05+0.09, p=0.64), but a significant differ-
ence between homozygous Bcl
I *G carriers and heterozygous individuals (mean difference=-
0.25+0.12, p=0.03) and a strong trend towards higher cortisol levels in non-carriers compared
to homozygous patients (mean difference=-0.21+0.12, p=0.07).
Twenty-three of the 105 heterozygous/non-carriers of the Bcl
I*G SNP had received stress
doses of hydrocortisone after the preoperative time point vs. 6 of the 21 homozygous carriers.
Heterozygous/non-carriers who had received hydrocortisone had significantly higher log10
transformed plasma cortisol levels than heterozygous/non-carriers who were not treated with
glucocorticoids (1.3+0.4 vs. 1.0 +0.4 µg/dl, p=0.02). In homozygous individuals, the use of
hydrocortisone did not result in increased plasma cortisol levels and log10 cortisol plasma
concentrations in homozygous individuals with and without the administration of hydrocorti-
sone were nearly identical (1.0+0.6 vs. 1.0+0.5 µg/dl, p=0.99).
I *G carriers had more traumatic memories from ICU therapy
The number of recollected traumatic memories from ICU therapy differed significantly be-
tween homozygous and heterozygous/non-carriers. Individuals homozygous for the Bcl
SNP had nearly double the number of traumatic memories from ICU treatment at 6 months as
had heterozygous/non-carriers (1.9+1.4 vs. 1.0+1.2, p=0.01) with no significant differences at
the other two time points (p>0.25, Figure 2). Additional comparisons between non-carriers,
heterozygous and homozygous subgroups revealed a gene-dose effect. When compared to
non-carriers, heterozygous Bcl
I *G individuals had a higher number of traumatic memories
(mean difference to non-carriers: 0.3+0.3), this difference was, however, not statistically sig-
nificant (p=0.23). The difference between homozygotes and non-carriers (mean differ-
ence=1.1+0.4, p<0.01) as well as the difference to heterozygotes (mean difference: 0.8+0.4,
p<0.05) was significant (Figure 3). Anxiety during ICU therapy was significantly more often
remembered at 6 months after surgery by homozygous Bcl
carriers than by heterozyg-
ous/non-carriers (57% vs. 26% of all patients, p=0.03). Corresponding percentages for recol-
lection of pain were 52% vs. 26%, for respiratory distress 38% vs. 26% and for nightmares
52% vs. 33% but these differences were not statistically significant (p>0.10).
I *G carriers had higher PTSD symptom scores after ICU therapy
At the preoperative time point, there were no significant differences in PTSD symptom scores
between groups. PTSD symptom scores were higher at 1 week after discharge from the ICU
in homozygous Bcl
carriers than in heterozygous or non-carriers (25+11 vs. 19+9,
p=0.02). Subgroup analyses according to the Bcl
I *G carrier state revealed comparable PTSD
symptom scores between non-carriers and heterozygotes (mean difference: -1.0+0.2, p=0.64)
and significantly higher stress-symptom scores in homozygotes as compared to heterozygotes
(mean difference: -5.4+2.6, p=0.04) and non-carriers (mean difference: -6.3+2.7, p=0.02).
PTSD stress-symptom scores in the Bcl
homozygotes were still higher at 6 months after
surgery but due to an increase in scores in the heterozygous/non-carrier group during the fol-
low-up period this difference was no longer statistically significant (p=0.37, Figure 4). Four
of 21 patients (19%) from the homozygous Bcl
group were above the 35 point cut-off
value for diagnosis of PTSD vs. 11 from 105 individuals (10%) in the heterozygous/non-
I *G carriers had lower health-related quality of life outcomes
SF-36 HRQL physical function summary scores at 6 months after surgery were significantly
lower in homozygotes as compared to heterozygous or non Bcl
I *G carriers (38.0±11.6 in
homozygotes vs. 45.6±10.4 heterozygous or non-carriers, p=0.02). Subgroup analyses accord-
ing to the Bcl
I *G carrier state demonstrated a gene – dose effect. Homozygotes reported sig-
nificantly lower physical function summary scores than heterozygous individuals (mean dif-
ference=-7.36+3.6, p=0.04) and non-carriers (mean difference=-7.89+3.4, p=0.02). There
were no other significant differences in HRQL outcomes between groups. Homozygous indi-
viduals showed a trend towards higher VAS chronic pain scores at 6 months after surgery
when compared to the heterozygous or non-carrier group (3.1±4.1 vs. 1.4±2.4, p=0.08). There
were no significant preoperative differences in HRQL or VAS pain scores between carriers of
The main finding of this study is that homozygous Bcl
I *G carriers are at an increased risk for
adverse outcomes of CS and ICU therapy when compared to heterozygous or non-carriers of
I *G allele. This unfavorable outcome did not only include the presence of more trau-
matic memories from the ICU and an associated increase in PTSD stress symptoms but also
impairment in physical function and a trend towards a higher incidence of chronic pain. As
this increased susceptibility of Bcl
I GG carriers for the development of traumatic memories
and PTSD-related stress symptoms became only evident after exposure to the stressful events
of CS and ICU therapy, this effect may represent a gene-environment interaction.
Homozygous BclI *G carriers had lower plasma cortisol levels
During the moderately stressful preoperative period, homozygous Bcl
I *G carriers showed
significantly lower cortisol plasma levels. This finding is corroborated by another study which
investigated healthy volunteers exposed to a standardized psychological laboratory stressor
(the Trier Stress Test). Homozygous Bcl
I *G allele carriers in this study showed a significant-
ly lower cortisol response (31) which was more pronounced when the stress exposure was
repeated (32). Interestingly, when Bcl
I GG homozygotes in our study received stress doses of
hydrocortisone, plasma cortisol levels did not increase whereas heterozygotes/non-carriers
showed a significant augmentation of cortisol concentrations. The lower cortisol levels in ho-
mozygous carriers of the Bcl
I *G genotype could be due to an enhanced adrenal negative
feedback action on the hypothalamus-pituitary-adrenal (HPA) axis (19), an increase in corti-
sol metabolism or a combination of these and possibly other, unknown factors.
In a well-characterized sample of Vietnam veterans with PTSD, the presence of the G-allele
in the Bcl
I gene was associated with lower basal cortisol levels and higher scores on the
Clinican Administered PTSD Scale (CAPS) in a gene-dose dependent fashion. Furthermore,
CAPS scores and basal cortisol levels were negatively correlated (33). Other recently de-
scribed SNPs of the GR gene which enhance receptor responsiveness to cortisol (in particular
the FKBP5 gene) resulted in a comparable phenotype in individuals with traumatic memories
after exposure to a massive stressor (childhood maltreatment or the World Trade Center at-
tack) with low basal cortisol levels (34) and an increased risk for PTSD (10).
Homozygous BclI *G carriers had more traumatic memories and higher PTSD stress-
Glucocorticoids play an important role in the regulation of emotional memory. Enhanced glu-
corticoid signaling during stress has repeatedly been shown to strengthen the consolidation of
emotionally arousing experiences (35) but to impair emotional memory retrieval (6, 36, 37).
Moreover, glucocorticoids are known to have long-term facilitating effects on the extinction
of traumatic memories (3). Homozygous Bcl
I *G allele carriers show enhanced GR sensitivity
(19) but lower basal cortisol concentrations. At the moment it is not entirely understood how
this genotype resulted in an increased number of traumatic memories and higher PTSD stress-
symptom scores. It is possible that the increased GR sensitivity of homozygous Bcl
I *G allele
carriers resulted in an enhanced consolidation of the traumatic experiences. On the other hand,
it is also possible that the lower plasma cortisol levels found in homozygous Bcl
I *G allele
carriers facilitated the retrieval of traumatic memories accompanied by a failure to extinguish
traumatic information (3). Both effects – and their interaction – could help to explain our find-
ings. These assumptions are corroborated by a number of recent findings. One study indicated
that long-term survivors of severe acute respiratory distress syndrome with septic shock and
multiple traumatic memories from ICU therapy had significantly lower plasma cortisol levels
and significantly higher PTSD-symptom scores (38). On the other hand, increasing cortisol
levels by administering stress doses of hydrocortisone to critically ill patients undergoing CS
as well as to patients with septic shock resulted in significantly lower PTSD stress-symptom
scores and an improvement in HRQL outcomes in several controlled studies (13, 14, 39, 40).
Likewise, low doses of hydrocortisone administered to individuals with PTSD of non-medical
origin resulted in a significant improvement of memory-related PTSD symptoms in a small
proof-of-concept study (41). These findings suggest that glucocorticoid signaling plays an
important role in the formation and retrieval of traumatic memories and the development of
PTSD symptoms in critically ill patients and that some of these effects may be mediated by
genetic polymorphisms which influence GR sensitivity.
Although we found evidence of lower plasma cortisol concentrations during preoperative
stress and after the administration of hydrocortisone in the homozygous Bcl
I GG carriers
which could be due to enhanced HPA – axis feed back as a result of increased GR respon-
siveness (19), we did not specifically test our patients for the presence for GR hypersensitivity
but draw further evidence from several other, carefully performed studies. Increased glucocor-
ticoid sensitivity with the GG phenotype is suggested by hyperinsulinemia, increased abdo-
minal visceral fat, lower lean body mass (42-44) and the abovementioned increased negative
feed back sensitivity of the HPA-axis (19). The increased risk for stress-related disorders after
trauma exposure in the presence of a genetically determined GR hyperresponsiveness has
been confirmed by other studies in different patient populations and with different GR SNPs
(34, 45). Furthermore, the Bcl
I polymorphism has highly tissue-specific effects and this, as
mentioned above, could result in both, increased and decreased GR sensitivity in different
tissues and different neuronal networks within the brain (31, 46), which makes it difficult to
directly relate glucocorticoid signaling in different brain areas to specific neuropsychological
findings. Furthermore, the Bcl
I polymorphism is intronic and its effect on the GR gene may
be indirect, serving only as a marker of other mutations affecting receptor function. There is,
however, evidence that intronic polymorphisms are involved in the splicing process by,
among other effects, changing the sequence of so-called intronic splicing silencers and en-
hancers, and through other effects that are important for gene expression (47). And finally,
despite the fact that our study was hypothesis driven and had a good rationale for the associa-
tion under study and investigated a relatively large and homogenous cohort of patients ex-
posed to a standardized stressor, the power of our study to exclude possible false positive as-
sociations is still relatively low. Our findings need therefore replication in a larger study co-
Regardless of these limitations, our findings support the notion that variants of the GR gene
might influence traumatic memories, PTSD symptoms and HRQL after ICU therapy and that
some of these outcome variables may positively respond to pharmacologic manipulation of
glucocorticoid signaling. Preoperative genotyping of the GR may help to identify individuals
This study is part of the dissertation of Julia Lieke at the Faculty of Medicine of the Ludwig-
Maximilians University of Munich (in preparation).
There is no conflict of interest for any of the authors
Wolf OT. HPA axis and memory. Best Pract Res Clin Endocrinol Metab
Roozendaal B, Quirarte GL, McGaugh JL. Stress-activated hormonal systems and the
regulation of memory storage. Ann NY Acad Sci 1997;821:247-258. 3.
de Quervain DJ, Aerni A, Schelling G, et al. Glucocorticoids and the regulation of
memory in health and disease. Front Neuroendocrinol 2009;30(3):358-370. 4.
Roozendaal B, Quirarte GL, McGaugh JL. Glucocorticoids interact with the
basolateral amygdala beta-adrenoceptor--cAMP/PKA system in influencing memory consolidation. Eur J Neurosci 2002;15(3):553-560. 5.
Kuhlmann S, Wolf OT. Arousal and cortisol interact in modulating memory
consolidation in healthy young men. Behav Neurosci 2006;120(1):217-223. 6.
de Quervain D-F, Roozendaal B, McGaugh JL. Stress and glucocorticoids impair
retrieval of long-term spatial memory. Nature 1998;394(6695):787-790. 7.
Kuhlmann S, Piel M, Wolf OT. Impaired memory retrieval after psychosocial stress in
healthy young men. J Neuroscience 2005;25(11):2977-2982. 8.
Yehuda R, Yang RK, Golier JA, et al. Effect of topiramate on glucocorticoid receptor
mediated action. Neuropsychopharmacology 2004;29(2):433-439. 9.
Yehuda R, Boisoneau D, Lowy MT, et al. Dose-response changes in plasma cortisol
and lymphocyte glucocorticoid receptors following dexamethasone administration in combat veterans with and without posttraumatic stress disorder. Arch Gen Psychiatry 1995;52(7):583-593. 10.
Binder EB, Bradley RG, Liu W, et al. Association of FKBP5 polymorphisms and
childhood abuse with risk of posttraumatic stress disorder symptoms in adults. J Am Med Ass 2008;299(11):1291-1305. 11.
Cohen H, Zohar J, Gidron Y, et al. Blunted HPA axis response to stress influences
susceptibility to posttraumatic stress response in rats. Biol Psychiatry 2006;59(12):1208-1218. 12.
Schelling G, Richter M, Roozendaal B, et al. Exposure to high stress in the intensive
care unit may have negative effects on health-related quality-of-life outcomes after cardiac surgery. Crit Care Med 2003;31(7):1971-1980. 13.
Schelling G, Kilger E, Roozendaal B, et al. Stress doses of hydrocortisone, traumatic
memories, and symptoms of posttraumatic stress disorder in patients after cardiac surgery: a randomized study. Biol Psychiatry 2004;55(6):627-633. 14.
Weis F, Kilger E, Roozendaal B, et al. Stress doses of hydrocortisone reduce chronic
stress symptoms and improve health-related quality of life in high-risk patients after cardiac surgery: A randomized study. J Thor Cardiovascular Surgery 2006;131(2):277-282. 15.
Duval F, Crocq MA, Guillon MS, et al. Increased adrenocorticotropin suppression
after dexamethasone administration in sexually abused adolescents with posttraumatic stress disorder. Ann N Y Acad Sci 2004;1032:273-275. 16.
van Rossum EF, Binder EB, Majer M, et al. Polymorphisms of the glucocorticoid
receptor gene and major depression. Biol Psychiatry 2006;59(8):681-688. 17.
Derijk RH, van Leeuwen N, Klok MD, et al. Corticosteroid receptor-gene variants:
modulators of the stress-response and implications for mental health. Eur J Pharmacol 2008;585(2-3):492-501. 18.
Kumsta R, Entringer S, Koper JW, et al. Glucocorticoid receptor gene polymorphisms
and glucocorticoid sensitivity of subdermal blood vessels and leukocytes. Biol Psychol 2008;79(2):179-184.
van Rossum EF, Koper JW, van den Beld AW, et al. Identification of the BclI
polymorphism in the glucocorticoid receptor gene: association with sensitivity to glucocorticoids in vivo and body mass index. Clin Endocrinol(Oxf) 2003;59(5):585-592. 20.
Huizenga NA, Koper JW, De Lange P, et al. A polymorphism in the glucocorticoid
receptor gene may be associated with and increased sensitivity to glucocorticoids in vivo. J Clin Endocrinol Metab 1998;83(1):144-151. 21.
Rosmond R. The glucocorticoid receptor gene and its association to metabolic
syndrome. Obes Res 2002;10(10):1078-1086. 22.
Stoll C, Kapfhammer HP, Rothenhausler HB, et al. Sensitivity and specificity of a
screening test to document traumatic experiences and to diagnose post-traumatic stress disorder in ARDS patients after intensive care treatment. Intensive Care Med 1999;25(7):697-704. 23.
Schelling G, Stoll C, Haller M, et al. Health-related quality of life and posttraumatic
stress disorder in survivors of the acute respiratory distress syndrome. Crit Care Med 1998;26(4):651-659. 24.
Deja M, Denke C, Weber-Carstens S, et al. Social support during intensive care unit
stay might improve mental impairment and consequently health-related quality of life in survivors of severe acute respiratory distress syndrome. Crit Care 2006;10(5):R147. 25.
Girard TD, Shintani AK, Jackson JC, et al. Risk factors for post-traumatic stress
disorder symptoms following critical illness requiring mechanical ventilation: a prospective cohort study. Crit Care 2007;11(1):R28. 26.
Boer KR, van RO, van Emmerik AA, et al. Factors associated with posttraumatic
stress symptoms in a prospective cohort of patients after abdominal sepsis: a nomogram. Intensive Care Med 2008;34(4):664-674. 27.
Eid J, Thayer JF, Johnsen BH. Measuring post-traumatic stress: a psychometric
evaluation of symptom--and coping questionnaires based on a Norwegian sample. Scand J Psychol 1999;40(2):101-108. 28.
Bullinger M. German translation and psychometric testing of the SF-36 Health
Survey: preliminary results from the IQOLA Project. International Quality of Life Assessment. Soc Sci Med 1995;41(10):1359-1366. 29.
Vogeser M, Briegel J, Jakob K. Determination of plasma cortisol by isotope-dilution
liquid-chromatography electrospray ionization tandem mass spectrometry with online extraction. Clin Chem Lab Med 2001;39:944-947. 30.
Kilger E, Weis F, Briegel J, et al. Stress doses of hydrocortisone reduce severe
systemic inflammatory response syndrome and improve early outcome in a risk group of patients after cardiac surgery. Crit Care Med 2003;31(4):1068-1074. 31.
Wust S, van Rossum EF, Federenko IS, et al. Common polymorphisms in the
glucocorticoid receptor gene are associated with adrenocortical responses to psychosocial stress. J Clin Endocrinol Metab 2004;89(2):565-573. 32.
Ising M, Depping AM, Siebertz A, et al. Polymorphisms in the FKBP5 gene region
modulate recovery from psychosocial stress in healthy controls. Eur J Neurosci 2008;28(2):389-398. 33.
Bachmann AW, Sedgley TL, Jackson RV, et al. Glucocorticoid receptor
polymorphisms and post-traumatic stress disorder. Psychoneuroendocrinology 2005;30(3):297-306. 34.
Yehuda R, Cai G, Golier JA, et al. Gene expression patterns associated with
posttraumatic stress disorder following exposure to the World Trade Center attacks. Biol Psychiatry 2009;66(7):708-711. 35.
McGaugh JL, Roozendaal B. Role of adrenal stress hormones in forming lasting
memories in the brain. Curr Opinion Neurobiol 2002;12(2):205-210.
de Quervain DJ, Roozendaal B, Nitsch RM, et al. Acute cortisone administration
impairs retrieval of long-term declarative memory in humans. Nat Neurosci 2000;3(4):313-314. 37.
Tollenaar MS, Elzinga BM, Spinhoven P, et al. Immediate and prolonged effects of
cortisol, but not propranolol, on memory retrieval in healthy young men. Neurobiol Learn Mem 2008. 38.
Hauer D, Weis F, Krauseneck T, et al. Traumatic memories, post-traumatic stress
disorder and plasma cortisol levels in long-term survivors of the acute respiratory distress syndrome. Brain Research 2009;1293:114-120. 39.
Schelling G, Stoll C, Kapfhammer HP, et al. The effect of stress doses of
hydrocortisone during septic shock on posttraumatic stress disorder and health-related quality of life in survivors. Crit Care Med 1999;27(12):2678-2683. 40.
Schelling G, Briegel J, Roozendaal B, et al. The effect of stress doses of
hydrocortisone during septic shock on posttraumatic stress disorder in survivors. Biol Psychiatry 2001;50(12):978-985. 41.
Aerni A, Traber A, Hock C, et al. Low-dose cortisol treatment reduces symptoms of
post-traumatic stress disorder. Am J Psychiatry 2004;161:1488-1490. 42.
Weaver JU, Hitman GA, Kopelman PG. An association between a Bc1I restriction
fragment length polymorphism of the glucocorticoid receptor locus and hyperinsulinaemia in obese women. J Mol Endocrinol 1992;9(3):295-300. 43.
Buemann B, Vohl MC, Chagnon M, et al. Abdominal visceral fat is associated with a
BclI restriction fragment length polymorphism at the glucocorticoid receptor gene locus. Obes Res 1997;5(3):186-192. 44.
van Rossum EF, Lamberts SW. Polymorphisms in the glucocorticoid receptor gene
and their associations with metabolic parameters and body composition. Recent Prog Horm Res 2004;59:333-357. 45.
Binder EB. The role of FKBP5, a co-chaperone of the glucocorticoid receptor in the
pathogenesis and therapy of affective and anxiety disorders. Psychoneuroendocrinology 2009;34 Suppl 1:S186-195. 46.
Panarelli M, Holloway CD, Fraser R, et al. Glucocorticoid receptor polymorphism,
skin vasoconstriction, and other metabolic intermediate phenotypes in normal human subjects. J Clin Endocrinol Metab 1998;83(6):1846-1852. 47.
van Rossum EF, Russcher H, Lamberts SW. Genetic polymorphisms and
multifactorial diseases: facts and fallacies revealed by the glucocorticoid receptor gene. Trends Endocrinol Metab 2005;16(10):445-450.
Comparison of log10 transformed plasma cortisol levels between heterozygous or
non-carriers of the Bcl
I *G polymorphism and homozygous Bcl
I GG carriers. Preoperative
cortisol measurements were performed in the morning before surgery and post-operative mea-
surements in the morning on the day after surgery. *indicates significantly lower preoperative
log10 transformed plasma cortisol concentrations in homozygous patients (p=0.04, t-test).
Lower log10 transformed plasma cortisol levels in homozygous carriers correspond to 5.0±0.5
vs. 8.2±1.2 µg/dl in heterozygous/non carriers. Data are mean±SEM.
Comparison of changes in the number of standardized traumatic memories from
ICU treatment in cardiac surgical patients across 3 time points of measurements between hete-
rozygous or non-carriers of the Bcl
I *G allele and homozygous Bcl
I *G allele carriers
Number of traumatic memories from ICU treatment at 6 months after CS in rela-
tionship to the Bc/I *G polymorphism of the GR gene. *p<0.01 when homozygotes were
compared to non-carriers of the G-allele. #indicates p<0.05 for the difference in traumatic
memories between heterozygotes and homozygotes. Data are mean±SEM.
Comparison of changes in PTSD stress-symptom scores following ICU treatment in
cardiac surgical patients across 3 time points of measurements between heterozygous or non-
carriers of the Bcl
I *G allele and homozygous Bcl
I *G allele carriers (*p=0.02). Data are
Patient and Treatment Variables
Heterozygotes and non-
carriers of the BclI*G
tiona [min] Duration of aortic cross-clampinga
[min] avalues are mean ±SD bAmerican Society of Anesthesiologists classification of perioperative risk cNew York Heart Association classification of heart failure dCanadian Cardiovascular Society classification of angina pectoris eAcute Physiology and Chronic Health Evaluation score
Comparison of patient and treatment variables and disease severity at study inclu-
sion between homozygous Bcl
I *G allele carriers and heterozygous or non-carriers of the al-
BclI GG carriers
non-carriers of the
BclI *G allele
ICU [d] Duration of postoperative mechanical
ventilationa [hrs] Duration of epinephrine therapya [d]
antagonists [% of patients] Perioperative use of hydrocortisonef
[% of patients] Acute heart failurec [% of patients]
avalues are mean+SD bpostoperative sedation was performed in the ICU with either midazolam or propofol cAcute heart failure was defined by a significantly reduced cardiac function necessitating the application of positively inotropic drugs (drug of first choice was epinephrine in all patients). dAcute renal failure was defined by a doubling of the preoperative plasma creatinine level or oliguria. eAcute lung injury was defined as a pO2/FiO2 ratio of less than 300 during post-operative mechanical ventilation fthere were no significant differences in the demographic-, short- or long-term outcome variables described in the table when homozygous Bcl
I GG – carriers who had received hydrocortisone (n=6) were compared to homozygous individuals who did not (n=13). Likewise, no differences were found between demographic, treatment and outcome variables when heterozygous/non-carriers with (n=23) and without hydrocortisone use (n=72) were compared (data nor shown).
Treatment variables and incidence of post-operative organ failures in the homozy-
gote and heterozygote/non-carrier group of the Bcl
I *G allele.
The effect of the levonorgestrel-releasing intrauterinesystem and the copper intrauterine device onsubendometrial microvascularization and uterineartery blood flowenez, M.D.,Elisangela Arbo, M.D.,Daniela Vetori, M.D.,Fernando Monteiro de Freitas, Ph.D.,and Jo~ao Sabino Lahorgue Cunha-Filho, Ph.D. a Programa de Pos-graduacx~ao em Medicina: Ci^encias Medicas, and b Obstetrics and Gynecology De
FABRICATION AND CHARACTERIZATION OF CURCUMIN NANOEMULSION AS COLLOIDAL CARRIER Department of Chemical and Environmental Engineering, University of Nottingham (Malaysia campus), Selangor 43500, Malaysia Curcumin, a yellow figment extracted from Curcuma Longa dried rhizome, was found to have significantpharmaceutical activities, for instance anti-cancer, anti- carcinogenic, anti-inflamma