Circulating levels of vasoactive intestinal polypeptide in liver disease.

In animals, the effects of vasoactive intestinal polypeptide (VIP) include peripheral vasodilation, hyperdynamic circulation, hyperglycemia, and hyperventilation. Because these phenomena are noted in patients with cirrhosis, it has been postulated that VIP might be escaping hepatic inactivation and entering the systemic circulatory system and contributing to these abnormalities. The major purpose of this study is to establish whether or not VIP levels are elevated in patients with cirrhosis. Additional goals are to determine if VIP levels are elevated in acute liver disease and in chronic illnesses with secondary liver involvement. The data demonstrate that patients with cirrhosis and those with acute liver disease or chronic illnesses with secondary hepatic involvement have a wide range of VIP levels with mean values significantly above that of normal individuals and patients with chronic illness and no liver involvement.     

Galanin inhibition of vasoactive intestinal polypeptide release and circular muscle motility in the isolated perfused canine ileum.

The role of porcine galanin, infused arterially into isolated perfused canine ileal segments, in modulating the tonically elevated neural release of vasoactive intestinal polypeptide and possible concomitant motor actions dependent on vasoactive intestinal polypeptide modulation was studied. Galanin infusions (9-minute) inhibited vasoactive intestinal polypeptide release in a concentration-dependent manner (maximum during minutes 8-10) irrespective of the absence (quiescence) or presence of phasic circular muscle contractions induced by local electrical field stimulation of nerves. During quiescence, galanin induced phasic contractions in four of five segments beginning in the 8th minute of the infusion. During stimulated contractions, galanin inhibited phasic motor activity within 2 minutes of initiation of the infusion; this inhibition may result from direct smooth previously reported muscle inhibition. Thus galanin may inhibit both neural release of vasoactive intestinal polypeptide and circular muscle motility directly. The delayed period of phasic activity initiated by galanin during quiescence may be related to inhibition of vasoactive intestinal polypeptide release, freeing the muscle from tonic inhibition by vasoactive intestinal polypeptide. Because galanin and vasoactive intestinal polypeptide are colocalized in some enteric nerves, galanin may regulate vasoactive intestinal polypeptide release by negative feedback.     

High vasoactive intestinal polypeptide plasma levels in patients with Barrett's esophagus

We have evaluated the correlation between vasoactive intestinal polypeptide (VIP) plasma concentration and severity of gastroesophageal reflux in patients with Barrett's esophagus and the possible differences in the VIP values of these patients compared with healthy volunteers. We also evaluated the relation between VIP plasma concentration and lower esophageal sphincter (LES) pressure in 24 patients with Barrett's esophagus. The mean VIP plasma concentration in 14 patients with severe gastroesophageal reflux was 25.6 +/- 0.75 pg/ml, significantly higher than the mean value observed in 10 patients with moderate reflux (18.9 +/- 0.67 pg/ml) (p less than 0.01). The mean LES resting pressure was significantly lower in the group of patients with severe gastroesophageal reflux than that observed in patients with moderate reflux (3 +/- 0.64 and 10.3 +/- 0.69 mm Hg, respectively; p less than 0.01). The mean VIP plasma concentration in 11 healthy volunteers (20.6 +/- 0.65 pg/ml) was significantly lower than the mean value observed in the subgroup of patients with severe gastroesophageal reflux (p less than 0.01). VIP values in patients with moderate reflux were not significantly different from those observed in our volunteers. There was a significant correlation between LES pressure and VIP plasma level (r = -0.9253; p less than 0.01). In conclusion, it is possible that the decreased LES resting pressure observed in patients with Barrett's esophagus and severe gastroesophageal reflux may be due to impairment of the VIPergic innervation, resulting in an increased local VIP release with possible overflow to peripheral plasma.     

Nitrergic innervation and relaxant response of rectal circular smooth muscle

PURPOSE: This study was designed to investigate whether nitric oxide mediates inhibitory innervation in human rectal circular smooth muscle. METHODS: Tissue was obtained from the midrectum of patients undergoing anterior resection for carcinoma. Adjacent strips of circular muscle were dissected and mounted in superfusion organ baths for isometric tension recording and initially loaded with 1 g of weight. Strips were continuously bathed with standard Krebs solution (37°C, bubbled with 97 percent O ₂ /3 percent CO ₂ ) containing 3×10 ^?6 M guanethidine and 3×10 ^?6 M atropine sulfate to block adrenergic and muscarinic cholinergic neurotransmission. After equilibration, strips had no intrinsic tone, and reproducible and stable tension was, therefore, induced by the addition of 3×10 ^?6 M histamine for five-minute “test” periods, during which electrical field stimulation (EFS) and additional drugs were applied. RESULTS: EFS elicited frequency-dependent, neurogenic (tetrodotoxin-sensitive) relaxations of precontracted strips. Addition of N-ω-nitro- l -arginine, a powerful competitive inhibitor of nitric oxide synthase, reduced the relaxant response to EFS in a dose-dependent fashion, an effect reversed by addition of 3×10 ^?4 M l -arginine but not by D-arginine. Addition of exogenous nitric oxide (sodium nitroprusside) mimicked the relaxant response induced by EFS. CONCLUSIONS: Human rectal circular smooth muscle receives an intrinsic inhibitory innervation mediated by nitric oxide. The presence of a residual response following blockade of the enzyme nitric oxide synthase suggests the involvement of additional neurotransmitters.     

Osmoregulation in rats with long-term enhanced cerebrospinal fluid levels of vasopressin or vasoactive intestinal polypeptide

The cerebrospinal fluid level of arginine vasopressin (AVP) or vasoactive intestinal polypeptide (VIP) was enhanced chronically by implantation of a device for controlled drug delivery in the lateral ventricle of the rat. Urine production, water consumption, urine osmolality as well as urinary AVP excretion were then measured for a period of 26 days. During this period the rats were studied under normal hydration and under conditions of osmotic stress induced by water deprivation (2 days) and the drinking of 2% (w/v) NaCl (6 days), in order to see whether the capacity of central systems to react adequately to osmotic stimuli was affected by high central peptide levels. Immediately after the central AVP treatment was started, a temporary increase was found in urinary AVP levels which was not accompanied by a change in any of the other parameters but which decreased again to control levels within 10 days. After this burst of AVP excretion, AVP-treated rats showed a tendency during periods of normal hydration for a lower urine osmolality, combined with a higher water intake and urine production without changes in urinary AVP excretion. Since there was no clear-cut correlation between urinary AVP excretion and body water turnover, this could still indicate a slowly acquired and slight inhibition of pituitary AVP release by long-term centrally administered AVP. However, the capacity of these rats to respond to osmotic stimuli was not different from the controls. In the VIP-treated rats a slight but significant reduction in urine production was found in all three periods of normal hydration.(ABSTRACT TRUNCATED AT 250 WORDS)     

Altered vasoactive intestinal peptides expression in irritable bowel syndrome patients and rats with trinitrobenzene sulfonic acid-induced colitis

AIM: To investigate the vasoactive intestinal peptides(VIP) expression in irritable bowel syndrome(IBS) and trinitrobenzene sulfonic acid(TNBS) induced colitis.METHODS: The VIP gene expression and protein plasma levels were measured in adult participants(45.8% male) who met Rome Ⅲ criteria for IBS for longer than 6 mo and in a rat model of colitis as induced by TNBS.Plasma and colons were collected from naive and inflamed rats.Markers assessing inflammation(i.e.,weight changes and myeloperoxidase levels) were assessed on days 2,7,14 and 28 and compared to controls.Visceral hypersensitivity of the rats was assessed with colo-rectal distension and mechanical threshold testing on hind paws.IBS patients(n = 12) were age,gender,race,and BMI-matched with healthy controls(n = 12).Peripheral whole blood and plasma from fasting participants was collected and VIP plasma levels were assayed using a VIP peptide-enzyme immunoassay.Human gene expression of VIP was analyzed using a custom PCR array.RESULTS: TNBS induced colitis in the rats was confirmed with weight loss(13.7 ± 3.2 g) and increased myeloperoxidase activity.Visceral hypersensitivity tocolo-rectal distension was increased in TNBS treated rats up to 21 d and resolved by day 28.Somatic hypersensitivity was also increased up to 14 d post TNBS induction of colitis.The expression of an inflammatory marker myeloperoxidase was significantly elevated in the intracellular granules of neutrophils in rat models following TNBS treatment compared to naive rats.This confirmed the induction of inflammation in rats following TNBS treatment.VIP plasma concentration was significantly increased in rats following TNBS treatment as compared to naive animals(P 0.05).Likewise,the VIP gene expression from peripheral whole blood was significantly upregulated by 2.91-fold in IBS patients when compared to controls(P 0.00001; 95%CI).VIP plasma protein was not significantly different when compared with controls(P = 0.193).CONCLUSION: Alterations in VIP expression may play a role in IBS.Therefore,a better understanding of the physiology of VIP could lead to new therapeutics.     

Plasma vasoactive intestinal polypeptide concentration determination in patients with diarrhea

Determination of plasma levels of vasoactive intestinal polypeptide (VIP) has been used for screening patients with chronic diarrhea to identify potential neuroendocrine tumors. This 6-year blinded study from 1981 to 1986 examines the causes of elevated VIP levels in patients. In healthy volunteers ( n = 144), VIP concentrations ranged from 14 to 76 pg/mL (mean +/- SE, 28 +/- 12), whereas in chronic renal failure, 4 of 34 patients or 12% [serum creatinine 4.5 - 9.0 mg/dL (397-795 mumols/L)] had an elevation to greater than 100 pg/mL. No patient with idiopathic hepatic cirrhosis (n = 12) had elevation of serum concentration of this peptide. Among 588 consecutive unselected patients undergoing evaluation for chronic diarrhea (n = 362; 62%) or possible neuroendocrine tumor (n = 214; 36%), 23 patients (3.9%) had concentrations greater than 76 pg/mL. In this group, 5 patients had functioning (VIP, 160-5975 pg/mL) and 5 had nonfunctioning (VIP, 80-120 pg/mL) pancreatic islet cell carcinomas: all 10 patients had hepatic metastases. Other known cases of elevated levels of VIP, ranging from 80 to 340 pg/mL, included other neurogenic tumors (n = 3), small- bowel resection (n = 2), inflammatory bowel disease (n = 2), chronic renal failure (n = 1), and prolonged fasting (n = 1). Patients with diarrhea in which VIP-secreting tumors were identified had plasma vasoactive intestinal peptide concentrations greater than 140 pg/mL. In patients with chronic diarrhea, determination of plasma vasoactive intestinal peptide levels did identify tumors secreting this peptide, but the results from this referral institution did not show identification of these tumors early in their clinical course.     

Effects of high in vivo levels of vasoactive intestinal polypeptide on function of circulating lymphocytes in humans.

To examine the possible in vivo significance of the immunomodulatory effects of vasoactive intestinal polypeptide described in vitro, several parameters of peripheral blood lymphocyte function were studied in a patient with a pancreatic endocrine tumor and high circulating levels of vasoactive intestinal polypeptide. There was no imbalance of the circulating lymphocyte subpopulations, and the in vitro responses of the patient's lymphocytes to mitogens were normal. However, there was an increased number (32%) of peripheral lymphocytes expressing interleukin 2 receptor. Serum immunoglobulin M levels were higher than in controls, and the patient's lymphocytes exhibited a spontaneous in vitro immunoglobulin M production higher than normal. Comparable increases in both interleukin 2 receptor expression and immunoglobulin M production were induced in vitro in normal peripheral lymphocyte cultures by the addition of vasoactive intestinal polypeptide concentrations similar to that detected in the patient's plasma. These findings indicate that a modulatory effect of vasoactive intestinal polypeptide on lymphocyte activation and immunoglobulin synthesis may be operating in vivo. They also suggest that vasoactive intestinal polypeptide does not mediate major defects in peripheral blood lymphocyte function in vivo.     

Patterns of innervation of vasoactive intestinal polypeptide, neuropeptide Y, and gastrin-releasing peptide immunoreactive nerves in the feline pancreas.

In this study, we performed a detailed analysis of the immunoreactive (IR) patterns and tissue distribution of vasoactive intestinal polypeptide (VIP), neuropeptide Y (NPY), and gastrin-releasing peptide (GRP) in the feline pancreas by means of immunohistochemical and radioimmunological techniques. Immunoreactivity for each peptide is localized to varicose nerve fibers distributed throughout the exocrine and endocrine pancreas, with some differences in the density and pattern of fiber distribution. In the acinar and stromal compartments, VIP-IR processes have a higher density than NPY- and GRP-containing fibers, the latter being the least abundant. The vasculature receives a particularly prominent NPY innervation, while GRP- and VIP-IR fibers are found occasionally in association with blood vessels. Around ducts, NPY- and VIP-IR nerves are more numerous than those positive for GRP-IR, which are quite sparse. One of the most interesting findings of the present work is the visualization of all peptide-IRs both in neuronal cell bodies and fibers within the intrapancreatic ganglia. VIP-IR is observed in virtually all ganglion cells, while GRP- and NPY-IRs are seen in a few neuronal cells. VIP and NPY tissue levels are much higher than GRP concentrations in all regions of the pancreas. VIP content in the head and body is greater than in the tail. The morphological relationship of VIP-, NPY-, and GRP-IR fibers with different pancreatic structures is consistent with specific peptidergic neural inputs in the regulation of pancreatic functions.     

Effects of vasoactive intestinal peptide and pancreatic polypeptide in rabbit intestine.

The effects of porcine vasoactive intestinal peptide (VIP) and bovine pancreatic polypeptide (PP) on jejunal, ileal, and colonic fluid transport were studied in the rabbit. VIP produced secretion in the small intestine (jejunum greater than ileum) but did not affect absorption in the colon. PP had no secretory effects in jejunum, ileum, or colon. The small intestinal secretion induced by VIP was not associated with raised cAMP concentrations in the mucosa; this suggests that the secretory effects of VIP in vivo are mediated by a mechanism other than stimulation of adenylate cyclase.     

Increase in retinal vasoactive intestinal polypeptide after eyelid fusion in primates.

Lids were fused in six neonatal and one adult macaque monkey (Macaca mulatta and Macaca arctoides) and were kept fused for 1 to 18.5 months. The juvenile macaques, but not the adult one, developed myopia due to excessive elongation of the eye. In all animals, the immunohistochemical reactivity of the retina for vasoactive intestinal polypeptide (VIP) was much higher in the closed than in the open eyes. The neuropeptide was localized to the perikaryon and dendrites of amacrine cells. No difference was observed in substance P immunoreactivity between open and closed eyes, suggesting that the observed effect is selective. The change in VIP immunoreactivity could be the result of an increase in peptide synthesis, a decrease in peptide release, or a combination of the two. These results indicate that VIP may play a part in the regulation of postnatal ocular growth.     

Receptors for pituitary adenylate cyclase-activating polypeptide Comparison with vasoactive intestinal peptide receptors.

Pituitary adenylate cyclase-activating polypeptide (PACAP) is a new member of the secretin glucagon-vasoactive intestinal peptide (VIP) family of peptides, being most homologous to VIP. PACAP exists in two amidated forms with 38 residues (PACAP38) and 27 residues (PACAP27), respectively. PACAP38 is the major form in tissues. There are two types of high-affinity receptors for PACAP: type I, which specifically binds to both PACAPs, and type II, which is shared with VIP. Type I PACAP receptors appear to have two subtypes: type IA, which binds to both PACAP38 and PACAP27, with slight preference for the latter, and type IB, with greater preference for PACAP38. Distribution of the type I PACAP receptor is different from that of VIP, and it is found in high concentrations in brain, spinal cord, anterior pituitary, adrenal medulla, spermatogonia at certain stages, mature spermatozoa, and some cell lines. Type II PACAP receptors are found in lung, liver, intestine, and other tissues, and their distribution is similar to that of the VIP receptor. Type II PACAP receptor might be similar to or identical with the VIP receptor.     

Substance P- and vasoactive intestinal polypeptide-immunoreactive innervation in normal and inflamed pouches after restorative proctocolectomy for ulcerative colitis

Recent studies suggest that the intestinal polypeptides substance P (SP) and vasoactive intestinal polypeptide (VIP) play a role in the bowel inflammatory processes. The aim of this study was to evaluate the distribution of SP and VIP immunoreactivities in the ileal pouch of the patients with ulcerative colitis (UC). Thirty-six patients underwent clinical evaluation, endoscopy, and histological examinations. Samples were taken from normal ileum (N=9), ileum of UC patients (N=9), normal ileal pouch (N=9), and pouchitis (N=9). SP- and VIP-containing nerve fibers were visualized in sections processed for immunofluorescence microscopy. The number and intensity of SP and VIP immunoreactivities were subjected to quantitative scoring. On samples from all groups lamina propria contained fibers showing bright immunofluorescence for SP and VIP. The number and intensity of SP immunoreactive nerve fibers were markedly increased in pouchitis as compared to normal pouch (P<0.005), to ileum of UC patients (P<0.001), and to normal ileum (P<0.05). The number and intensity of VIP-immunoreactive nerve fibers in the lamina propria were markedly increased in pouchitis patients and in those having a normal pouch as compared to pooled values of ileum of UC patients and normal ileum (P<0.05). The results suggest that SP, which may play a role in mediating inflammatory processes, is increased in pouchitis and that VIP, which may contribute to the regulation of intestinal motility, is increased in the pouch.     

Effects of hexamethonium and atropine on the basal levels of immunoreactive vasoactive intestinal polypeptide in dogs

The basal levels of immunoreactive vasoactive intestinal polypeptide (IR-VIP) in veins of the gastrointestinal tract and the effect of hexamethonium and atropine on basal levels of IR-VIP were examined in anesthetized dogs. The basal mean plasma IR-VIP levels in the pancreaticoduodenal vein, the mesenteric vein of the jejunum, the mesenteric vein of the ileum and the right colonic vein, but not the left gastroepiploic vein, were significantly higher than those in the femoral vein. These basal levels of IR-VIP were decreased by atropine, but not by hexamethonium. Thus, the main source of basal VIP in the portal vein is probably the duodenum (and pancreas) and the small and large intestine, and the basal levels of VIP are under the control of muscarinic receptors, in canine gastrointestinal tract.     

Intracerebroventricular injection of cholecystokinin octapeptide elevates plasma prolactin levels through stimulation of vasoactive intestinal polypeptide

We investigated the effect of cholecystokinin octapeptide (CCK-8) on plasma PRL levels in freely moving male rats. Intravenous injection of CCK-8 did not affect basal plasma PRL levels in doses up to 5000 ng/rat; however, plasma PRL increased significantly after intracerebroventricular (icv) injection of the peptide at a dose of 40 ng/rat. Proglumide (0.2 mg/kg, iv) and benzotript (0.2 mg/kg, iv), specific CCK receptor antagonists, blocked the icv CCK-8-induced increase in plasma PRL levels. There was no apparent effect of icv CCK-8 on the enhancement of PRL release by haloperidol (0.2 mg/kg, iv), sulpiride (0.1 mg/kg, iv), domperidone (0.1 mg/kg, iv), or RO22-1319 (0.1 mg/kg, iv). However, the apomorphine-induced inhibition of PRL secretion was significantly antagonized by icv CCK-8. Furthermore, icv CCK-8 increased plasma PRL levels in rats depleted of dopamine by pretreatment with reserpine and alpha-methyl-p-tyrosine. Finally, the elevation in plasma PRL levels produced by icv CCK-8 was substantially antagonized by vasoactive intestinal polypeptide antiserum (1:3; 10 microliter/rat, icv). These results suggest that CCK-8 increases plasma PRL through an interaction with a central CCK receptor, which stimulates the activity of vasoactive intestinal polypeptide, a putative PRL-releasing factor.     

Fat-induced jejunal inhibition of gastric acid secretion and release of pancreatic glucagon, enteroglucagon, gastric inhibitory polypeptide, and vasoactive intestinal polypeptide in man.

The effect of intrajejunal (i.j.) infusion of fat on meal-stimulated gastric acid secretion and release of pancreatic glucagon (PG), enteroglucagon (EG), gastric inhibitory polypeptide (GIP), and vasoactive intestinal polypeptide (VIP) was studied in seven healthy volunteers. I.j. fat markedly inhibited meal-stimulated acid secretion as compared to a control study with i.j. saline infusion. The acid inhibition was accompanied by augmental plasma concentrations of EG, GIP, and VIP but not of PG, suggesting that EG, GIP, and VIP may be among mediators of fat-induced jejunal inhibition of acid secretion. Concentration-time relationship makes it unlikely that the observed inhibition could be ascribed to any single peptide studied.     

Twenty-four-hour secretory pattern of vasoactive intestinal polypeptide in the elderly

A chronobiological study was carried out in 8 elderly male subjects (74-85 years) to evaluate the 24-hour vasoactive intestinal polypeptide (VIP) secretory pattern. Eight young adult males (21-32 years) made up the control group. Blood samples were drawn from each subject every 2 h during the day and hourly during the night for a 24-hour period. Mean 24-hour VIP values in elderly (21.1 +/- 0.3 pg/ml) and young adults (19.1 +/- 0.3 pg/ml) did not differ statistically, but daytime VIP values observed in elderly subjects (21.4 +/- 0.5 pg/ml) were higher (p less than 0.05) than those recorded in young adults (17.5 +/- 0.5 pg/ml). The young adults showed significant (p less than 0.05) circadian VIP fluctuations with highest values during the nighttime, while the elderly subjects did not. An age-related decreased activity of the peripheral neuronal VIP-ergic network is hypothesized.     

Hepatic metabolism of vasoactive intestinal polypeptide during liver transplantation in the pig.

In order to investigate hepatic clearance of vasoactive intestinal polypeptide we measured its concentration in blood from the common carotid artery, right atrium and portal vein during orthotopic liver transplantation in six pigs. Just after laparotomy we found a significantly higher concentration of vasoactive intestinal polypeptide in portal plasma compared to that of the right atrium (p less than 0.05). This difference was soon eliminated by a fall in portal concentration, and, apart from fluctuations in portal concentration, no significant gradient between portal and atrial blood was recorded during the remaining part of the operation. When portal concentrations exceeded 30 pmol/l, the median reduction after transhepatic passage was 29% (range 16.8%-63.9%), while portal concentrations less than 30 pmol/l had a median reduction of only 6.3% (range 1.4%-16.5%) (p less than 0.05). No gradient between right atrial and systemic arterial blood was recorded. We suggest that a concentration-dependent clearance of splanchnic vasoactive intestinal polypeptide takes place in the porcine liver.     

Comparative distribution of immunoreactive pituitary adenylate cyclase activating polypeptide and vasoactive intestinal polypeptide in rat forebrain.

Pituitary adenylate cyclase activating polypeptide (PACAP) and vasoactive intestinal polypeptide (VIP) are structurally similar, share the same high affinity site in same peripheral tissues and increase the intracellular content of adenylate cyclase. To establish which neural circuits are signaling with each of these two peptides, we systematically compared the immunohistochemical distribution of PACAP and VIP in selected rat forebrain regions using previously characterized antiserum. The PACAP antiserum recognized both PACAP27 and PACAP38, and PACAP immunoreactivity was unaffected by preincubation with various other peptides. PACAP-immunoreactive perikarya and fibers were observed in both hypothalamic and extrahypothalamic regions. In the hypothalamus PACAP perikarya were located in the supraoptic, paraventricular, anterior commissural, periventricular, and perifornical nuclei. In intact rats PACAP immunolabeled fibers were present in the internal zone of the median eminence and posterior pituitary. One week after hypophysectomy the intensity of staining in the internal zone was enhanced and immunoreactive fibers appeared in the external zone of the median eminence. Two or 3 weeks later a dense fiber network was observed around the portal capillaries in the external zone, and immunoreactive material further accumulated in the fibers of the internal zone. PACAP-immunoreactive perikarya and fibers were also observed in several extrahypothalamic regions including central thalamic nuclei, amygdaloid complex, bed nucleus of stria terminalis, septum, hippocampus and cingulate, and entorhinal cortices. In the lateral septum and entorhinal cortex PACAP fibers surrounded unstained neuronal cell bodies and small blood vessels. In intact rats, VIP-immunoreactive perikarya were present in all regions of the cerebral cortex, hippocampus, amygdaloid complexus and in the suprachiasmatic nucleus, but not in the paraventricular and supraoptic nuclei. In colchicine-treated rats the VIP perikarya appeared in the preoptic area and paraventricular nucleus. The fibers were organized in two main pathways: the stria terminalis and an ascending pathway from the suprachiasmatic nucleus to the paraventricular area. Hypophysectomy induced the appearance of VIP-immunoreactive fibers in the internal zone of the median eminence and perikarya in the supraoptic and paraventricular nuclei in addition to the suprachiasmatic nucleus. The dissimilar distributions of PACAP and VIP suggest that PACAP neural circuits are independent of that of VIP in the rat forebrain. These findings support possible multifunctional roles for PACAP as a posterior pituitary hormone, a hypophysiotrophic factor, and a neurotransmitter/neuromodulator.