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Wang K, Xue Y, Liu Y, Su X, Wei L, Lv C, Zhang X, Zhang L, Jia L, Zheng S, Ma Y, Yan H, Jiang G, Song H, Wang F, Lin Q, Hou Y. The detoxification ability of sex-role reversed seahorses determines the sexual dimorphism in immune responses to benzo[a]pyrene exposure. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 933:173088. [PMID: 38735333 DOI: 10.1016/j.scitotenv.2024.173088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/15/2024] [Accepted: 05/07/2024] [Indexed: 05/14/2024]
Abstract
Sexual dimorphism in immune responses is an essential factor in environmental adaptation. However, the mechanisms involved remain obscure owing to the scarcity of data from sex-role-reversed species in stressed conditions. Benzo[a]pyrene (BaP) is one of the most pervasive and carcinogenic organic pollutants in coastal environments. In this study, we evaluated the potential effects on renal immunotoxicity of the sex-role-reversed lined seahorse (Hippocampus erectus) toward environmental concentrations BaP exposure. Our results discovered the presence of different energy-immunity trade-off strategies adopted by female and male seahorses during BaP exposure. BaP induced more severe renal damage in female seahorses in a concentration-dependent manner. BaP biotransformation and detoxification in seahorses resemble those in mammals. Benzo[a]pyrene-7,8-dihydrodiol-9,10-oxide (BPDE) and 9-hydroxybenzo[a]pyrene (9-OH-BaP) formed DNA adducts and disrupted Ca2+ homeostasis may together attribute the renal immunotoxicity. Sexual dimorphisms in detoxification of both BPDE and 9-OH-BaP, and in regulation of Ca2+, autophagy and inflammation, mainly determined the extent of renal damage. Moreover, the mechanism of sex hormones regulated sexual dimorphism in immune responses needs to be further elucidated. Collectively, these findings contribute to the understanding of sexual dimorphism in the immunotoxicity induced by BaP exposure in seahorses, which may attribute to the dramatic decline in the biodiversity of the genus.
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Affiliation(s)
- Kai Wang
- School of Agriculture, Ludong University, Yantai 264025, China; Research and Development Center of Science, Technology and Industrialization of Seahorses, Ludong University, Yantai 264025, China.
| | - Yuanyuan Xue
- School of Agriculture, Ludong University, Yantai 264025, China; Research and Development Center of Science, Technology and Industrialization of Seahorses, Ludong University, Yantai 264025, China
| | - Yali Liu
- CAS Key Laboratory of Tropical Marine Bio-resources and Ecology, South China Sea Institute of Oceanology, Chinese Academy of Sciences, Guangzhou 510301, China.
| | - Xiaolei Su
- School of Agriculture, Ludong University, Yantai 264025, China; Research and Development Center of Science, Technology and Industrialization of Seahorses, Ludong University, Yantai 264025, China
| | - Lei Wei
- School of Agriculture, Ludong University, Yantai 264025, China
| | - Chunhui Lv
- School of Agriculture, Ludong University, Yantai 264025, China; Research and Development Center of Science, Technology and Industrialization of Seahorses, Ludong University, Yantai 264025, China
| | - Xu Zhang
- School of Agriculture, Ludong University, Yantai 264025, China
| | - Lele Zhang
- School of Agriculture, Ludong University, Yantai 264025, China; Research and Development Center of Science, Technology and Industrialization of Seahorses, Ludong University, Yantai 264025, China
| | - Longwu Jia
- School of Agriculture, Ludong University, Yantai 264025, China; Research and Development Center of Science, Technology and Industrialization of Seahorses, Ludong University, Yantai 264025, China
| | - Shiyi Zheng
- School of Agriculture, Ludong University, Yantai 264025, China; Research and Development Center of Science, Technology and Industrialization of Seahorses, Ludong University, Yantai 264025, China
| | - Yicong Ma
- School of Agriculture, Ludong University, Yantai 264025, China; Research and Development Center of Science, Technology and Industrialization of Seahorses, Ludong University, Yantai 264025, China
| | - Hansheng Yan
- School of Agriculture, Ludong University, Yantai 264025, China; Research and Development Center of Science, Technology and Industrialization of Seahorses, Ludong University, Yantai 264025, China
| | - Guangjun Jiang
- School of Agriculture, Ludong University, Yantai 264025, China
| | - Hongce Song
- School of Agriculture, Ludong University, Yantai 264025, China
| | - Fang Wang
- Department of Pathology, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai 264025, China
| | - Qiang Lin
- CAS Key Laboratory of Tropical Marine Bio-resources and Ecology, South China Sea Institute of Oceanology, Chinese Academy of Sciences, Guangzhou 510301, China
| | - Yuping Hou
- School of Life Sciences, Ludong University, Yantai 264025, China
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Li X, Wang Y, Chen Y, Lu Z, Sun Y, Zhong C, Lv Z, Pan H, Chen J, Yao D, Huang X, Yu C. Icariside II alleviates lipopolysaccharide-induced acute lung injury by inhibiting lung epithelial inflammatory and immune responses mediated by neutrophil extracellular traps. Life Sci 2024; 346:122648. [PMID: 38631668 DOI: 10.1016/j.lfs.2024.122648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/27/2024] [Accepted: 04/11/2024] [Indexed: 04/19/2024]
Abstract
AIMS Acute lung injury (ALI) is a life-threatening lung disease characterized by inflammatory cell infiltration and lung epithelial injury. Icariside II (ICS II), one of the main active ingredients of Herba Epimedii, exhibits anti-inflammatory and immunomodulatory effects. However, the effect and mechanism of ICS II in ALI remain unclear. The purpose of the current study was to investigate the pharmacological effect and underlying mechanism of ICS II in ALI. MAIN METHODS Models of neutrophil-like cells, human peripheral blood neutrophils, and lipopolysaccharide (LPS)-induced ALI mouse model were utilized. RT-qPCR and Western blotting determined the gene and protein expression levels. Protein distribution and quantification were analyzed by immunofluorescence. KEY FINDINGS ICS II significantly reduced lung histopathological damage, edema, and inflammatory cell infiltration, and it reduced pro-inflammatory cytokines in ALI. There is an excessive activation of neutrophils leading to a significant production of NETs in ALI mice, a process mitigated by the administration of ICS II. In vivo and in vitro studies found that ICS II could decrease NET formation by targeting neutrophil C-X-C chemokine receptor type 4 (CXCR4). Further data showed that ICS II reduces the overproduction of dsDNA, a NETs-related component, thereby suppressing cGAS/STING/NF-κB signalling pathway activation and inflammatory mediators release in lung epithelial cells. SIGNIFICANCE This study suggested that ICS II may alleviate LPS-induced ALI by modulating the inflammatory response, indicating its potential as a therapeutic agent for ALI treatment.
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Affiliation(s)
- Xiuchun Li
- Division of Pulmonary Medicine, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou Key Laboratory of Interdiscipline and Translational Medicine, Wenzhou Key Laboratory of Heart and Lung, Wenzhou, Zhejiang 325000, China
| | - Yangyue Wang
- Division of Pulmonary Medicine, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou Key Laboratory of Interdiscipline and Translational Medicine, Wenzhou Key Laboratory of Heart and Lung, Wenzhou, Zhejiang 325000, China
| | - Yuxin Chen
- Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Ziyi Lu
- Division of Pulmonary Medicine, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou Key Laboratory of Interdiscipline and Translational Medicine, Wenzhou Key Laboratory of Heart and Lung, Wenzhou, Zhejiang 325000, China
| | - Yihan Sun
- Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Chuyue Zhong
- Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Zhanghang Lv
- Division of Pulmonary Medicine, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou Key Laboratory of Interdiscipline and Translational Medicine, Wenzhou Key Laboratory of Heart and Lung, Wenzhou, Zhejiang 325000, China
| | - Haofeng Pan
- Division of Pulmonary Medicine, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou Key Laboratory of Interdiscipline and Translational Medicine, Wenzhou Key Laboratory of Heart and Lung, Wenzhou, Zhejiang 325000, China
| | - Jun Chen
- Division of Pulmonary Medicine, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou Key Laboratory of Interdiscipline and Translational Medicine, Wenzhou Key Laboratory of Heart and Lung, Wenzhou, Zhejiang 325000, China
| | - Dan Yao
- Division of Pulmonary Medicine, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou Key Laboratory of Interdiscipline and Translational Medicine, Wenzhou Key Laboratory of Heart and Lung, Wenzhou, Zhejiang 325000, China.
| | - Xiaoying Huang
- Division of Pulmonary Medicine, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou Key Laboratory of Interdiscipline and Translational Medicine, Wenzhou Key Laboratory of Heart and Lung, Wenzhou, Zhejiang 325000, China.
| | - Chang Yu
- Intervention Department, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
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Hussein MM, Fouda EM, Shehab Y, Nabih ES, Osman AM, Ishak SR. Association between arachidonate lipoxygenase 15,c.-292 C > T gene polymorphism and non-cystic fibrosis bronchiectasis in children: a pilot study on the effects on airway lipoxin A4 and disease phenotype. Ital J Pediatr 2024; 50:90. [PMID: 38685084 PMCID: PMC11059722 DOI: 10.1186/s13052-024-01654-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 04/07/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Persistent airway inflammation is a central feature of bronchiectasis. Arachidonate 15-lipoxygenase (ALOX-15) controls production of endogenous lipid mediators, including lipoxins that regulate airway inflammation. Mutations at various positions in ALOX-15 gene can influence airway disease development. We investigated association between ALOX-15,c.-292 C > T gene polymorphism and bronchiectasis unrelated to cystic fibrosis in Egyptian children. Also, lipoxin A4 (LXA4) level in bronchoalveolar lavage (BAL) was studied in relation to polymorphism genotypes and disease phenotypes determined by clinical, pulmonary functions, and radiological severity parameters. METHODS This was an exploratory study that included 60 participants. Thirty children with non-cystic fibrosis bronchiectasis (NCFB) were compared with 30 age and sex-matched controls. ALOX-15,c.-292 C > T polymorphism was genotyped using TaqMan-based Real-time PCR. LXA4 was measured in BAL using ELISA method. RESULTS There was no significant difference between patients and controls regarding ALOX-15,c.-292 C > T polymorphism genotypes and alleles (OR = 1.75; 95% CI (0.53-5.7), P = 0.35) (OR = 1; 95% CI (0.48-2), p = 1). BAL LXA4 level was significantly lower in patients, median (IQR) of 576.9 (147.6-1510) ng/ml compared to controls, median (IQR) of 1675 (536.8-2542) (p = 0.002). Patients with severe bronchiectasis had a significantly lower LXA4 level (p < 0.001). There were significant correlations with exacerbations frequency (r=-0.54, p = 0.002) and FEV1% predicted (r = 0.64, p = 0.001). Heterozygous CT genotype carriers showed higher LXA4 levels compared to other genotypes(p = 0.005). CONCLUSIONS Low airway LXA4 in children with NCFB is associated with severe disease phenotype and lung function deterioration. CT genotype of ALOX-15,c.-292 C > T polymorphism might be a protective genetic factor against bronchiectasis development and/or progression due to enhanced LXA4 production.
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Affiliation(s)
| | - Eman Mahmoud Fouda
- Pediatrics Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Yasmine Shehab
- Pediatrics Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Enas Samir Nabih
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed Mohamed Osman
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sally Raafat Ishak
- Pediatrics Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Hu F, Qu Z, Chen K, Zhang P, Wang B, Jiang R, Zuo Y, Xia P, Chen H. Lipoxin A4 Ameliorates Imiquimod-Induced Psoriasis-Like Dermatitis via Promoting the Regression of Inflammation. Clin Cosmet Investig Dermatol 2023; 16:2103-2111. [PMID: 37575152 PMCID: PMC10422962 DOI: 10.2147/ccid.s418467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/03/2023] [Indexed: 08/15/2023]
Abstract
Introduction As a mediator of inflammation resolution, lipoxin A4 (LXA4) mainly plays an anti-inflammatory role and promotes inflammation resolution. LXA4 plays an inhibiting inflammatory role in a variety of diseases, tissues and cells, including keratinocytes. Psoriasis is a chronic inflammatory skin disease mediated by dysregulation of inflammation of immune cells and keratinocytes. However, the expression and role of LXA4 in psoriasis-like mouse models are still unclear. Methods Imiquimod (IMQ) topical treatment of dorsal skin induces psoriasis-like dermatitis in BALB/c mice, pretreated intraperitoneally with or without LXA4 prior to IMQ application. Severity of dorsal lesions is assessed by using a modified human scoring system and histopathology. The concentration of LXA4 and the expression of ALOX15 (a key gene in LXA4 metabolic synthesis) in lesional skins were detected by ELISA and Western blot. Quantitative PCR and ELISA were conducted to detect the mRNA and secretion levels of inflammatory cytokines. The proportion of IL-17A-producing γδT cells in skin and skin draining cervical lymph nodes and helper (Th) 17 cells in spleens was evaluated by flow cytometry. Western blotting was used to analyze the expressions of p-STAT3 and TRAF6. Results The concentration of LXA4 and the expression of ALOX15 were decreased in IMQ-induced lesional skin. LXA4 significantly relieved psoriasis-like lesions in IMQ-induced mouse models. Furthermore, LXA4 decreased IMQ-induced systemic inflammation, including reduced the proportion of IL-17A-producing gdT cells in skin and skin draining cervical lymph nodes and Th17 cells in spleens, the secretion and expression of CCL20, IL-17A, IL-1β, and TNF-α in skin and serum. LXA4 markedly inhibited IMQ-induced expression of TRAF6 and p-STAT3. Conclusion LXA4 significantly ameliorates IMQ-induced psoriasis-like inflammation, and LXA4 can be used as a target for psoriasis treatment.
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Affiliation(s)
- Feng Hu
- Department of Dermatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
- Hubei Province & Key Laboratory of Skin Infection and Immunity, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Zilu Qu
- Department of Dermatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
- Hubei Province & Key Laboratory of Skin Infection and Immunity, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Kai Chen
- Department of Dermatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
- Hubei Province & Key Laboratory of Skin Infection and Immunity, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Ping Zhang
- Department of Dermatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Bei Wang
- Department of Dermatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Ruili Jiang
- Department of Dermatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Yuyue Zuo
- Department of Dermatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Ping Xia
- Department of Dermatology, Wuhan No. 1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
| | - Hongxiang Chen
- Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, 518052, People’s Republic of China
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People’s Republic of China
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Wang S, Qian X, Shen C, Sun Q, Jing Y, Liu B, Zhang K, Li M, Wang J, Zhou H, Dong C. The protective effects of lipoxin A4 on type 2 diabetes mellitus: A Chinese prospective cohort study. Front Endocrinol (Lausanne) 2023; 14:1109747. [PMID: 36742389 PMCID: PMC9892446 DOI: 10.3389/fendo.2023.1109747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/09/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Several cellular and animal studies have suggested that lipoxin A4 (LXA4) has a protective effect on type 2 diabetes mellitus (T2DM) development. However, little is known about whether LXA4 influences T2DM development at the population level. METHODS We included 2755 non-diabetic participants from a cohort study in China who were followed for about seven years. Cox proportional hazards model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CI) for the association between LXA4 and incident T2DM. Mediation models were used to examine how serum lipids as mediators impact the association between LXA4 and T2DM. RESULTS In total, 172 newly diagnosed T2DM cases were identified. Multivariate-adjusted HR for T2DM in the fourth compared with the first quartile of LXA4 was 0.62 (95% CI: 0.40-0.96). When used the optimal cutoff value determined by the receiver operating characteristic curve, the results showed participants with LXA4 > 2.84 ng/mL had a decreased T2DM risk compared to those with LXA4 ≤ 2.84 ng/mL (HR: 0.63, 95% CI: 0.45-0.89). The effect of LXA4 on incident T2DM was significantly modified by gender (P -interaction = 0.024) and family history of diabetes (P -interaction = 0.025). Additionally, the association between LXA4 and incident T2DM was partially suppressed by the TyG and TG/HDL-c ratio, with a suppression proportion of 22.2% and 16.0%, respectively. CONCLUSIONS Higher LXA4 levels are significantly associated with a lower risk of T2DM development. The present findings would be helpful in understanding the effect of LXA4 on T2DM development at the population level.
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Affiliation(s)
- Sudan Wang
- Department of Epidemiology and Statistics, School of Public Health, Medical College of Soochow University, Soochow, Jiangsu, China
| | - Xiaoyan Qian
- Division of non-communicable diseases, Suzhou Industrial Park Centers for Disease Control and Prevention, Soochow, China
| | - Chao Shen
- Division of non-communicable diseases, Suzhou Industrial Park Centers for Disease Control and Prevention, Soochow, China
| | - Qian Sun
- Department of Epidemiology and Statistics, School of Public Health, Medical College of Soochow University, Soochow, Jiangsu, China
| | - Yang Jing
- Division of non-communicable diseases, Suzhou Industrial Park Centers for Disease Control and Prevention, Soochow, China
| | - Bingyue Liu
- Department of Epidemiology and Statistics, School of Public Health, Medical College of Soochow University, Soochow, Jiangsu, China
| | - Kexin Zhang
- Department of Epidemiology and Statistics, School of Public Health, Medical College of Soochow University, Soochow, Jiangsu, China
| | - Mengyuan Li
- Department of Epidemiology and Statistics, School of Public Health, Medical College of Soochow University, Soochow, Jiangsu, China
| | - Junrong Wang
- Department of Epidemiology and Statistics, School of Public Health, Medical College of Soochow University, Soochow, Jiangsu, China
| | - Hui Zhou
- Division of non-communicable diseases, Suzhou Industrial Park Centers for Disease Control and Prevention, Soochow, China
- *Correspondence: Chen Dong, ; Hui Zhou,
| | - Chen Dong
- Department of Epidemiology and Statistics, School of Public Health, Medical College of Soochow University, Soochow, Jiangsu, China
- *Correspondence: Chen Dong, ; Hui Zhou,
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Yamaguchi A, Botta E, Holinstat M. Eicosanoids in inflammation in the blood and the vessel. Front Pharmacol 2022; 13:997403. [PMID: 36238558 PMCID: PMC9551235 DOI: 10.3389/fphar.2022.997403] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/05/2022] [Indexed: 01/14/2023] Open
Abstract
Polyunsaturated fatty acids (PUFAs) are structural components of membrane phospholipids in cells. PUFAs regulate cellular function through the formation of derived lipid mediators termed eicosanoids. The oxygenation of 20-carbon PUFAs via the oxygenases cyclooxygenases, lipoxygenases, or cytochrome P450, generates a class of classical eicosanoids including prostaglandins, thromboxanes and leukotrienes, and also the more recently identified hydroxy-, hydroperoxy-, epoxy- and oxo-eicosanoids, and the specialized pro-resolving (lipid) mediators. These eicosanoids play a critical role in the regulation of inflammation in the blood and the vessel. While arachidonic acid-derived eicosanoids are extensively studied due to their pro-inflammatory effects and therefore involvement in the pathogenesis of inflammatory diseases such as atherosclerosis, diabetes mellitus, hypertension, and the coronavirus disease 2019; in recent years, several eicosanoids have been reported to attenuate exacerbated inflammatory responses and participate in the resolution of inflammation. This review focused on elucidating the biosynthesis and the mechanistic signaling of eicosanoids in inflammation, as well as the pro-inflammatory and anti-inflammatory effects of these eicosanoids in the blood and the vascular wall.
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Affiliation(s)
- Adriana Yamaguchi
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Eliana Botta
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Michael Holinstat
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI, United States,Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, United States,*Correspondence: Michael Holinstat,
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