Lung effects during a generalized Shwartzman reaction and therapeutic intervention with dexamethasone or vitamin E

Inflammatory processes during acute respiratory distress syndrome: a complex system

PURPOSE OF REVIEW

ARDS is a severe pulmonary disease characterized by inflammation. However, inflammation-directed therapies have yet failed to improve the outcome in ARDS patients. One of the reasons may be the underestimated complexity of inflammation. Here, we summarize recent insights into the complex interrelations between inflammatory circuits.

RECENT FINDINGS

Gene expression analysis from animal models or from patients with ARDS, sepsis or trauma show an enormous number of differentially expressed genes with highly significant overlaps between the various conditions. These similarities, however, should not obscure the complexity of inflammation. We suggest to consider inflammation in ARDS as a system controlled by scale-free networks of genome-wide molecular interaction with hubs (e.g. NFκB, C/EBPβ, ATF3), exhibiting nonlinear emergence and the ability to adapt, meaning for instance that mild and life-threatening inflammation in ARDS are distinct processes. In order to comprehend this complex system, it seems necessary to combine model-driven simulations, data-driven modelling and hypothesis-driven experimental studies. Recent experimental studies have illustrated how several regulatory circuits interact during pulmonary inflammation, including the resolution of inflammation, the inflammasome, autophagy and apoptosis.

SUMMARY

We suggest that therapeutic interventions in ARDS should be based on a systems approach to inflammation.

Tacrolimus downregulates inflammation by regulating pro‑/anti‑inflammatory responses in LPS‑induced keratitis

Lipopolysaccharide (LPS)-induced keratitis is a progressive infectious ocular disease in which innate inflammatory responses often cause clinical tissue damage and vision loss. The present study aimed to investigate the effects of tacrolimus, an effective immunomodulator, on LPS-induced innate immune responses. The effects of tacrolimus on the apoptotic rate and viability of human corneal epithelial cells (HCECs), polymorphonuclear neutrophils (PMNs) and monocytes (THP-1 cells) were examined using flow cytometry and MTT assays. Subsequently, the role of tacrolimus on LPS-induced inflammation in HCECs, PMNs and THP-1 cells was evaluated by detecting the expression levels of pro-inflammatory cytokines, including interleukin (IL)-1β, IL-6 and matrix metallopeptidase 9; anti-inflammatory cytokines, including IL-10 and transforming growth factor-β; and proangiogenic factors, including vascular endothelial growth factor and tumor necrosis factor-α using quantitative polymerase chain reaction. The results demonstrated that tacrolimus had good biocompatibility with HCECs, while promoting apoptosis and decreasing the viability of PMNs and THP-1 cells. Furthermore, tacrolimus effectively reduced the expression levels of pro-inflammatory cytokines and increased anti-inflammatory cytokines in LPS-induced keratitis in vitro. Notably, tacrolimus decreased the levels of proangiogenic factors, which are highly increased following LPS stimulation. Conclusively, tacrolimus appears to be a safe and effective treatment to suppress neutrophil and monocyte activity, modulate the balance of pro-/anti-inflammatory cytokines, and reduce the inflammatory response and angiogenic activity in LPS-induced bacterial keratitis.

Super-low dose endotoxin pre-conditioning exacerbates sepsis mortality

Sepsis mortality varies dramatically in individuals of variable immune conditions, with poorly defined mechanisms. This phenomenon complements the hypothesis that innate immunity may adopt rudimentary memory, as demonstrated in vitro with endotoxin priming and tolerance in cultured monocytes. However, previous in vivo studies only examined the protective effect of endotoxin tolerance in the context of sepsis. In sharp contrast, we report herein that pre-conditioning with super-low or low dose endotoxin lipopolysaccharide (LPS) cause strikingly opposite survival outcomes. Mice pre-conditioned with super-low dose LPS experienced severe tissue damage, inflammation, increased bacterial load in circulation, and elevated mortality when they were subjected to cecal-ligation and puncture (CLP). This is in contrast to the well-reported protective phenomenon with CLP mice pre-conditioned with low dose LPS. Mechanistically, we demonstrated that super-low and low dose LPS differentially modulate the formation of neutrophil extracellular trap (NET) in neutrophils. Instead of increased ERK activation and NET formation in neutrophils pre-conditioned with low dose LPS, we observed significantly reduced ERK activation and compromised NET generation in neutrophils pre-conditioned with super-low dose LPS. Collectively, our findings reveal a mechanism potentially responsible for the dynamic programming of innate immunity in vivo as it relates to sepsis risks.

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Super-low dose endotoxin pre-conditioning exacerbates, while higher dose endotoxin alleviates sepsis mortality.

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Super-low dose endotoxin reduces, while higher dose endotoxin facilitates neutrophil extracellular trap (NET) formation.

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Super-low dose endotoxin suppresses, while higher dose endotoxin induces ERK activation required for NET formation.

Innate immune programing by endotoxin and its pathological consequences

Monocytes and macrophages play pivotal roles in inflammation and homeostasis. Recent studies suggest that dynamic programing of macrophages and monocytes may give rise to distinct "memory" states. Lipopolysaccharide (LPS), a classical pattern recognition molecule, dynamically programs innate immune responses. Emerging studies have revealed complex dynamics of cellular responses to LPS, with high doses causing acute, resolving inflammation, while lower doses are associated with low-grade and chronic non-resolving inflammation. These phenomena hint at dynamic complexities of intra-cellular signaling circuits downstream of the Toll-like receptor 4 (TLR4). In this review, we examine pathological effects of varying LPS doses with respect to the dynamics of innate immune responses and key molecular regulatory circuits responsible for these effects.

Attenuation of lipopolysaccharide (LPS)-induced cytotoxicity by tocopherols and tocotrienols

Lipopolysaccharide (LPS) induces host inflammatory responses and tissue injury and has been implicated in the pathogenesis of various age-related diseases such as acute respiratory distress syndrome, vascular diseases, and periodontal disease. Antioxidants, particularly vitamin E, have been shown to suppress oxidative stress induced by LPS, but the previous studies with different vitamin E isoforms gave inconsistent results. In the present study, the protective effects of α- and γ-tocopherols and α- and γ-tocotrienols on the oxidative stress induced by LPS against human lung carcinoma A549 cells were studied. They suppressed intracellular reactive oxygen formation, lipid peroxidation, induction of inflammatory mediator cytokines, and cell death. Tocopherols were incorporated into cultured cells much slower than tocotrienols but could suppress LPS-induced oxidative stress at much lower intracellular concentration than tocotrienols. Considering the bioavailability, it was concluded that α-tocopherol may exhibit the highest protective capacity among the vitamin E isoforms against LPS-induced oxidative stress.

Endotoxin tolerance variation over 24 h during porcine endotoxemia: association with changes in circulation and organ dysfunction

Endotoxin tolerance (ET), defined as reduced inflammatory responsiveness to endotoxin challenge following a first encounter with endotoxin, is an extensively studied phenomenon. Although reduced mortality and morbidity in the presence of ET has been demonstrated in animal studies, little is known about the temporal development of ET. Further, in acute respiratory distress syndrome ET correlates to the severity of the disease, suggesting a complicated relation between ET and organ dysfunction. Eighteen pigs were subjected to intensive care and a continuous endotoxin infusion for 24 h with the aim to study the time course of early ET and to relate ET to outcome in organ dysfunction. Three animals served as non-endotoxemic controls. Blood samples for cytokine analyses were taken and physiological variables registered every third hour. Production of TNF-α, IL-6, and IL-10 before and after endotoxin stimulation ex vivo was measured. The difference between cytokine values after and before ex vivo LPS stimulation (Δ-values) was calculated for all time points. ΔTNF-α was employed as the principal marker of ET and lower ΔTNF-α values were interpreted as higher levels of ET. During endotoxin infusion, there was suppression of ex vivo productions of TNF-α and IL-6 but not of IL-10 in comparison with that at 0 h. The ex vivo TNF-α values followed another time concentration curve than those in vivo. ΔTNF-α was at the lowest already at 6 h, followed by an increase during the ensuing hours. ΔTNF-α at 6 h correlated positively to blood pressure and systemic vascular resistance and negatively to cardiac index at 24 h. In this study a temporal variation of ET was demonstrated that did not follow changes in plasma TNF-α concentrations. Maximal ET occurred early in the course and the higher the ET, the more hyperdynamic the circulation 18 h later.

Differences in organ dysfunction in endotoxin-tolerant pigs under intensive care exposed to a second hit of endotoxin

Endotoxin tolerance is a well-studied phenomenon associated with a reduced inflammatory response. In the switch from an inflammatory to an anti-inflammatory response in clinical sepsis, the concept of endotoxin tolerance is of obvious interest. However, only limited data exist regarding the effect of endotoxin tolerance on organ dysfunction, and therefore, this was investigated in a porcine intensive care sepsis model. Twenty-seven healthy pigs, including nine control animals, were included in the study. Twelve pigs pre-exposed to 24 h of intravenous endotoxin infusion and intensive care and six unexposed pigs were given either a high- or low-dose endotoxin challenge for 6 h. Inflammatory, circulatory, hypoperfusion, and organ dysfunction parameters were followed. The inflammatory responses as well as parameters representing circulation, hypoperfusion, and cardiac and renal function were all markedly attenuated in animals pre-exposed to endotoxin and intensive care as compared with animals not pre-exposed. In animals pre-exposed to endotoxin and given the high-dose of endotoxin challenge, deterioration in pulmonary function was equal to or even worse than in animals not pre-exposed. In contrast to the overall protective effect of endotoxin tolerance observed in other organ systems, the lungs of endotoxin-tolerant animals demonstrated an increased responsiveness to high-dose endotoxin challenge.

In vitro effect of combined hybrid molecules from vitamin E analogues and betulinic acid on macrophage activity

Macrophage activity was studied after treatment with hybrid molecules obtained by condensation of terpenic acid residues (betulinic and betulonic acids) and α-tocopherol analogues (α-tocopherol hemisuccinate and Trolox acid). As distinct from betulinic acid and α-tocopherol hemisuccinate, hybrid molecules did not exhibit cytotoxicity in relation to mouse peritoneal macrophages in the MTT test. Test substances inhibited the production of NO by mouse peritoneal macrophages. However, hybrid molecules had no effect on activity of macrophage arginase. Our results indicate that new molecules have anti-inflammatory activity. It can be hypothesized that these substances have immunomodulatory properties.

Models and mechanisms of acute lung injury caused by direct insults

Acute lung injury (ALI) and its more severe form acute respiratory distress syndrome (ARDS) are life-threatening diseases that are characterized by acute onset, pulmonary inflammation, oedema due to increased vascular permeability and severe hypoxemia. Clinically, ARDS can be divided into ARDS due to direct causes such as pneumonia, aspiration or injurious ventilation, and due to extrapulmonary indirect causes such as sepsis, severe burns or pancreatitis. In order to identify potential therapeutic targets, we asked here whether common molecular mechanisms can be identified that are relevant in different models of the direct form of ALI/ARDS. To this end, we reviewed three widely used models: (a) one based on a biological insult, i.e. instillation of bacterial endotoxins; (b) one based on a chemical insult, i.e. instillation of acid; and (c) one based on a mechanical insult, i.e. injurious ventilation. Studies were included only if the mediator or mechanism of interest was studied in at least two of the three animal models listed above. As endpoints, we selected neutrophil sequestration, permeability, hypoxemia (physiological dysfunction) and survival. Our analysis showed that most studies have focused on mechanisms of pulmonary neutrophil sequestration and models with moderate forms of oedema. The underlying mechanisms that involve canonical inflammatory pathways such as MAP kinases, CXCR2 chemokines, PAF, leukotrienes, adhesions molecules (CD18, ICAM-1) and elastase have been defined relatively well. Further mechanisms including TNF, DARC, HMGB1, PARP, GADD45 and collagenase are under investigation. Such mechanisms that are shared between the three ALI models may represent viable therapeutic targets. However, only few studies have linked these pathways to hypoxemia, the most important clinical aspect of ALI/ARDS. Since moderate oedema does not necessarily lead to hypoxemia, we suggest that the clinical relevance of experimental studies can be further improved by putting greater emphasis on gas exchange.

Effects of repeated intratracheally administered lipopolysaccharide on primary and secondary specific antibody responses and on body weight gain of broilers

Earlier, we reported that pathogen-associated molecular patterns such as lipopolysaccharide (LPS), when administered intratracheally (i.t.), affected primary and secondary specific antibody responses to antigens administered concurrently, either i.t. or systemically, and also affected BW gain (BWG) of layers and broilers. In the present study, we evaluated the effects of repeated i.t. challenge with LPS concurrently with or before i.t. immunizations with the specific antigens human serum albumin (HuSA) and rabbit gamma globulin (RGG) on primary (HuSA, RGG) and secondary (HuSA) systemic antibody responses and (isotype) IgM and IgG responses at 2 different ages. Broilers were challenged via the trachea at 3 and 7 wk of age with various combinations of LPS, HuSA, and RGG. All treatments affected immune responses at several time points and also affected BWG, albeit temporarily for the latter. Lipopolysaccharide enhanced primary antibody responses to HuSA and to RGG, when challenged concurrently, but birds challenged solely with LPS at 3 wk of age also showed enhanced primary antibody responses to HuSA and RGG given at 7 wk of age. This was true for IgM as well as IgG isotype responses. Lipopolysaccharide challenge negatively affected BWG at 3 wk of age, whereas the negative effects of LPS after a secondary LPS challenge at 7 wk of age were most pronounced in the birds challenged with LPS at 3 wk of age. The present results indicated that LPS, when administered i.t. at a young age, may affect specific humoral immune responsiveness to antigens administered simultaneously and to BWG of broilers, but also when challenged 4 wk later with specific antigens, suggesting an enhanced status of immune reactivity or sensitivity. The hygienic status of broiler houses at a young age may thus influence BWG, immune responsiveness, and, consequently, the vaccine efficacy and disease resistance in broilers at later ages. The consequences of our findings are discussed.

A nutrient approach to prostate cancer prevention: The Selenium and Vitamin E Cancer Prevention Trial (SELECT)

The Selenium and Vitamin E Cancer Prevention Trial (SELECT) randomized 35,533 healthy men, >55 yr old (>50 yr if African American), with normal digital rectal exams and prostate specific antigens <4 ng/ml to 1) 200 μg/day l-selenomethionine, 2) 400 IU/day all-rac-alpha-tocopheryl acetate (vitamin E), 3) both supplements, or 4) placebo for 7 to 12 yr. The hypotheses underlying SELECT, that selenium and vitamin E individually and together decrease prostate cancer incidence, derived from epidemiologic and laboratory evidence and significant secondary endpoints in the Nutritional Prevention of Cancer (selenium) and Alpha-Tocopherol Beta-Carotene (vitamin E) trials. In SELECT, prostate cancer incidence did not differ among the 4 arms: hazard ratios [99% confidence intervals (CIs)] for prostate cancer were 1.13 (99% CI = 0.95-1.35, P = 0.06; n = 473) for vitamin E, 1.04 (99% CI = 0.87-1.24, P = 0.62; n = 432) for selenium, and 1.05 (99% CI = 0.88-1.25, P = 0.52; n = 437) for selenium + vitamin E vs. 1.00 (n = 416) for placebo. Statistically nonsignificant increased risks of prostate cancer with vitamin E alone [relative risk (RR) = 1.13, P = 0.06) and newly diagnosed Type 2 diabetes mellitus with selenium alone (RR = 1.07, P = 0.16) were observed. SELECT data show that neither selenium nor vitamin E, alone or together, in the doses and formulations used, prevented prostate cancer in this heterogeneous population of healthy men.

Effects of fluid resuscitation with hypertonic saline dextrane or Ringer's acetate after nonhemorrhagic shock caused by pulmonary contusion

BACKGROUND

Injured lungs are sensitive to fluid resuscitation after trauma. Such treatment can increase lung water content and lead to desaturation. Hypertonic saline with dextran (HSD) has hyperosmotic properties that promote plasma volume expansion, thus potentially reducing these side effects. The aim of this study was to (1) evaluate whether fluid treatment counteracts hypotension and improves survival after nonhemorrhagic shock caused by lung contusion and (2) analyze whether resuscitation with HSD is more efficient than treatment with Ringer's acetate (RA) in terms of blood oxygenation, the amount of lung water, circulatory effects, and inflammatory response.

METHODS

Twenty-nine pigs, all wearing body armor, were shot with a 7.62-mm assault rifle to produce a standardized pulmonary contusion. These animals were allocated into three groups: HSD, RA, and an untreated shot control group. Exposed animals were compared with animals not treated with fluid and shot with blank ammunition. For 2 hours after the shot, the inflammatory response and physiologic parameters were monitored.

RESULTS

The impact induced pulmonary contusion, desaturation, hypotension, increased heart rate, and led to an inflammatory response. No change in blood pressure was observed after fluid treatment. HSD treatment resulted in significantly less lung water (p < 0.05) and tended to give better Pao2 (p = 0.09) than RA treatment. Tumor necrosis factor-α release and heart rate were significantly lower in animals given fluids.

CONCLUSION

Fluid treatment does not affect blood pressure or mortality in this model of nonhemorrhagic shock caused by lung contusion. However, our data indicate that HSD, when compared with RA, has advantages for the injured lung.

Intratracheally Administered Pathogen-Associated Molecular Patterns Affect Antibody Responses of Poultry

Various potential immune-modulating microbially derived pathogen-associated molecular patterns (PAMP), or so called homotopes, are present in high concentrations in the environment of food animals. In previous studies, intravenously administered PAMP had variable effects on specific primary and secondary immune responses of poultry to systemically administered antigens. In the present study, we evaluated the effects of intratracheal (i.t.) challenge with the PAMP lipopolysaccharide, lipoteichoic acid (LTA), and Zymosan-A (containing 1,3 beta-glucan) on primary and secondary (total) antibody (Ab) responses and (isotype) IgM, IgG, and IgA responses to systemically administered human serum albumin (HuSA), and Ab titers to infectious bursal disease (Gumboro virus) and infectious bronchitis vaccines in layer hens at 9 and 22 wk of age. Birds were challenged via the trachea with PAMP for 5 consecutive days prior to primary and secondary immunization with HuSA. Intratracheally administered LTA and, to a minor extent, lipopolysaccharide significantly enhanced secondary total and IgG Ab responses to HuSA. 1,3 beta-Glucan did not significantly affect Ab responses to HuSA. All birds challenged with PAMP showed a decreased BW. Higher total Ab titers to infectious bursal disease and infectious bronchitis were found in birds challenged with LTA. The present results indicate that i.t. administered PAMP affect the humoral immune responsiveness of poultry, which may lead to an enhanced status of immune reactivity. Furthermore, our results suggest that the hygienic status of the environment influences BW (gain). The consequences of immune modulation by airborne PAMP or hygienic conditions in chicken husbandry for vaccine delivery and immune responsiveness of poultry are discussed.

Vitamin E down-modulates mitogen-activated protein kinases, nuclear factor-kappaB and inflammatory responses in lung epithelial cells

The airway epithelium plays an active role in acute lung inflammation by producing chemotactic factors and by expressing cell adhesion molecules involved in the migration of leucocytes to extravascular spaces. We have reported previously that neutrophil migration to airways can be down-modulated by exogenously administered vitamin E (alpha-tocopherol). The mechanism for this effect is not well understood, however. The action of alpha-tocopherol was investigated in human alveolar type II and bronchial epithelial cells stimulated with tumour necrosis factor-alpha. Treatment of alveolar epithelial cells with alpha-tocopherol resulted in down-regulated cell surface expression of intercellular adhesion molecule-1 (ICAM-1). On bronchial epithelial cells, both ICAM-1 and vascular adhesion molecule-1 were decreased, leading to diminished adherence of leucocytes to the cells. The production of the neutrophil chemoattractant interleukin-8 was attenuated in both alveolar and bronchial cells. These effects were preceded by reduced activation of the mitogen-activated protein kinases (MAPK), extracellular signal-regulated kinase (ERK1/2) and p38, as well as down-regulation of nuclear factor-kappaB. Comparing the effects of alpha-tocopherol with that of specific inhibitors of MAPK and protein kinase C (PKC) revealed that effects appear to be partly independent of PKC inhibition. These results implicate the anti-inflammatory action of alpha-tocopherol in addition to its anti-oxidant properties.

Age- and Breed-Dependent Adapted Immune Responsiveness of Poultry to Intratracheal-Administered, Pathogen-Associated Molecular Patterns

Immune modulation of poultry by airborne pathogen-associated molecular patterns (PAMP) was studied. White and Brown layer chicks were exposed intratracheally during 5 consecutive days at 7 wk of age with Escherichia coli-derived lipopolysaccharide (LPS), Saccharomyces cerevisiae-derived 1,3 beta-glucan (BGL), a combination of both, or PBS as a control. Six weeks later, birds received similar or crossover PAMP treatments. Body weight (gain), feed conversion, (primary and secondary) specific antibody responses to model antigens, and natural antibody levels were measured. In general, BGL enhanced but LPS exposure decreased primary immune responses at 7 wk of age, whereas both PAMP-enhanced secondary immune responses but decreased primary immune responses at 13 wk of age. Body weight gain and feed conversion at both ages were negatively affected by LPS, especially in White birds, but not by BGL. Pathogen-associated molecular patterns exposure at 7 wk of age also affected Ab responses at 13 wk of age. Birds exposed to a combination of LPS + BGL at 7 wk of age had significantly lower secondary total and IgG Ab responses at 13 wk of age. Birds from both breeds showed enhanced BW gain after exposure to LPS at 13 wk of age, when initially challenged at 7 wk of age with LPS, BGL, or a combined challenge with both. Pathogen-associated molecular patterns exposure at 7 wk of age affected humoral immunity and BW gain at 13 wk of age in a positive (BGL) or negative (LPS) fashion. Repeated exposure to PAMP did not affect Ab responses, but crossover exposure to PAMP in general enhanced Ab responses. Body weight gain was positively affected by repeated exposure but not by crossover exposure, suggesting adaptation of the birds to early PAMP exposure. Our findings suggest that sensitivity of poultry for immune modulation by airborne PAMP differs between ages, is breed-dependent, and is not irreversible of nature. In addition, our data suggest different adaptation to hygienic conditions, both with respect to immune reactivity and BW gain.