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Marzec J, Nadadur S. Countermeasures against Pulmonary Threat Agents. J Pharmacol Exp Ther 2024; 388:560-567. [PMID: 37863486 PMCID: PMC10801713 DOI: 10.1124/jpet.123.001822] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/22/2023] Open
Abstract
Inhaled toxicants are used for diverse purposes, ranging from industrial applications such as agriculture, sanitation, and fumigation to crowd control and chemical warfare, and acute exposure can induce lasting respiratory complications. The intentional release of chemical warfare agents (CWAs) during World War I caused life-long damage for survivors, and CWA use is outlawed by international treaties. However, in the past two decades, chemical warfare use has surged in the Middle East and Eastern Europe, with a shift toward lung toxicants. The potential use of industrial and agricultural chemicals in rogue activities is a major concern as they are often stored and transported near populated areas, where intentional or accidental release can cause severe injuries and fatalities. Despite laws and regulatory agencies that regulate use, storage, transport, emissions, and disposal, inhalational exposures continue to cause lasting lung injury. Industrial irritants (e.g., ammonia) aggravate the upper respiratory tract, causing pneumonitis, bronchoconstriction, and dyspnea. Irritant gases (e.g., acrolein, chloropicrin) affect epithelial barrier integrity and cause tissue damage through reactive intermediates or by direct adduction of cysteine-rich proteins. Symptoms of CWAs (e.g., chlorine gas, phosgene, sulfur mustard) progress from airway obstruction and pulmonary edema to acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), which results in respiratory depression days later. Emergency treatment is limited to supportive care using bronchodilators to control airway constriction and rescue with mechanical ventilation to improve gas exchange. Complications from acute exposure can promote obstructive lung disease and/or pulmonary fibrosis, which require long-term clinical care. SIGNIFICANCE STATEMENT: Inhaled chemical threats are of growing concern in both civilian and military settings, and there is an increased need to reduce acute lung injury and delayed clinical complications from exposures. This minireview highlights our current understanding of acute toxicity and pathophysiology of a select number of chemicals of concern. It discusses potential early-stage therapeutic development as well as challenges in developing countermeasures applicable for administration in mass casualty situations.
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Affiliation(s)
- Jacqui Marzec
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina
| | - Srikanth Nadadur
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina
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2
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Addis DR, Aggarwal S, Lazrak A, Jilling T, Matalon S. Halogen-Induced Chemical Injury to the Mammalian Cardiopulmonary Systems. Physiology (Bethesda) 2021; 36:272-291. [PMID: 34431415 DOI: 10.1152/physiol.00004.2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The halogens chlorine (Cl2) and bromine (Br2) are highly reactive oxidizing elements with widespread industrial applications and a history of development and use as chemical weapons. When inhaled, depending on the dose and duration of exposure, they cause acute and chronic injury to both the lungs and systemic organs that may result in the development of chronic changes (such as fibrosis) and death from cardiopulmonary failure. A number of conditions, such as viral infections, coexposure to other toxic gases, and pregnancy increase susceptibility to halogens significantly. Herein we review their danger to public health, their mechanisms of action, and the development of pharmacological agents that when administered post-exposure decrease morbidity and mortality.
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Affiliation(s)
- Dylan R Addis
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama.,Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Saurabh Aggarwal
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular and Translational Biomedicine, University of Alabama at Birmingham, Birmingham, Alabama.,Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ahmed Lazrak
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular and Translational Biomedicine, University of Alabama at Birmingham, Birmingham, Alabama.,Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Tamas Jilling
- Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Pediatrics, Division of Neonatology, Children's Hospital, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sadis Matalon
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular and Translational Biomedicine, University of Alabama at Birmingham, Birmingham, Alabama.,Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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3
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Watkins R, Perrott R, Bate S, Auton P, Watts S, Stoll A, Rutter S, Jugg B. Development of chlorine-induced lung injury in the anesthetized, spontaneously breathing pig. Toxicol Mech Methods 2021; 31:257-271. [PMID: 33929275 DOI: 10.1080/15376516.2021.1906808] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Chlorine is a toxic industrial chemical produced in vast quantities globally, being used in a range of applications such as water purification, sanitation and industrial processes. Its use and transport cannot be restricted; exposure may occur following accidental or deliberate releases. The OPCW recently verified the use of chlorine gas against civilians in both Syria and Iraq. Chlorine inhalation produces damage to the lungs, which may result in the development of an acute lung injury, respiratory failure and death. Treatment remains an intractable problem. Our objective was to develop a clinically relevant pre-clinical model of a moderate to severe lung injury in the pig. This would enable future assessment of therapeutic drugs or interventions to be implemented in the pre-hospital phase after exposure. Due to the irritant nature of chlorine, a number of strategies for exposing terminally anesthetized pigs needed to be investigated. A number of challenges (inconsistent acute changes in respiratory parameters; early deaths), resulted in a moderate to severe lung injury not being achieved. However, most pigs developed a mild lung injury by 12 h. Further investigation is required to optimize the model and enable the assessment of therapeutic candidates. In this paper we describe the exposure strategies used and discuss the challenges encountered in establishing a model of chlorine-induced lung injury. A key aim is to assist researchers navigating the challenges of producing a clinically relevant model of higher dose chlorine exposure where animal welfare is protected by use of terminal anesthesia.
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Affiliation(s)
| | | | - Simon Bate
- CBR Division, Dstl Porton Down, Salisbury, UK
| | | | - Sarah Watts
- CBR Division, Dstl Porton Down, Salisbury, UK
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4
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Radbel J, Laskin DL, Laskin JD, Kipen HM. Disease-modifying treatment of chemical threat agent-induced acute lung injury. Ann N Y Acad Sci 2020; 1480:14-29. [PMID: 32726497 DOI: 10.1111/nyas.14438] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/10/2020] [Accepted: 06/21/2020] [Indexed: 02/04/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is a highly morbid lung pathology induced by exposure to chemical warfare agents, including vesicants, phosgene, chlorine, and ricin. In this review, we describe the pathology associated with the development of ARDS in humans and experimental models of acute lung injury following animal exposure to these high-priority threat agents. Potential future approaches to disease-modifying treatment used in preclinical animal studies, including antioxidants, anti-inflammatories, biologics, and mesenchymal stem cells, are also described. As respiratory pathologies, including ARDS, are the major cause of morbidity and mortality following exposure to chemical threat agents, understanding mechanisms of disease pathogenesis is key to the development of efficacious therapeutics beyond the primary intervention principle, which remains mechanical ventilation.
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Affiliation(s)
- Jared Radbel
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Debra L Laskin
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey
| | - Jeffrey D Laskin
- Department of Environmental and Occupational Health, School of Public Health, Rutgers University, Piscataway, New Jersey
| | - Howard M Kipen
- Department of Environmental and Occupational Health, School of Public Health, Rutgers University, Piscataway, New Jersey
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5
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Achanta S, Jordt SE. Transient receptor potential channels in pulmonary chemical injuries and as countermeasure targets. Ann N Y Acad Sci 2020; 1480:73-103. [PMID: 32892378 PMCID: PMC7933981 DOI: 10.1111/nyas.14472] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 12/17/2022]
Abstract
The lung is highly sensitive to chemical injuries caused by exposure to threat agents in industrial or transportation accidents, occupational exposures, or deliberate use as weapons of mass destruction (WMD). There are no antidotes for the majority of the chemical threat agents and toxic inhalation hazards despite their use as WMDs for more than a century. Among several putative targets, evidence for transient receptor potential (TRP) ion channels as mediators of injury by various inhalational chemical threat agents is emerging. TRP channels are expressed in the respiratory system and are essential for homeostasis. Among TRP channels, the body of literature supporting essential roles for TRPA1, TRPV1, and TRPV4 in pulmonary chemical injuries is abundant. TRP channels mediate their function through sensory neuronal and nonneuronal pathways. TRP channels play a crucial role in complex pulmonary pathophysiologic events including, but not limited to, increased intracellular calcium levels, signal transduction, recruitment of proinflammatory cells, neurogenic inflammatory pathways, cough reflex, hampered mucus clearance, disruption of the integrity of the epithelia, pulmonary edema, and fibrosis. In this review, we summarize the role of TRP channels in chemical threat agents-induced pulmonary injuries and how these channels may serve as medical countermeasure targets for broader indications.
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Affiliation(s)
- Satyanarayana Achanta
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Sven-Eric Jordt
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
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6
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Lazrak A, Song W, Zhou T, Aggarwal S, Jilling T, Garantziotis S, Matalon S. Hyaluronan and halogen-induced airway hyperresponsiveness and lung injury. Ann N Y Acad Sci 2020; 1479:29-43. [PMID: 32578230 PMCID: PMC7680259 DOI: 10.1111/nyas.14415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/18/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
Chlorine (Cl2 ) and bromine (Br2 ) are produced in large quantities throughout the world and used in the industry and the sanitation of water. These halogens can pose a significant threat to public health when released into the atmosphere during transportation and industrial accidents, or as acts of terrorism. In this review, we discuss the evidence showing that the activity of Cl2 and Br2 , and of products formed by their interaction with biomolecules, fragment high-molecular-weight hyaluronan (HMW-HA), a key component of the interstitial space and present in epithelial cells, to form proinflammatory, low-molecular-weight hyaluronan fragments that increase intracellular calcium (Ca2+ ) and activate RAS homolog family member A (RhoA) in airway smooth muscle and epithelial and microvascular cells. These changes result in airway hyperresponsiveness (AHR) to methacholine and increase epithelial and microvascular permeability. The increase in intracellular Ca2+ is the result of the activation of the calcium-sensing receptor by Cl2 , Br2 , and their by-products. Posthalogen administration of a commercially available form of HMW-HA to mice and to airway cells in vitro reverses the increase of Ca2+ and the activation of RhoA, and restores AHR to near-normal levels of airway function. These data have established the potential of HMW-HA to be a countermeasure against Cl2 and Br2 toxicity.
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Affiliation(s)
- Ahmed Lazrak
- Division of Molecular and Translational Biomedicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Weifeng Song
- Division of Molecular and Translational Biomedicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Ting Zhou
- Division of Molecular and Translational Biomedicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Saurabh Aggarwal
- Division of Molecular and Translational Biomedicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Tamas Jilling
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Division of Neonatology, Department of Pediatrics, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Stavros Garantziotis
- Matrix Biology Group, Immunity, Inflammation, and Disease Laboratory, NIH/NIEHS, RTP, NC
| | - Sadis Matalon
- Division of Molecular and Translational Biomedicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
- Pulmonary Injury and Repair Center, Department of Anesthesiology and Perioperative Medicine, the University of Alabama at Birmingham School of Medicine, Birmingham, AL
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7
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van Haren FMP, Page C, Laffey JG, Artigas A, Camprubi-Rimblas M, Nunes Q, Smith R, Shute J, Carroll M, Tree J, Carroll M, Singh D, Wilkinson T, Dixon B. Nebulised heparin as a treatment for COVID-19: scientific rationale and a call for randomised evidence. Crit Care 2020; 24:454. [PMID: 32698853 PMCID: PMC7374660 DOI: 10.1186/s13054-020-03148-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/03/2020] [Indexed: 12/16/2022] Open
Abstract
Nebulised unfractionated heparin (UFH) has a strong scientific and biological rationale and warrants urgent investigation of its therapeutic potential, for COVID-19-induced acute respiratory distress syndrome (ARDS). COVID-19 ARDS displays the typical features of diffuse alveolar damage with extensive pulmonary coagulation activation resulting in fibrin deposition in the microvasculature and formation of hyaline membranes in the air sacs. Patients infected with SARS-CoV-2 who manifest severe disease have high levels of inflammatory cytokines in plasma and bronchoalveolar lavage fluid and significant coagulopathy. There is a strong association between the extent of the coagulopathy and poor clinical outcomes.The anti-coagulant actions of nebulised UFH limit fibrin deposition and microvascular thrombosis. Trials in patients with acute lung injury and related conditions found inhaled UFH reduced pulmonary dead space, coagulation activation, microvascular thrombosis and clinical deterioration, resulting in increased time free of ventilatory support. In addition, UFH has anti-inflammatory, mucolytic and anti-viral properties and, specifically, has been shown to inactivate the SARS-CoV-2 virus and prevent its entry into mammalian cells, thereby inhibiting pulmonary infection by SARS-CoV-2. Furthermore, clinical studies have shown that inhaled UFH safely improves outcomes in other inflammatory respiratory diseases and also acts as an effective mucolytic in sputum-producing respiratory patients. UFH is widely available and inexpensive, which may make this treatment also accessible for low- and middle-income countries.These potentially important therapeutic properties of nebulised UFH underline the need for expedited large-scale clinical trials to test its potential to reduce mortality in COVID-19 patients.
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Affiliation(s)
- Frank M P van Haren
- Australian National University, Medical School, Canberra, Australia.
- Intensive Care Unit, the Canberra Hospital, Canberra, Australia.
| | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, London, UK
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland
- Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Galway, Ireland
| | - Antonio Artigas
- Critical Center, Corporació Sanitaria Parc Tauli , CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain
| | - Marta Camprubi-Rimblas
- Institut d'Investigació I Innovació Parc Tauli (I3PT), CIBER de Enfermedades Respiratorias, Sabadell, Spain
| | - Quentin Nunes
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Roger Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Janis Shute
- School of Pharmacy and Biomedical Science, University of Portsmouth, Portsmouth, UK
| | - Mary Carroll
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Julia Tree
- National Infection Service, Public Health England, Porton Down, UK
| | - Miles Carroll
- National Infection Service, Public Health England, Porton Down, UK
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester, UK
| | - Tom Wilkinson
- Department of Respiratory Medicine, University of Southampton, Southampton, UK
| | - Barry Dixon
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
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8
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Choking agents and chlorine gas – History, pathophysiology, clinical effects and treatment. Toxicol Lett 2020; 320:73-79. [DOI: 10.1016/j.toxlet.2019.12.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 12/19/2022]
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9
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Achanta S, Jordt SE. Toxic effects of chlorine gas and potential treatments: a literature review. Toxicol Mech Methods 2019; 31:244-256. [PMID: 31532270 DOI: 10.1080/15376516.2019.1669244] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Chlorine gas is one of the highly produced chemicals in the USA and around the world. Chlorine gas has several uses in water purification, sanitation, and industrial applications; however, it is a toxic inhalation hazard agent. Inhalation of chlorine gas, based on the concentration and duration of the exposure, causes a spectrum of symptoms, including but not limited to lacrimation, rhinorrhea, bronchospasm, cough, dyspnea, acute lung injury, death, and survivors develop signs of pulmonary fibrosis and reactive airway disease. Despite the use of chlorine gas as a chemical warfare agent since World War I and its known potential as an industrial hazard, there is no specific antidote. The resurgence of the use of chlorine gas as a chemical warfare agent in recent years has brought speculation of its use as weapons of mass destruction. Therefore, developing antidotes for chlorine gas-induced lung injuries remains the need of the hour. While some of the pre-clinical studies have made substantial progress in the understanding of chlorine gas-induced pulmonary pathophysiology and identifying potential medical countermeasure(s), yet none of the drug candidates are approved by the U.S. Food and Drug Administration (FDA). In this review, we summarized pathophysiology of chlorine gas-induced pulmonary injuries, pre-clinical animal models, development of a pipeline of potential medical countermeasures under FDA animal rule, and future directions for the development of antidotes for chlorine gas-induced lung injuries.
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Affiliation(s)
| | - Sven-Eric Jordt
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA.,Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, USA
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10
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Aggarwal S, Jilling T, Doran S, Ahmad I, Eagen JE, Gu S, Gillespie M, Albert CJ, Ford D, Oh JY, Patel RP, Matalon S. Phosgene inhalation causes hemolysis and acute lung injury. Toxicol Lett 2019; 312:204-213. [PMID: 31047999 DOI: 10.1016/j.toxlet.2019.04.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/28/2019] [Accepted: 04/18/2019] [Indexed: 12/23/2022]
Abstract
Phosgene (Carbonyl Chloride, COCl2) remains an important chemical intermediate in many industrial processes such as combustion of chlorinated hydrocarbons and synthesis of solvents (degreasers, cleaners). It is a sweet smelling gas, and therefore does not prompt escape by the victim upon exposure. Supplemental oxygen and ventilation are the only available management strategies. This study was aimed to delineate the pathogenesis and identify novel biomarkers of acute lung injury post exposure to COCl2 gas. Adult male and female C57BL/6 mice (20-25 g), exposed to COCl2 gas (10 or 20 ppm) for 10 min in environmental chambers, had a dose dependent reduction in PaO2 and an increase in PaCO2, 1 day post exposure. However, mortality increased only in mice exposed to 20 ppm of COCl2 for 10 min. Correspondingly, these mice (20 ppm) also had severe acute lung injury as indicated by an increase in lung wet to dry weight ratio, extravasation of plasma proteins and neutrophils into the bronchoalveolar lavage fluid, and an increase in total lung resistance. The increase in acute lung injury parameters in COCl2 (20 ppm, 10 min) exposed mice correlated with simultaneous increase in oxidation of red blood cells (RBC) membrane, RBC fragility, and plasma levels of cell-free heme. In addition, these mice had decreased plasmalogen levels (plasmenylethanolamine) and elevated levels of their breakdown product, polyunsaturated lysophosphatidylethanolamine, in the circulation suggesting damage to cellular plasma membranes. This study highlights the importance of free heme in the pathogenesis of COCl2 lung injury and identifies plasma membrane breakdown product as potential biomarkers of COCl2 toxicity.
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Affiliation(s)
- Saurabh Aggarwal
- Department of Anesthesiology and Perioperative Medicine, Birmingham, AL, 35205-3703, United States; Division of Molecular and Translational Biomedicine, Birmingham, AL, 35205-3703, United States; Pulmonary Injury and Repair Center, Birmingham, AL, 35205-3703, United States; Center for Free Radical Biology, Birmingham, AL, 35205-3703, United States; School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35205-3703, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; St. Louis University, St. Louis, MO, 63104, United States
| | - Tamas Jilling
- Pulmonary Injury and Repair Center, Birmingham, AL, 35205-3703, United States; Department of Pediatrics, Division of Neonatology, Birmingham, AL, 35205-3703, United States; Center for Free Radical Biology, Birmingham, AL, 35205-3703, United States; School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35205-3703, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; St. Louis University, St. Louis, MO, 63104, United States
| | - Stephen Doran
- Department of Anesthesiology and Perioperative Medicine, Birmingham, AL, 35205-3703, United States; Division of Molecular and Translational Biomedicine, Birmingham, AL, 35205-3703, United States; School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35205-3703, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; St. Louis University, St. Louis, MO, 63104, United States
| | - Israr Ahmad
- Department of Anesthesiology and Perioperative Medicine, Birmingham, AL, 35205-3703, United States; Division of Molecular and Translational Biomedicine, Birmingham, AL, 35205-3703, United States; School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35205-3703, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; St. Louis University, St. Louis, MO, 63104, United States
| | - Jeannette E Eagen
- Department of Anesthesiology and Perioperative Medicine, Birmingham, AL, 35205-3703, United States; Division of Molecular and Translational Biomedicine, Birmingham, AL, 35205-3703, United States; School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35205-3703, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; St. Louis University, St. Louis, MO, 63104, United States
| | - Stephen Gu
- Department of Anesthesiology and Perioperative Medicine, Birmingham, AL, 35205-3703, United States; Division of Molecular and Translational Biomedicine, Birmingham, AL, 35205-3703, United States; School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35205-3703, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; St. Louis University, St. Louis, MO, 63104, United States
| | - Mark Gillespie
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35205-3703, United States; Department of Pharmacology, Mobile, AL, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; St. Louis University, St. Louis, MO, 63104, United States
| | - Carolyn J Albert
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35205-3703, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; Department of Biochemistry and Molecular Biology, St. Louis, MO, 63104, United States; St. Louis University, St. Louis, MO, 63104, United States
| | - David Ford
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35205-3703, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; Department of Biochemistry and Molecular Biology, St. Louis, MO, 63104, United States
| | - Joo-Yeun Oh
- Department of Pathology, Division of Cellular and Molecular Pathology, Birmingham, AL, 35205-3703, United States; Center for Free Radical Biology, Birmingham, AL, 35205-3703, United States; School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35205-3703, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; St. Louis University, St. Louis, MO, 63104, United States
| | - Rakesh P Patel
- Pulmonary Injury and Repair Center, Birmingham, AL, 35205-3703, United States; Department of Pathology, Division of Cellular and Molecular Pathology, Birmingham, AL, 35205-3703, United States; Center for Free Radical Biology, Birmingham, AL, 35205-3703, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; St. Louis University, St. Louis, MO, 63104, United States
| | - Sadis Matalon
- Department of Anesthesiology and Perioperative Medicine, Birmingham, AL, 35205-3703, United States; Division of Molecular and Translational Biomedicine, Birmingham, AL, 35205-3703, United States; Pulmonary Injury and Repair Center, Birmingham, AL, 35205-3703, United States; Center for Free Radical Biology, Birmingham, AL, 35205-3703, United States; University of South Alabama Health College of Medicine, Mobile, AL, United States; St. Louis University, St. Louis, MO, 63104, United States.
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11
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Huynh Tuong A, Despréaux T, Loeb T, Salomon J, Mégarbane B, Descatha A. Emergency management of chlorine gas exposure - a systematic review. Clin Toxicol (Phila) 2019; 57:77-98. [PMID: 30672349 DOI: 10.1080/15563650.2018.1519193] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Chlorine exposure can lead to pulmonary obstruction, reactive airway dysfunction syndrome, acute respiratory distress syndrome and, rarely, death. OBJECTIVE We performed a systematic review of published animal and human data regarding the management of chlorine exposure. METHODS Three databases were searched from 2007 to 2017 using the following keywords "("chlorine gas" OR "chlorine-induced" OR" chlorine-exposed") AND ("therapy" OR "treatment" OR "post-exposure")". Forty-five relevant papers were found: 22 animal studies, 6 reviews, 19 case reports and 1 human randomized controlled study. General management: Once the casualty has been removed from the source of exposure and adequately decontaminated, chlorine-exposed patients should receive supportive care. Humidified oxygen: If dyspnea and hypoxemia are present, humidified oxygen should be administered. Inhaled bronchodilators: The use of nebulized or inhaled bronchodilators to counteract bronchoconstriction is standard therapy, and the combination of ipratropium bromide with beta2-agonists effectively reversed bronchoconstriction, airway irritation and increased airway resistance in experimental studies. Inhaled sodium bicarbonate: In a randomized controlled trial, humidified oxygen, intravenous prednisolone and inhaled salbutamol were compared with nebulized sodium bicarbonate. The only additional benefit of sodium bicarbonate was to increase the forced expiratory volume in one second, 2 and 4 h after administration. Corticosteroids: Dexamethasone 100 mg/kg intraperitoneally (IP) reduced lung edema when given within 1 h of chlorine inhalation and when administered within 6 h significantly decreased (p < 0.01) the leukocyte count in the bronchoalveolar lavage (BAL). As corticosteroids were never given alone in clinical studies, it is impossible to assess whether they had an additional beneficial effect. Antioxidants: An ascorbic acid/deferoxamine combination (equivalent to 100 mg/kg and 15 mg/kg, respectively) was administered intramuscularly 1 h after chlorine exposure, then every 12 h up to 60 h, then as an aerosol, and produced a significant reduction (p < 0.05) in BAL leukocytes and a significant reduction (p < 0.007) in mortality at 72 h. The single clinical case reported was uninterpretable. Sodium nitrite: Sodium nitrite 10 mg/kg intramuscularly (IM), 30 min post-chlorine exposure in mice and rabbits significantly reduced (p < 0.01) the number of leukocytes and the protein concentration in BAL and completely reversed mortality in rabbits and decreased mortality by about 50% in mice. No clinical studies have reported the use of sodium nitrite. Dimethylthiourea: Dimethylthiourea 100 mg/kg IP significantly decreased (p < 0.05) lymphocytes and neutrophils in BAL fluid 24 h after chlorine exposure in experimental studies. No clinical studies have been undertaken. AEOL 10150: Administration of AEOL10150 5 mg/kg IP at 1 h and 9 h post-chlorine exposure reduced significantly the neutrophil (p < 0.001) and macrophage (p < 0.05) bronchoalveolar cell counts. Transient receptor potential vanilloid 4 (TRPV4): IM or IP TRPV4 reduced significantly (p < 0.001) bronchoalveolar neutrophil and macrophage counts to baseline at 24 h. No clinical studies have been performed. Reparixin and triptolide: In experimental studies, triptolide 100-1000 µg/kg IP 1 h post-exposure caused a significant decrease (p < 0.001) in bronchoalveolar neutrophils, whereas reparixin 15 mg/kg IP 1 h post-exposure produced no benefit. Rolipram: Nanoemulsion formulated rolipram administered intramuscularly returned airway resistance to baseline. Rolipram (40%)/poly(lactic-co-glycolic acid) (60%) 0.36 mg/mouse given intramuscularly 1 h post-exposure significantly reduced (p < 0.05) extravascular lung water by 20% at t + 6 h. Prophylactic antibiotics: Studies in patients have failed to demonstrate benefit. Sevoflurane: Sevoflurane has been used in one intubated patient in addition to beta2-agonists. Although the peak inspiratory pressure was decreased after 60 min, the role of sevofluorine is not known. CONCLUSIONS Various therapies seem promising based on animal studies or case reports. However, these recommendations are based on low-level quality data. A systematic list of outcomes to monitor and improve may help to design optimal therapeutic protocols to manage chlorine-exposed patients.
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Affiliation(s)
- Alice Huynh Tuong
- a AP-HP, EMS (Samu 92) Occupational Health Unit , Poincaré Hospital , Garches , France.,b Population-based Epidemiologic Cohorts Unit , INSERM, UMS011 , Villejuif , France.,c Aging and Chronic Diseases: Epidemiological and Public Health Approaches , INSERM, U1168 , Villejuif , France
| | - Thomas Despréaux
- a AP-HP, EMS (Samu 92) Occupational Health Unit , Poincaré Hospital , Garches , France.,b Population-based Epidemiologic Cohorts Unit , INSERM, UMS011 , Villejuif , France.,c Aging and Chronic Diseases: Epidemiological and Public Health Approaches , INSERM, U1168 , Villejuif , France
| | - Thomas Loeb
- a AP-HP, EMS (Samu 92) Occupational Health Unit , Poincaré Hospital , Garches , France
| | - Jérôme Salomon
- d Versailles Saint Quentin-en-Yvelines University , Institut Pasteur, INSERM, UMR 1181 , Paris , France.,e Department of Acute Medicine , CHU PIFO, APHP, Poincaré Hospital , Garches , France
| | - Bruno Mégarbane
- f Department of Medical and Toxicological Critical Care Medicine , APHP, Lariboisière Hospital , Paris , France.,g Paris-Diderot University, INSERM UMR-S 1144 , Paris , France
| | - Alexis Descatha
- a AP-HP, EMS (Samu 92) Occupational Health Unit , Poincaré Hospital , Garches , France.,b Population-based Epidemiologic Cohorts Unit , INSERM, UMS011 , Villejuif , France.,c Aging and Chronic Diseases: Epidemiological and Public Health Approaches , INSERM, U1168 , Villejuif , France
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12
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Zhou T, Song WF, Shang Y, Yao SL, Matalon S. Halogen Inhalation-Induced Lung Injury and Acute Respiratory Distress Syndrome. Chin Med J (Engl) 2018; 131:1214-1219. [PMID: 29722341 PMCID: PMC5956773 DOI: 10.4103/0366-6999.231515] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Exposure to halogens, such as chlorine or bromine, results in environmental and occupational hazard to the lung and other organs. Chlorine is highly toxic by inhalation, leading to dyspnea, hypoxemia, airway obstruction, pneumonitis, pulmonary edema, and acute respiratory distress syndrome (ARDS). Although bromine is less reactive and oxidative than chlorine, inhalation also results in bronchospasm, airway hyperresponsiveness, ARDS, and even death. Both halogens have been shown to damage the systemic circulation and result in cardiac injury as well. There is no specific antidote for these injuries since the mechanisms are largely unknown. DATA SOURCES This review was based on articles published in PubMed databases up to January, 2018, with the following keywords: "chlorine," "bromine," "lung injury," and "ARDS." STUDY SELECTION The original articles and reviews including the topics were the primary references. RESULTS Based on animal studies, it is found that inhaled chlorine will form chlorine-derived oxidative products that mediate postexposure toxicity; thus, potential treatments will target the oxidative stress and inflammation induced by chlorine. Antioxidants, cAMP-elevating agents, anti-inflammatory agents, nitric oxide-modulating agents, and high-molecular-weight hyaluronan have shown promising effects in treating acute chlorine injury. Elevated free heme level is involved in acute lung injury caused by bromine inhalation. Hemopexin, a heme-scavenging protein, when administered postexposure, decreases lung injury and improves survival. CONCLUSIONS At present, there is an urgent need for additional research to develop specific therapies that target the basic mechanisms by which halogens damage the lungs and systemic organs.
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Affiliation(s)
- Ting Zhou
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
- Department of Critical Care Medicine, Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Wei-Feng Song
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - You Shang
- Department of Critical Care Medicine, Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Shang-Long Yao
- Department of Critical Care Medicine, Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Sadis Matalon
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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13
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Juschten J, Tuinman PR, Juffermans NP, Dixon B, Levi M, Schultz MJ. Nebulized anticoagulants in lung injury in critically ill patients-an updated systematic review of preclinical and clinical studies. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:444. [PMID: 29264361 DOI: 10.21037/atm.2017.08.23] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pneumonia, inhalation trauma and acute respiratory distress syndrome (ARDS), typical causes of lung injury in critically ill patients, are all three characterized by dysregulated inflammation and coagulation in the lungs. Nebulized anticoagulants are thought to have beneficial effects as they could attenuate pulmonary coagulopathy and maybe even affect pulmonary inflammation. A systematic search of the medical literature was performed using terms referring to aspects of the condition ('pneumonia', 'inhalation trauma' and 'ARDS'), the intervention ('nebulized', 'vaporized', and 'aerosolized') and anticoagulants limited to agents that are commercially available and frequently given or tested in critically ill patients ['heparin', 'danaparoid', 'activated protein C' (APC), 'antithrombin' (AT) and 'tissue factor pathway inhibitor' (TFPI)]. The systematic search identified 16 articles reporting on preclinical studies and 11 articles reporting on human trials. All nebulized anticoagulants attenuate pulmonary coagulopathy in preclinical studies using various models for lung injury, but the effects on inflammation are less consistent. Nebulized heparin, danaparoid and TFPI, but not APC and AT also reduced systemic coagulation. Nebulized heparin in lung injury patients shows contradictory results, and there is concern over systemic side effects of this strategy. Future studies need to focus on the way to nebulize anticoagulants, as well as on efficient but safe dosages, and other side effects.
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Affiliation(s)
- Jenny Juschten
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, the Netherlands.,Department of Intensive Care and Research VUmc Intensive Care (REVIVE), VU Medical Center, Amsterdam, the Netherlands.,Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care and Research VUmc Intensive Care (REVIVE), VU Medical Center, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, the Netherlands.,Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
| | - Barry Dixon
- Department of Intensive Care Medicine, St. Vincent's Hospital, Melbourne, Australia
| | - Marcel Levi
- Department of Medicine, University College London Hospitals, London, UK
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, the Netherlands.,Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands.,Mahidol-Oxford Research Unit (MORU), Mahidol University, Bangkok, Thailand
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14
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8-Isoprostane is an early biomarker for oxidative stress in chlorine-induced acute lung injury. Toxicol Lett 2017; 282:1-7. [PMID: 29017959 DOI: 10.1016/j.toxlet.2017.10.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 10/04/2017] [Accepted: 10/06/2017] [Indexed: 11/21/2022]
Abstract
Inhalation of chlorine (Cl2) may cause oxidative acute lung injury (ALI) characterized by pulmonary edema, pneumonitis, and hyperreactive airways. The aim of the study was to identify possible biomarkers for Cl2-induced ALI. Female BALB/c mice were exposed to Cl2 for 15min using two protocols 1) concentration-dependent response (25-200ppm) and 2) time-kinetics (2h-14days post-exposure). Exposure to 50-200ppm Cl2 caused a concentration-dependent inflammatory response with increased expression of IL-1β, IL-6 and CXCL1/KC in bronchoalveolar lavage fluid 2-6h after exposure which was followed by increased lung permeability and a neutrophilic inflammation 12-24h post-exposure. The early inflammatory cytokine response was associated with a clear but transient increase of 8-isoprostane, a biomarker for oxidative stress, with its maximum at 2h after exposure. An increase of 8-isoprostane could also be detected in serum 2h after exposure to 200ppm Cl2, which was followed by increased levels of IL-6 and CXCL1/KC and signs of increased fibrinogen and PAI-1. Melphalan, a non-oxidizing mustard gas analog, did not increase the 8-isoprostane levels, indicating that 8-isoprostane is induced in airways through direct oxidation by Cl2. We conclude that 8-isoprostane represents an early biomarker for oxidative stress in airways and in the blood circulation following Cl2-exposure.
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Summerhill EM, Hoyle GW, Jordt SE, Jugg BJ, Martin JG, Matalon S, Patterson SE, Prezant DJ, Sciuto AM, Svendsen ER, White CW, Veress LA. An Official American Thoracic Society Workshop Report: Chemical Inhalational Disasters. Biology of Lung Injury, Development of Novel Therapeutics, and Medical Preparedness. Ann Am Thorac Soc 2017; 14:1060-1072. [PMID: 28418689 PMCID: PMC5529138 DOI: 10.1513/annalsats.201704-297ws] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
This report is based on the proceedings from the Inhalational Lung Injury Workshop jointly sponsored by the American Thoracic Society (ATS) and the National Institutes of Health (NIH) Countermeasures Against Chemical Threats (CounterACT) program on May 21, 2013, in Philadelphia, Pennsylvania. The CounterACT program facilitates research leading to the development of new and improved medical countermeasures for chemical threat agents. The workshop was initiated by the Terrorism and Inhalational Disasters Section of the Environmental, Occupational, and Population Health Assembly of the ATS. Participants included both domestic and international experts in the field, as well as representatives from U.S. governmental funding agencies. The meeting objectives were to (1) provide a forum to review the evidence supporting current standard medical therapies, (2) present updates on our understanding of the epidemiology and underlying pathophysiology of inhalational lung injuries, (3) discuss innovative investigative approaches to further delineating mechanisms of lung injury and identifying new specific therapeutic targets, (4) present promising novel medical countermeasures, (5) facilitate collaborative research efforts, and (6) identify challenges and future directions in the ongoing development, manufacture, and distribution of effective and specific medical countermeasures. Specific inhalational toxins discussed included irritants/pulmonary toxicants (chlorine gas, bromine, and phosgene), vesicants (sulfur mustard), chemical asphyxiants (cyanide), particulates (World Trade Center dust), and respirable nerve agents.
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Mulloy B, Hogwood J, Gray E, Lever R, Page CP. Pharmacology of Heparin and Related Drugs. Pharmacol Rev 2016; 68:76-141. [PMID: 26672027 DOI: 10.1124/pr.115.011247] [Citation(s) in RCA: 227] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Heparin has been recognized as a valuable anticoagulant and antithrombotic for several decades and is still widely used in clinical practice for a variety of indications. The anticoagulant activity of heparin is mainly attributable to the action of a specific pentasaccharide sequence that acts in concert with antithrombin, a plasma coagulation factor inhibitor. This observation has led to the development of synthetic heparin mimetics for clinical use. However, it is increasingly recognized that heparin has many other pharmacological properties, including but not limited to antiviral, anti-inflammatory, and antimetastatic actions. Many of these activities are independent of its anticoagulant activity, although the mechanisms of these other activities are currently less well defined. Nonetheless, heparin is being exploited for clinical uses beyond anticoagulation and developed for a wide range of clinical disorders. This article provides a "state of the art" review of our current understanding of the pharmacology of heparin and related drugs and an overview of the status of development of such drugs.
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Affiliation(s)
- Barbara Mulloy
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - John Hogwood
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - Elaine Gray
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - Rebecca Lever
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
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17
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Is inhaled prophylactic heparin useful for prevention and management of pneumonia in ventilated ICU patients? J Crit Care 2016; 35:231-239. [PMID: 27591357 DOI: 10.1016/j.jcrc.2016.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE The purpose was to determine the efficacy of prophylactic inhaled heparin for the prevention and treatment of pneumonia in patients receiving mechanical ventilation (MV). METHODS A phase 2, double-blind, randomized controlled trial stratified for study center and patient type (nonoperative, postoperative) was conducted in 3 university-affiliated intensive care units. Patients aged at least 18 years and requiring invasive MV for more than 48 hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 U in 2 mL), or nebulization with 0.9% sodium chloride (2 mL) 4 times daily with the main outcome measures, the development of ventilator-associated pneumonia (VAP), ventilator-associated complication, and Sequential Organ Failure Assessment scores in patients with admission pneumonia or developing VAP. TRIAL REGISTRATION ACTRN12612000038897. RESULTS A total of 214 patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP using either Klompas criteria (6%-7%, P=1.00) or clinical diagnosis (24%-26%, P=.85). CONCLUSION Low-dose nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.
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Aggarwal S, Lam A, Bolisetty S, Carlisle MA, Traylor A, Agarwal A, Matalon S. Heme Attenuation Ameliorates Irritant Gas Inhalation-Induced Acute Lung Injury. Antioxid Redox Signal 2016; 24:99-112. [PMID: 26376667 PMCID: PMC4742996 DOI: 10.1089/ars.2015.6347] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIMS Exposure to irritant gases, such as bromine (Br2), poses an environmental and occupational hazard that results in severe lung and systemic injury. However, the mechanism(s) of Br2 toxicity and the therapeutic responses required to mitigate lung damage are not known. Previously, it was demonstrated that Br2 upregulates the heme degrading enzyme, heme oxygenase-1 (HO-1). Since heme is a major inducer of HO-1, we determined whether an increase in heme and heme-dependent oxidative injury underlies the pathogenesis of Br2 toxicity. RESULTS C57BL/6 mice were exposed to Br2 gas (600 ppm, 30 min) and returned to room air. Thirty minutes postexposure, mice were injected intraperitoneally with a single dose of the heme scavenging protein, hemopexin (Hx) (3 μg/gm body weight), or saline. Twenty-four hours postexposure, saline-treated mice had elevated total heme in bronchoalveolar lavage fluid (BALF) and plasma and acute lung injury (ALI) culminating in 80% mortality after 10 days. Hx treatment significantly lowered heme, decreased evidence of ALI (lower protein and inflammatory cells in BALF, lower lung wet-to-dry weight ratios, and decreased airway hyperreactivity to methacholine), and reduced mortality. In addition, Br2 caused more severe ALI and mortality in mice with HO-1 gene deletion (HO-1-/-) compared to wild-type controls, while transgenic mice overexpressing the human HO-1 gene (hHO-1) showed significant protection. INNOVATION This is the first study delineating the role of heme in ALI caused by Br2. CONCLUSION The data suggest that attenuating heme may prove to be a useful adjuvant therapy to treat patients with ALI.
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Affiliation(s)
- Saurabh Aggarwal
- 1 Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama.,2 Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Adam Lam
- 1 Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Subhashini Bolisetty
- 3 Division of Nephrology, Department of Medicine, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama.,4 Nephrology Research and Training Center, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Matthew A Carlisle
- 1 Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Amie Traylor
- 3 Division of Nephrology, Department of Medicine, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama.,4 Nephrology Research and Training Center, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Anupam Agarwal
- 3 Division of Nephrology, Department of Medicine, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama.,4 Nephrology Research and Training Center, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Sadis Matalon
- 1 Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama.,2 Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham , Birmingham, Alabama
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Zaky A, Ahmad A, Dell'Italia LJ, Jahromi L, Reisenberg LA, Matalon S, Ahmad S. Inhaled matters of the heart. ACTA ACUST UNITED AC 2015; 2. [PMID: 26665179 DOI: 10.14800/crm.997] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Inhalations of atmospheric pollutants, especially particulate matters, are known to cause severe cardiac effects and to exacerbate preexisting heart disease. Heart failure is an important sequellae of gaseous inhalation such as that of carbon monoxide. Similarly, other gases such as sulphur dioxide are known to cause detrimental cardiovascular events. However, mechanisms of these cardiac toxicities are so far unknown. Increased susceptibility of the heart to oxidative stress may play a role. Low levels of antioxidants in the heart as compared to other organs and high levels of reactive oxygen species produced due to the high energetic demand and metabolic rate in cardiac muscle are important in rendering this susceptibility. Acute inhalation of high concentrations of halogen gases is often fatal. Severe respiratory injury and distress occurs upon inhalation of halogens gases, such as chlorine and bromine; however, studies on their cardiac effects are scant. We have demonstrated that inhalation of high concentrations of halogen gases cause significant cardiac injury, dysfunction, and failure that can be critical in causing mortalities following exposures. Our studies also demonstrated that cardiac dysfunction occurs as a result of a direct insult independent of coexisting hypoxia, since it is not fully reversed by oxygen supplementation. Therefore, studies on offsite organ effects of inhaled toxic gases can impact development of treatment strategies upon accidental or deliberate exposures to these agents. Here we summarize the knowledge of cardiovascular effects of common inhaled toxic gases with the intent to highlight the importance of consideration of cardiac symptoms while treating the victims.
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Affiliation(s)
- Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Alabama ; Department of Medicine, Birmingham Veteran Affairs Medical Center, Birmingham, Alabama and Division of Cardiovascular Disease, University of Alabama Medical Center, Birmingham, Alabama
| | - Aftab Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Alabama
| | - Louis J Dell'Italia
- Department of Medicine, Birmingham Veteran Affairs Medical Center, Birmingham, Alabama and Division of Cardiovascular Disease, University of Alabama Medical Center, Birmingham, Alabama
| | - Leila Jahromi
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Alabama
| | - Lee Ann Reisenberg
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Alabama
| | - Sadis Matalon
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Alabama
| | - Shama Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Alabama
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Zaky A, Bradley WE, Lazrak A, Zafar I, Doran S, Ahmad A, White CW, Dell'Italia LJ, Matalon S, Ahmad S. Chlorine inhalation-induced myocardial depression and failure. Physiol Rep 2015; 3:3/6/e12439. [PMID: 26109193 PMCID: PMC4510636 DOI: 10.14814/phy2.12439] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Victims of chlorine (Cl2) inhalation that die demonstrate significant cardiac pathology. However, a gap exists in the understanding of Cl2-induced cardiac dysfunction. This study was performed to characterize cardiac dysfunction occurring after Cl2 exposure in rats at concentrations mimicking accidental human exposures (in the range of 500 or 600 ppm for 30 min). Inhalation of 500 ppm Cl2 for 30 min resulted in increased lactate in the coronary sinus of the rats suggesting an increase in anaerobic metabolism by the heart. There was also an attenuation of myocardial contractile force in an ex vivo (Langendorff technique) retrograde perfused heart preparation. After 20 h of return to room air, Cl2 exposure at 500 ppm was associated with a reduction in systolic and diastolic blood pressure as well echocardiographic/Doppler evidence of significant left ventricular systolic and diastolic dysfunction. Cl2 exposure at 600 ppm (30 min) was associated with biventricular failure (observed at 2 h after exposure) and death. Cardiac mechanical dysfunction persisted despite increasing the inspired oxygen fraction concentration in Cl2-exposed rats (500 ppm) to ameliorate hypoxia that occurs after Cl2 inhalation. Similarly ex vivo cardiac mechanical dysfunction was reproduced by sole exposure to chloramine (a potential circulating Cl2 reactant product). These results suggest an independent and distinctive role of Cl2 (and its reactants) in inducing cardiac toxicity and potentially contributing to mortality.
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Affiliation(s)
- Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama Department of Medicine, Birmingham Veteran Affairs Medical Center, Birmingham, Alabama Division of Cardiovascular Disease, University of Alabama Medical Center, Birmingham, Alabama
| | - Wayne E Bradley
- Department of Medicine, Birmingham Veteran Affairs Medical Center, Birmingham, Alabama Division of Cardiovascular Disease, University of Alabama Medical Center, Birmingham, Alabama
| | - Ahmed Lazrak
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Iram Zafar
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephen Doran
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aftab Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carl W White
- Department of Pediatrics, University of Colorado Denver, Boulder, Colorado
| | - Louis J Dell'Italia
- Department of Medicine, Birmingham Veteran Affairs Medical Center, Birmingham, Alabama Division of Cardiovascular Disease, University of Alabama Medical Center, Birmingham, Alabama
| | - Sadis Matalon
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shama Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Song W, Yu Z, Doran SF, Ambalavanan N, Steele C, Garantziotis S, Matalon S. Respiratory syncytial virus infection increases chlorine-induced airway hyperresponsiveness. Am J Physiol Lung Cell Mol Physiol 2015; 309:L205-10. [PMID: 26071553 DOI: 10.1152/ajplung.00159.2015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 06/08/2015] [Indexed: 12/21/2022] Open
Abstract
Exposure to chlorine (Cl2) damages airway and alveolar epithelia resulting in acute lung injury and reactive airway hyperresponsiveness (AHR) to methacholine. However, little is known about the effect of preexisting respiratory disease on Cl2-induced lung injury. By using a murine respiratory syncytial virus (RSV) infection model, we found that preexisting RSV infection increases Cl2 (187 ppm for 30 min)-induced lung inflammation and airway AHR at 24 h after exposure (5 days after infection). RSV infection and Cl2 exposure synergistically induced oxygen desaturation and neutrophil infiltration and increased MCP-1, MIP-1β, IL-10, IFN-γ, and RANTES concentrations in the bronchoalveolar lavage fluid (BALF). In contrast, levels of type 2 cytokines (i.e., IL-4, IL-5, IL-9, and IL-13) were not significantly affected by either RSV infection or Cl2 exposure. Cl2 exposure, but not RSV infection, induced AHR to methacholine challenge as measured by flexiVent. Moreover, preexisting RSV infection amplified BALF levels of hyaluronan (HA) and AHR. The Cl2-induced AHR was mitigated by treatment with inter-α-trypsin inhibitor antibody, which inhibits HA signaling, suggesting a mechanism of HA-mediated AHR from exacerbated oxidative injury. Our results show for the first time that preexisting RSV infection predisposes the lung to Cl2-induced injury. These data emphasize the necessity for further research on the effects of Cl2 in vulnerable populations and the development of appropriate treatments.
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Affiliation(s)
- Weifeng Song
- Department of Anesthesiology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Zhihong Yu
- Department of Anesthesiology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephen F Doran
- Department of Anesthesiology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Namasivayam Ambalavanan
- Department of Pediatrics (Neonatology), School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chad Steele
- Department of Medicine (Pulmonary, Critical Care and Sleep), and the Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Stavros Garantziotis
- Laboratory of Respiratory Biology, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina
| | - Sadis Matalon
- Department of Anesthesiology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama;
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Wigenstam E, Koch B, Bucht A, Jonasson S. N-acetyl cysteine improves the effects of corticosteroids in a mouse model of chlorine-induced acute lung injury. Toxicology 2014; 328:40-7. [PMID: 25497111 DOI: 10.1016/j.tox.2014.12.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 12/09/2014] [Accepted: 12/09/2014] [Indexed: 01/08/2023]
Abstract
Chlorine (Cl2) causes tissue damage and a neutrophilic inflammatory response in the airways manifested by pronounced airway hyperreactivity (AHR). The importance of early anti-inflammatory treatment has previously been addressed. In the previous study, both high-dose and low-dose of dexamethasone (DEX) decreased the risk of developing delayed effects, such as persistent lung injuries, while only high-dose treatment could significantly counteract acute-phase effects. One aim of this study was to evaluate whether a low-dose of DEX in combination with the antioxidant N-acetyl cysteine (NAC) and if different treatments (Triptolide, Reparixin and Rolipram) administered 1h after Cl2-exposure could improve protection against acute lung injury in Cl2-exposed mice. BALB/c mice were exposed to 300 ppm Cl2 during 15 min. Assessment of AHR and inflammatory cells in bronchoalveolar lavage was analyzed 24h post exposure. Neither of DEX nor NAC reduced the AHR and displayed only minor effects on inflammatory cell influx when given as separate treatments. When given in combination, a protective effect on AHR and a significant reduction in inflammatory cells (neutrophils) was observed. Neither of triptolide, Reparixin nor Rolipram had an effect on AHR but Triptolide had major effect on the inflammatory cell influx. Treatments did not reduce the concentration of either fibrinogen or plasminogen activator inhibitor-1 in serum, thereby supporting the theory that the inflammatory response is not solely limited to the lung. These results provide a foundation for future studies aimed at identifying new concepts for treatment of chemical-induced lung injury. Studies addressing combination of anti-inflammatory and antioxidant treatment are highly motivated.
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Affiliation(s)
- Elisabeth Wigenstam
- Swedish Defence Research Agency, Division of CBRN Defence and Security, Umeå, Sweden
| | - Bo Koch
- Swedish Defence Research Agency, Division of CBRN Defence and Security, Umeå, Sweden
| | - Anders Bucht
- Swedish Defence Research Agency, Division of CBRN Defence and Security, Umeå, Sweden; Department of Public Health and Clinical Medicine, Division of Respiratory Medicine, Umeå University, Sweden
| | - Sofia Jonasson
- Swedish Defence Research Agency, Division of CBRN Defence and Security, Umeå, Sweden.
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Luo S, Trübel H, Wang C, Pauluhn J. Phosgene- and chlorine-induced acute lung injury in rats: Comparison of cardiopulmonary function and biomarkers in exhaled breath. Toxicology 2014; 326:109-18. [DOI: 10.1016/j.tox.2014.10.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 10/14/2014] [Accepted: 10/19/2014] [Indexed: 12/14/2022]
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Matalon S. A critical review of the American Journal of Physiology-Lung Cellular and Molecular Physiology: 2012-2015. Am J Physiol Lung Cell Mol Physiol 2014; 307:L911-6. [PMID: 25381028 DOI: 10.1152/ajplung.00330.2014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
I have had the privilege of serving as Editor-in-Chief of the American Journal of Physiology: Lung Cellular and Molecular Physiology from 1/1/2012 to 1/1/2015 and have been reappointed for another 3-year term. When I took over as editor, I published an editorial in AJP-Lung in which I highlighted my vision and outlined the tasks to be accomplished to transform AJP-Lung into "The best place to publish basic, translational, and hypothesis-driven clinical lung research." Herein I review our accomplishments during the first term. As promised, we review each article submitted to this journal and our reviews always help the quality and impact of every paper. We recognized the contributions of junior authors by establishing a number of awards and increased the visibility of AJP-Lung by establishing Facebook and Blog electronic pages and sponsoring symposia in scientific meetings. Our impact factor increased from 3.523 in 2011 to 4.041 in 2012 and, thanks to our calls for papers, we are receiving large numbers of high-quality papers in all aspects of pulmonary cell biology and lung diseases. The best is yet to come.
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Affiliation(s)
- Sadis Matalon
- Department of Anesthesiology and Pulmonary Injury and Repair Center, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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