Mechanisms of gastric juice-induced hyperpermeability of the cultured human tracheal epithelium

Proton Pump Inhibitor Ameliorates Taste Disturbance among Patients with Laryngopharyngeal Reflux: A Randomized Controlled Study

Patients with laryngopharyngeal reflux (LPR) were reported to suffer from hypogeusia that affects quality of life. Proton pump inhibitor (PPI) is a useful drug in the treatment of LPR, but its effect on hypogeusia is not known. We therefore assessed the effects of PPI or a histamine H2 receptor antagonist (H2 blocker) on hypogeusia among patients with LPR. Both PPI and H2 blocker could inhibit acid reflux. LPR was diagnosed with reflux finding score and reflux symptom index. The visual analogue scale (VAS) of taste disturbance symptoms and the gustatory tests were assessed before and 8 weeks after treatment with esomeprazole, a PPI (20 patients, aged 50.0 ± 1.7 years) or famotidine, a H2 blocker (20 patients, aged 47.1 ± 1.8 years). There were no significant differences in VAS scores and recognition thresholds for four basic tastes between the two groups before treatment. Only PPI therapy significantly decreased the VAS scores, suggesting the improvement of taste perception. Moreover, PPI therapy significantly decreased recognition thresholds for bitter taste in the anterior tongue (chorda tympani nerve area) and the thresholds in the posterior tongue (glossopharyngeal nerve area) for salty, sour, and bitter tastes. By contrast, H2-blocker therapy caused no significant changes of thresholds in the anterior tongue, but improved the threshold only for bitter in the posterior tongue, the value of which was however significantly higher than that in PPI group. In conclusion, PPI could ameliorate hypogeusia by improving bitter, salty, and sour tastes among patients with LPR.

Post-intubation tracheobronchomalacia in a young adult: A rare case report

Tracheobronchomalacia (TBM) is characterized by weakness of cartilaginous supporting structures of tracheal and bronchial walls, resulting in central airway obstruction. It is a rare condition that can occur after prolonged intubation. Here, we report a 26-year-old, alcoholic male who had TBM, mild subglottic, and severe tracheal stenosis following 2 weeks of intubation.

Subglottic and tracheal stenosis can occur after extubation but TBM is uncommon. The exact mechanism is still unknown but post-intubation TBM is a life-threatening condition with high morbidity and mortality if left untreated. Early detection and timely management can improve the outcome of patients.

Chronic inflammation, lymphangiogenesis, and effect of an anti-VEGFR therapy in a mouse model and in human patients with aspiration pneumonia

Chronic inflammation induces lymphangiogenesis and blood vessel remodelling. Since aged pneumonia patients often have repeated episodes of aspiration pneumonia, the pathogenesis may involve chronic inflammation. For lymphangiogenesis, VEGFR-3 and its ligand VEGF-C are key factors. No previous studies have examined chronic inflammation or vascular changes in aspiration pneumonia or its mouse models. In lung inflammation, little is known about the effect of blocking VEGFR-3 on lung lymphangiogenesis and, moreover, its effect on the disease condition. This study aimed to establish a mouse model of aspiration pneumonia, examine the presence of chronic inflammation and vascular changes in the model and in patients, and evaluate the effect of inhibiting VEGFR-3 on the lymphangiogenesis and disease condition in this model. To induce aspiration pneumonia, we repeated inoculation of pepsin at low pH and LPS into mice for 21-28 days, durations in which bronchioalveolar lavage and plasma leakage in the lung suggested the presence of exaggerated inflammation. Conventional and immunohistochemical analysis of tracheal whole mounts suggested the presence of chronic inflammation, lymphangiogenesis, and blood vessel remodelling in the model. Quantitative RT-PCR of the trachea and lung suggested the involvement of lymphangiogenic factor VEGF-C, VEGFR-3, and pro-inflammatory cytokines. In the lung, the aspiration model showed the presence of chronic inflammation and exaggerated lymphangiogenesis. Treatment with the VEGFR inhibitor axitinib or the VEGFR-3 specific inhibitor SAR131675 impaired lymphangiogenesis in the lung and improved oxygen saturation in the aspiration model. Since the lung is the main site of aspiration pneumonia, the changes were intensive in the lung and mild in the trachea. Human lung samples also showed the presence of chronic inflammation and exaggerated lymphangiogenesis, suggesting the relevance of the model to the disease. These results suggest lymphatics in the lung as a new target of analysis and therapy in aspiration pneumonia.

Potential effects of medicinal plants and secondary metabolites on acute lung injury

Acute lung injury (ALI) is a life-threatening syndrome that causes high morbidity and mortality worldwide. ALI is characterized by increased permeability of the alveolar-capillary membrane, edema, uncontrolled neutrophils migration to the lung, and diffuse alveolar damage, leading to acute hypoxemic respiratory failure. Although corticosteroids remain the mainstay of ALI treatment, they cause significant side effects. Agents of natural origin, such as medicinal plants and their secondary metabolites, mainly those with very few side effects, could be excellent alternatives for ALI treatment. Several studies, including our own, have demonstrated that plant extracts and/or secondary metabolites isolated from them reduce most ALI phenotypes in experimental animal models, including neutrophil recruitment to the lung, the production of pro-inflammatory cytokines and chemokines, edema, and vascular permeability. In this review, we summarized these studies and described the anti-inflammatory activity of various plant extracts, such as Ginkgo biloba and Punica granatum, and such secondary metabolites as epigallocatechin-3-gallate and ellagic acid. In addition, we highlight the medical potential of these extracts and plant-derived compounds for treating of ALI.

Hyperosmotic stress enhances interleukin-1beta expression in Helicobacter pylori-infected murine gastric epithelial cells in vitro

BACKGROUND AND AIM

Gastric cancer is associated not only with Helicobacter pylori (H. pylori) infection, but also with the intake of a high salt diet. Interleukin-1beta (IL-1beta) is highly expressed in H. pylori-infected gastric mucosa. The aim of the present study was to determine if hyperosmotic stress induces IL-1beta expression in gastric epithelial cells in vitro.

METHOD

Murine gastric epithelial cells, GSM06, were cultured with or without H. pylori (Sydney strain-1) at different osmolarities in the range of 300-450 mOsM. Expressions of IL-1beta mRNA and mature IL-1beta protein were evaluated by reverse transcription-polymerase chain reaction (RT-PCR) and an IL-1beta enzyme-linked immunosorbent assay (ELISA), respectively. IL-1beta converting enzyme (ICE) activity was measured by an ICE colorimetric assay. Apoptosis was evaluated by a single stranded-DNA assay.

RESULTS

Addition of H. pylori at 300 mosM caused significant increases in IL-1beta mRNA, IL-1beta protein, ICE activity and apoptosis. Hyperosmotic stress alone also caused upregulation of IL-1beta mRNA and IL-1beta protein, enhanced ICE activity and accelerated apoptosis. Hyperosmotic stress accentuated the increases in IL-1beta mRNA, IL-1beta protein, ICE activity and apoptosis induced by H. pylori alone. Enhancement of IL-1beta protein release induced by hyperosmotic stress was significantly attenuated by an ICE inhibitor, Z-YVAD-FMK.

CONCLUSIONS

Hyperosmotic stress enhances the release of bioactive mature IL-1beta protein in H. pylori-infected gastric epithelial cells, in part by upregulating IL-1beta mRNA expression, and in part by enhancing ICE activity. These results may explain the mechanisms by which chronic intake of a high salt diet increases the risk of gastric cancer among H. pylori-infected human subjects.

Medical Treatments and Cares for Geriatric Syndrome: New Strategies Learned from Frail Elderly

In Japan, there are 21 million older people above 65 years, and about 8% of them are frail elderly. Geriatrics is to study the frail elderly as to why they become frail elderly, and to treat patients properly or the remaining 92% older people not to become frail elderly. In order to promote health of the older people, geriatricians have to take deep insights for cares as well as medical treatments. With such a will, we find the way to prevent diseases in the older people. In this review, we describe medical treatments and cares for promoting successful aging.

The role of gastric and duodenal agents in laryngeal injury: an experimental canine model

BACKGROUND AND AIMS

The specific agents responsible for producing laryngeal signs and symptoms are currently unknown. We systematically evaluated the damaging role of gastric (acid and pepsin) and duodenal (bile acids and trypsin) ingredients individually and in combination on different laryngeal structures in an experimental canine model.

METHODS

A total of 42 beagles were studied (wt 9-15 kg each). After pentathol anesthesia all dogs underwent laryngoscopy. Injury (punch biopsy) was caused to the right vocal cord, medial arytenoid wall, and posterior cricoid wall on day 1. Pepsin (0.5 mg/ml), conjugated bile acid (CBA) (ursodeoxycholic acid, 300 micromolar), unconjugated bile acids (UBA) (cholic, 300 micromolar), trypsin (0.5 mg/ml) at pH 1-2, 4-5, and 6-7 were applied bilaterally to laryngeal sites three times per week for a total of 9-12 applications. Changes in laryngeal sites were scored visually. All dogs were sacrificed 1 day post last application. Laryngeal tissue was harvested and sent for blinded pathological examination. Histologic and visual scores were compared to each other and to control- and sham-treated dogs.

RESULTS

Pepsin alone (8.5 +/- 1.66) or combined with CBA (16.63 +/- 1.66) at pH 1-2 resulted in significant (p < 0.001) severe histological inflammation much greater than with other agents. Duodenal ingredients caused no or minimal degree of histological damage at all pH values. Visual scores above subtle erythema were significantly (p < 0.001) higher in the animals exposed to pepsin followed by CBA alone or in combination with pepsin at pH 1-2. There was a significant (p < 0.01) correlation between histology and visual scores (rho = 0.47; 95% CI = 0.30-0.60) for all sites combined. Of the three laryngeal sites, vocal cords were the most sensitive to injury by applied solutions.

CONCLUSIONS

(i) In acidic refluxate, pepsin and CBAs are the most injurious agents affecting laryngeal tissue. (ii) Duodenal agents do not play a significant role in causing laryngeal injury. (iii) Aggressive acid suppression should eliminate the injurious potential of any gastroduodenal refluxate.

Acid stress in the pathology of asthma

Although alteration of airway pH may serve an innate host defense capacity, it also is implicated in the pathophysiology of obstructive airway diseases. Acid-induced asthma appears in association with gastroesophageal reflux after accidental inhalation of acid (fog, pollution, and workplace exposure) and in the presence of altered airway pH homeostasis. Endogenous and exogenous exposures to acids evoke cough, bronchoconstriction, airway hyperreactivity, microvascular leakage, and heightened production of mucous, fluid, and nitric oxide. Abnormal acidity of the airways is reflected in exhaled breath assays. The intimate mechanisms of acid-induced airway obstruction are dependent on activation of capsaicin-sensitive sensory nerves. Protons activate these nerves with the subsequent release of tachykinins (major mediators of this pathway) that, in conjunction with kinins, nitric oxide, oxygen radicals, and proteases, modulate diverse aspects of airway dysfunction and inflammation. The recognition that acid stress might initiate or exacerbate airway obstructive symptomatology has prompted the consideration of new therapies targeting pH homeostasis.

Acid aspiration induces bacterial pneumonia by enhanced bacterial adherence in mice

The issue of whether acid aspiration facilitates bacterial pneumonia caused by Pseudomonas aeruginosa by enhanced bacterial adherence was examined in mice. Survival or the number of bacteria in lung tissues was evaluated after an intratracheal challenge of hydrochloric acid (HCl), a sublethal dose of P. aeruginosa, or both in mice. Bacterial adherence to the tracheal epithelium after acid aspiration was also examined by scanning electron microscopy. A simultaneous intratracheal challenge of 50 microl of 10(-1) N HCl, but not 10(-2) to 10(-4) N HCl, combined with a sublethal dose of P. aeruginosa significantly increased the number of bacteria in the lung tissues and decreased survival, while all mice that received either HCl or P. aeruginosa survived. Significantly higher numbers of adherent bacteria on the tracheal epithelium were found in mice that received 10(-1)N HCl, compared with mice that received HCl (10(-2) to 10(-4) N) or saline. These data indicate that acid aspiration induced airway epithelial injury and enhanced P. aeruginosa adherence to the epithelium, and led to the subsequent development of bacterial pneumonia in mice. Enhanced bacterial adherence on the acid-injured epithelium may explain fatal bacterial pneumonias in patients with respiratory aspiration of gastric contents.

Acid stimulation reduces bactericidal activity of surface liquid in cultured human airway epithelial cells

To examine the effects of acid exposure with moderate acidity (pH 3.0-5.0) on bactericidal activity of airway surface liquid (ASL), ASL was collected by washing the surface of primary cultures of human tracheal epithelial cells 24 h after treatment with phosphate-buffered saline (PBS) adjusted to a pH of 3.0, 4.0, or 5.0. In all ASL, bactericidal activity was sensitive to sodium concentration. Escherichia coli (500 colony forming units [CFU]) was incubated in ASL, and the number of surviving bacteria was examined. The number of surviving bacteria in ASL from cultured cells with acid exposure at pH 3.0-5.0 was significantly higher than that in control ASL. The minimum inhibitory dilution ratio of ASL against 500 CFU of E. coli was also examined by microdilution assays. According to this assay, the bactericidal activity in ASL with acid challenge at a pH of 3.0 was less than half of that in control ASL. Reverse transcription-polymerase chain reaction and Western blot analysis showed that the production of mRNA and protein of human beta-defensin (HBD)-1 were significantly decreased by acid exposure at pH 3.0-5.0. In contrast, acid exposure did not change the production of mRNA and protein of HBD-2 and beta-actin mRNA. These results indicate that acid exposure, even with moderate acidity, may inhibit the production of bactericidal molecules, including HBD-1, in airway epithelial cells. Acid exposure may reduce bactericidal activity of ASL in human airway epithelial cells and may increase susceptibility of the airway to bacterial infection.

Function of the eustachian tube after weekly exposure to pepsin/hydrochloric acid

OBJECTIVE

To determine the effects of repeated pepsin/hydrochloric acid (HCl) exposure on the eustachian tube (ET).

STUDY DESIGN AND SETTING

ET function was studied in 22 rats. Group I (control) rats received transtympanic phosphate buffered saline solution; groups II (0.5 mg/ml) and III (2.0 mg/ml) received transtympanic pepsin/HCl. Test solutions were applied on day 0 with ET function evaluated on days 1, 2, 3, and 7 after exposure. Each 7-day period represents 1 cycle; all groups underwent 4 cycles. ET function was evaluated using passive opening and closing pressure, and active clearance of positive and negative pressure tests.

RESULTS

Rats exposed to pepsin/HCl had elevated passive opening pressures and a decreased ability to clear positive and negative pressure. A temporal relationship exists.

CONCLUSION

The results suggest middle ear exposure to pepsin/HCl leads to ET dysfunction in rats, and that this dysfunction is enhanced with repeated exposures.

SIGNIFICANCE

Gastroesophageal reflux may induce ET dysfunction.

Acid exposure stimulates the adherence of Streptococcus pneumoniae to cultured human airway epithelial cells: effects on platelet-activating factor receptor expression

To examine the effects of acid exposure on the adherence of Streptococcus pneumoniae to cultured human tracheal epithelial cells, cells were exposed to acid at various pH levels, and various concentrations of S. pneumoniae were added to the culture medium. The number of S. pneumoniae adhering to cultured human tracheal epithelial cells increased after acid exposure. Y-24180, a specific inhibitor of the receptor for the platelet-activating factor (PAF) and PAF itself decreased the number of S. pneumoniae adhering to cultured human tracheal epithelial cells after acid exposure. Acid exposure increased the activation of transcription factor nuclear factor (NF)-kappa B and the expression of protein and messenger RNA (mRNA) of the PAF receptor. The pyrrolidine derivative of dithiocarbamate (PDTC), an inhibitor of NF-kappa B, also decreased the number of S. pneumoniae adhering to the cultured human tracheal epithelial cells after acid exposure. Acid exposure increased the content of interleukin (IL)-1 alpha and IL-1 beta in the culture supernatants, but monoclonal antibodies to IL-1 alpha and IL-1 beta failed to inhibit the increased number of S. pneumoniae adhering to cultured human tracheal epithelial cells after acid exposure. These findings suggest that acid exposure stimulates the adherence of S. pneumoniae to the airway epithelial cells via increases in PAF receptors. Increases in PAF receptor expression may be, in part, mediated via activation of transcription factors and subsequent PAF receptor mRNA expression by acid exposure. Increased adherence of S. pneumoniae may be one of the reasons why pneumonia develops after gastric juice aspiration.

Interventions to prevent pneumonia among older adults

Pneumonia is a common cause of death in older people. Antimicrobial drugs do not prevent pneumonia and, because of increasingly resistant organisms, their value in curing infection will become more limited. Establishing new strategies to prevent pneumonia through consideration of the mechanisms of this devastating illness is essential. The purpose of this review is to discuss how pneumonia develops in older people and to suggest preventive strategies that may reduce the incidence of pneumonia among older adults. Aspiration of oropharyngeal bacterial pathogens to the lower respiratory tract is one of the most important risk factors for pneumonia; impairments in swallowing and cough reflexes among older adults, e.g., related to cerebrovascular disease, increase the risk for the development of pneumonia. Thus, strategies to reduce the volumes and pathogenicity of aspirated material should be pursued. For example, since both swallowing and cough reflexes are mediated by endogenous substance P, pharmacologic therapy using angiotensin-converting enzyme inhibitors, which decrease substance P catabolism, may improve both reflexes and result in the lowering of the risk of pneumonia. Similarly, since the production of substance P is regulated by dopaminergic neurons in the cerebral basal ganglia, treatment with dopamine analogs or potentiating drugs such as amantadine (and, of course, prevention of cerebral vascular disease, which can result in basal ganglia strokes) should affect the incidence of pneumonia. The purpose of this review is to consider promising pharmacologic treatments as methods of preventing pneumonia in older adults and to review other proven strategies, e.g., infection control and cerebrovascular disease prevention that will lessen the incidence of pneumonia.

Combined effects of both bacteria and gastric juice on pneumonia in mice

The effects of a combined inoculation of gastric juice and Streptococcus pneumoniae on the lungs of mice was investigated. Survival rates of mice inoculated with bacteria alone, gastric juice alone, and both bacteria and gastric juice were compared over 18 days. Xanthine oxidase (XO) activities in the lung tissues of mice inoculated with bacteria and gastric juice were measured and injected with a free radical scavenger, pyran-superoxide dismutase (pyran-SOD). A high mortality rate was observed in mice inoculated with both gastric juice and Streptococcus pneumoniae (81%). Mice inoculated with either Streptococcus pneumoniae or gastric juice showed a separate mortality rate of up to 10% during 18 days after inoculation. XO activity in the lung tissue of the mice inoculated with both gastric juice and bacteria was higher than in mice inoculated with either of them separately. The high mortality rate in the group inoculated with both two agents was reduced to 25% by the administration of pyran-SOD. XO activity raised by Streptococcus pneumoniae and gastric juice was significantly reduced by pyran-SOD. Thus, we suggest an important role in the combined effects of gastric juice and bacteria on pneumonia.