Environmental risk factors of type 2 diabetes-an exposome approach

Type 2 diabetes is one of the major chronic diseases accounting for a substantial proportion of disease burden in Western countries. The majority of the burden of type 2 diabetes is attributed to environmental risks and modifiable risk factors such as lifestyle. The environment we live in, and changes to it, can thus contribute substantially to the prevention of type 2 diabetes at a population level. The 'exposome' represents the (measurable) totality of environmental, i.e. nongenetic, drivers of health and disease. The external exposome comprises aspects of the built environment, the social environment, the physico-chemical environment and the lifestyle/food environment. The internal exposome comprises measurements at the epigenetic, transcript, proteome, microbiome or metabolome level to study either the exposures directly, the imprints these exposures leave in the biological system, the potential of the body to combat environmental insults and/or the biology itself. In this review, we describe the evidence for environmental risk factors of type 2 diabetes, focusing on both the general external exposome and imprints of this on the internal exposome. Studies provided established associations of air pollution, residential noise and area-level socioeconomic deprivation with an increased risk of type 2 diabetes, while neighbourhood walkability and green space are consistently associated with a reduced risk of type 2 diabetes. There is little or inconsistent evidence on the contribution of the food environment, other aspects of the social environment and outdoor temperature. These environmental factors are thought to affect type 2 diabetes risk mainly through mechanisms incorporating lifestyle factors such as physical activity or diet, the microbiome, inflammation or chronic stress. To further assess causality of these associations, future studies should focus on investigating the longitudinal effects of our environment (and changes to it) in relation to type 2 diabetes risk and whether these associations are explained by these proposed mechanisms.

Staphylococcus epidermidis graft infection is associated with locally suppressed major histocompatibility complex class II and elevated MAC-1 expression

OBJECTIVES

To determine the local cellular immune response in a series of human patients with Staphylococcus epidermidis prosthetic graft infection and to use a murine model to investigate the response in polytef (PTFE) and in a nonslime-producing S epidermidis variant.

METHODS

Externally supported Dacron and PTFE grafts, either sterile or colonized with slime (RP-62A)- or nonslime (RP-62NA)-producing S epidermidis (10(7) colony forming units/cm2) were implanted in a dorsal subcutaneous pocket of Swiss Webster mice (Taconic, Germantown, NY). The grafts were harvested at 7, 10, 14, and 28 days with local bacterial and leukocyte counts obtained. Perigraft and blood monocyte major histocompatibility complex class II (MHC-II) (immune antigen) and membrane attack complex type 1 (MAC-1) (glycoprotein) expression were analyzed by flow cytometry in the murine model and in 3 patients representing 4 Dacron graft infections.

RESULTS

The human infected Dacron perigraft monocytes revealed a suppressed MHC-II and elevated MAC-1 expression, and early correlation with the murine model was seen. No notable perigraft monocyte MHC-II suppression occurred in the infected PTFE graft. The reciprocal relationship in Dacron between monocyte MAC-1 and MHC-II expression was exaggerated with the lack of slime production. Bacterial clearance was variable. Supranormal expression was observed at 1 month in sterile Dacron but not in PTFE grafts.

CONCLUSIONS

Staphylococcus epidermidis infection is associated with local cellular immune suppression in Dacron but not PTFE grafts. Slime-producing S epidermidis induced a lesser cytotoxic-phagocytic response than the nonslime variant. The reduced immunologic response to slime-producing S epidermidis may explain, in part, its indolent nature and resistance to eradication.

In vitro and in vivo effects of rifampin on Staphylococcus epidermidis graft infections

Rifampin, bound in high concentrations to prosthetic grafts, has been proposed for the treatment of vascular graft infections. The optimum antibiotic concentration and duration of treatment for infected grafts is not known. This study compared the in vitro and in vivo efficacy of varying concentrations of rifampin against three different strains of slime producing Staphylococcus epidermidis (RP62A, KC2, and KB1) bound to the knitted Dacron at high and low concentrations at 10(4) and 10(7) CFU/cm2 of prosthetic. Time kill experiments were performed at 4, 18, and 42 hr, in which each Dacron bound bacterial strain was exposed in vitro to 4X, 64X, 100X, and 1,000X minimum inhibitory concentration (MIC) of rifampin. In vitro, the Dacron bound laboratory strain RP62A was implanted subcutaneously in the backs of male Swiss-Webster mice and exposed to 4X, 100X, and 1,000X the MIC of rifampin for similar time periods. In addition, systemic vancomycin (10 mg/kg) was assessed for synergy and prevention of rifampin resistance. In vitro, all concentrations of rifampin showed near total killing (< 1 log) of all bacterial strains at low initial concentrations (10(4) CFU/cm2) but not high (10(7) CFU/cm2) to 42 hr. Importantly, resistance was shown to develop in all three strains of S. epidermidis with high initial bacterial biofilm concentrations. In vivo, rifampin concentrations between 4X MIC and 100X MIC achieved a balance between optimal killing and prevention of resistance. Systemic vancomycin slightly improved bacterial clearance but did not alter the development of rifampin resistance at high local concentrations. Caution is advised with the use of antibiotic bonded grafts because resistance may develop even with the addition of systemic antibiotics.

Dacron stimulation of macrophage transforming growth factor-beta release

This study evaluated the effect of Dacron on the release of macrophage transforming growth factor-beta (TGF-beta),an endothelial cell growth inhibitor. Rabbit peritoneal macrophages were grown in minimum essential medium (MEM) with 10% fetal bovine serum (FBS) in the presence or absence of Dacron (0.5 mm x 3 mm particles). Media were collected three times each week for 7 weeks. For the TGF-beta bioassay, mink lung epithelial cells (CCL64) were grown in MEM with 10% FBS. Test-conditioned media, 100 mu 1, were added (n = 4), and incubated 48 h. 3(H)-Thymidine (3(H)-TdR) uptake was determined and compared with 3(H)-TdR uptake using known pure TGF-beta standards. Media samples were additionally pre-incubated with a neutralizing anti-TGF-beta(1) antibody and the 3(H)-TdR uptake again quantitated. TGF-beta activity in the conditioned media of macrophages exposed to Dacron exceeded the control media groups in all weeks, reaching significance (P<0.05) in weeks 3, 4,5, 6 and 7. Pre-incubation of media samples with the anti-TGF-beta antibody inhibited this TGF-beta activity in all weeks with statistical significance in weeks 1, 2, 3, 5 and 7. The inhibitory effects of Dacron on endothelialization may be explained by the Dacron-induced release of TGF-beta from macrophages.

Recognition of endogenous ecotropic murine leukaemia viruses by anti-AKR/Gross virus cytotoxic T lymphocytes (CTL): epitope variation in a CTL-resistant virus

AKR/Gross virus-specific cytotoxic T lymphocytes (CTL) from C57BL/6 (B6) mice are H-2Kb-restricted and recognize epitopes encoded by the prototype endogenous ecotropic murine leukaemia virus (Emv) AKR623. Four CTL epitopes have been identified by the use of synthetic peptides corresponding to AKR623-encoded amino acid sequences. Here we present both functional and nucleotide sequence data indicating that three closely related Emv share all of these CTL epitopes. We also found that one other murine leukaemia virus (MuLV) was not susceptible to lysis by these CTL. This is the ecotropic component of the LP-BM5 virus complex that causes murine AIDS. Nucleotide sequencing revealed that three of the four epitopes, including the immunodominant peptide, are altered in this virus. The other epitope was unchanged. These data implied that the inability of anti-AKR/Gross virus CTL to lyse cells infected with the LP-BM5 ecotropic (BM5eco) MuLV was due to the functional loss of three of the four CTL epitopes. Using recombinant vaccinia and Sindbis virus vectors, we have shown that the BM5eco-encoded form of the immunodominant epitope, which differs only by an arginine for lysine substitution at the N-terminal residue, fails to induce a CTL response in B6 mice. Immunization with BM5eco-infected cells also failed to induce MuLV-specific CTL. In light of the long in vivo passage history of the LP-BM5 complex in B6 mice, our results are consistent with a contribution of CTL-mediated immune selection to the evolution of the BM5eco MuLV.

Biomaterial-induced macrophage activation and monokine release

This study quantifies macrophage acid phosphatase release as a marker of cell activation when cultured with or without biomaterials. Peritoneal macrophages were harvested from six New Zealand White rabbits and cultured in minimum essential media with 10% equine serum. After cell identification by morphology, nonspecific esterase, and RAM 11 immunoperoxidase, cells were passaged twice, and second-passage macrophages were seeded in 96-well plates (5,000 cells/well) and grown to confluence. After collection of day zero media, circular disks of polyglactin 910 and two types of commercially available polyethylene terephthalate with different construction and sterilization characteristics were placed on the cell monolayer. Controls without biomaterials were also established. Media was collected and pooled for each group and time point beginning on day 2 and continuing every other day for 22 days. Conditioned media were quantitatively assayed for acid phosphatase colorimetrically at 402 nm using p-nitrophenylphosphate as the substrate. Acid phosphatase activity increased progressively at late time points for each group but no difference was noted between groups at any time point. These data show that the activation of cultured macrophages with time is not altered differentially by the presence of biomaterials. The previously demonstrated monokine release following biomaterial exposure is therefore a specific event and not simply part of the generalized activation phenomenon.

Novel regulation of an MHC class I gene response to interferon-gamma

The ability of IFN-gamma to increase the expression of MHC class I gene products is likely to enhance cytolytic T lymphocyte recognition of viral pathogens and tumor cells. The murine lymphoma AKR SL3-cl.F AZR (SL3-cl.F) responds aberrantly to treatment with interferon-gamma such that H-2Dk surface expression is augmented, but H-2Kk expression remains at constitutive levels. Somatic cell fusions have been used to demonstrate that the lesion responsible for this phenotype is cis-dominant, implicating a primary lesion within the SL3-cl.F H-2Kk gene. In this communication, we have used PCR to analyze the nucleotide sequence in regions of the SL3-cl.F H-2Kk promoter known to contain interferon-responsive enhancer elements. Comparison of the SL3-cl.F H-2Kk sequences to known consensus elements revealed complete identity. In order to identify the lesion responsible for the SL3-cl.F phenotype, two H-2Kk genomic clones were independently isolated from SL3-cl.F. Each clone exists as a 10.5-kbp EcoRI fragment containing the entire structural gene. The site of transcription initiation is at the center of this fragment; therefore, all regulatory elements within 5 kbp of the transcript start site which could alter steady-state message levels are included. Interestingly, IFN-gamma-augmented expression of the H-2Kk gene was restored following DNA-mediated transfection of either of these clones into fibroblast cell lines and the parental cell line SL3-cl.F. Because isolation of these clones required passage of the DNA through a prokaryotic host, which alters the pattern of DNA methylation, there was the possibility that demethylation was responsible for the newly acquired IFN-gamma-responsive phenotype. Treatment of SL3-cl.F with 5-azacytidine, which inhibits de novo methylation, did not restore IFN-gamma-augmented expression, however, thus excluding H-2Kk specific methylation as a potential mechanism. Collectively, these data demonstrate that the alteration responsible for the phenotype observed in SL3-cl.F does not involve known transcriptional regulatory elements. Potential mechanisms which might account for the mutant phenotype are discussed.

Kinetics of cell proliferation as a function of vascular graft material

Bioresorbable vascular grafts constructed for polyglactin 910 (PG910) and polydioxanone (PDS) and nonresorbable Dacron were interposed into the infrarenal abdominal aortas of New Zealand White rabbits. The prosthesis/tissue complexes were harvested after 2, 3, 4, 12, and 52 weeks. Seventeen, 9, and 1 h prior to sacrifice, animals received tritiated thymidine (0.5 mCi/kg/dose). All specimens were studied grossly and by light and transmission electron microscopy. Mitotic indices (MI's) were determined by autoradiography for inner capsule myofibroblasts at the proximal, mid, and distal segments of each prosthesis. There were no aortic-related deaths. All grafts were patent with no aneurysmal dilatation. At 4 weeks, PG910 resorption was evidenced by macrophage phagocytosis, less so in PDS while Dacron remained intact. At 12 weeks, the PG910 was completely resorbed while PDS resorption continued. The latter was completely resorbed by 52 weeks. There was no significant difference in MI's between proximal, mid, and distal regions for each graft type. The mitotic index paralleled the rate of prosthetic resorption in both PG910 and PDS groups, as high as 28.34 +/- 23.21 in the former 3 weeks after implantation and significantly higher at 4 weeks (7.58 +/- 2.02 and 7.50 +/- 2.66, respectively) than at 52 weeks (0.72 +/- 0.98 and 1.00 +/- 0.22, respectively) in both groups. The mitotic index in the Dacron group never surpassed 1.22 +/- 0.90. We conclude that higher levels of early cell proliferation in bioresorbable grafts closely parallel the kinetics of prosthetic resorption.

Basic fibroblast growth factor production in vitro by macrophages exposed to Dacron and polyglactin 910

Macrophage activation by implanted blood-contacting biomaterials modulates smooth muscle cell and endothelial cell ingrowth. The present study evaluates the in vitro interactions between Dacron or polyglactin 910 with macrophages derived from rabbits fed either normal or atherogenic diets. Peritoneal macrophages were cultured in the presence or absence (negative controls) of either biomaterial for 7 weeks. Conditioned media was evaluated for mitogenic activity using a rabbit aortic smooth muscle cell bioassay with or without preincubation with neutralizing anti-basic-FGF antibody. Results demonstrated increased mitogen release from macrophages harvested from the atherosclerotic rabbits. Only macrophages harvested from normal diet fed rabbits increased their mitogen release following exposure to either polyglactin 910 (p < 0.05) or to Dacron (p < 0.005) over controls. The stimulation of mitogen release by polyglactin 910 did not significantly exceed that in response to Dacron. In rabbits fed normal diets neutralization with the anti-basic-FGF antibody inhibited 100% of the Dacron induced mitogen release as compared to 36% of the polyglactin 910 induced mitogen release (p < 0.01). These results demonstrate significant induced mitogen release from macrophages exposed to biomaterials in vitro, much of the smooth muscle cell mitogen represented by basic-FGF.

Effects of hypercholesterolemia on monokine-induced smooth muscle cell proliferation

Macrophage/smooth muscle cell interactions play a role in atherogenesis and foreign body reactions to biomaterials. This study investigates the effect of a hypercholesterolemic diet on the ability of smooth muscle cells (SMCs) to respond to monokines which are produced in response to hypercholesterolemia, biomaterials or both. Peritoneal macrophages were harvested from rabbits fed either a normal (M phi NL) or a 2% cholesterol/6% peanut oil diet (M phi ATH) (plasma cholesterol 2840 vs 42.3 [p less than 0.005]). The macrophages were then cultured in the presence of either 1) polyglactin 910 (PG910), 2) Dacron, or 3) no biomaterial (control), and the media collected and pooled by week for the smooth muscle cell mitogenesis assays. Rabbit aortic smooth muscle cells were harvested and cultured from the same two groups of rabbits (SMCNL or SMCATH), quiesced in serum free media (48 h) followed by addition of the test media and 3H-TdR. The addition of either biomaterial to M phi NL-conditioned media increased 3H-TdR incorporation in both smooth muscle lines as compared to controls. PG910 resulted in significantly higher 3H-TdR incorporation than Dacron (weeks 3-5, p less than 0.005). The addition of either biomaterial to M phi ATH also increased 3H-TdR incorporation in both smooth muscle cell lines, however, the magnitude of the response was decreased as compared to the M phi NL-conditioned media in both cell lines (p less than 0.001 for either SMC line). In contrast to the M phi NL-conditioned media, the addition of Dacron to M phi ATH resulted in the highest level of 3H-TdR incorporation in both cell lines as compared to the media without biomaterial. The SMCNL had a higher response to both the monokines in conditioned media (2-fold) and to fetal bovine serum (3-fold) than the SMCATH (p less than 0.001). Although there is a generalized decrease in release of mitogens active on SMCs from M phi ATH, the M phi ATH exposed to Dacron release increased amounts of mitogenic factors, most active on the SMCATH cell line. A common mode of failure of small diameter Dacron grafts in man is pseudointimal hyperplasia, and it is inviting to postulate that the Dacron/macrophage/smooth muscle cell interactions in this atherosclerotic group of patients plays a role in the pathogenesis of this lesion.

The effects of an atherogenic diet on macrophage/biomaterial interactions

We previously reported that biomaterials differentially induced macrophages to secrete growth factors that mediate reendothelialization. The present study evaluates the effect of an atherogenic diet on macrophage/biomaterial interactions. Female New Zealand white rabbits were fed an atherogenic diet. Peritoneal macrophages were harvested from these as well as rabbits fed a normal diet and cultured in Minimum Essential Medium with platelet-poor serum. Dacron or polyglactin 910 were added to two of three conditions of both cell groups in passage 2. Conditioned media were collected weekly through week 15. Mitogenicity assays were performed with quiescent mouse embryonal (BALB/c3T3) fibroblasts, atherosclerotic rabbit aortic smooth muscle cells, and murine capillary lung (LE-II) endothelial cells. Mitogenic activity was assayed by scintillation counting of tritiated thymidine incorporation into deoxyribonucleic acid (DNA). Results showed increased mitogenic activity released by macrophages from atherosclerotic rabbits, in the absence of prosthetic material, when assayed against every cell line. In normal diet macrophages, polyglactin 910 stimulated mitogen release for every cell line, and Dacron yielded minimal mitogen release. In lipid diet macrophages polyglactin 910 slightly increased mitogen release for all three cell lines, whereas Dacron resulted in stimulation of DNA synthesis in smooth muscle cells and BALB/c3T3 cells but less DNA synthesis in LE-II cells than in control, no graft material, media. Western blotting demonstrated immunoreactivity to basic fibroblast growth factor in media from normal diet macrophages but only in the presence of polyglactin 910 or Dacron. Radioimmunoassay for platelet-derived growth factor B chain was negative in all groups, and polymerase chain reaction techniques to amplify transforming growth factor-beta messenger ribonucleic was negative. These data demonstrate the effect of in vivo dietary manipulation on macrophage activation as well as the effect of an atherogenic diet in modulating macrophage/biomaterial interactions. Additionally, different biomaterials differentially induce macrophages to release factors that stimulate and inhibit growth.

Kinetics of collagen deposition within bioresorbable and nonresorbable vascular prostheses

This study compares the kinetics of collagen deposition within the prosthesis/tissue complexes formed following implantation of either polyglactin 910 (PG910), polydioxanone (PDS), or Dacron prostheses into rabbit infrarenal aortas. The grafts were explanted in triplicate at 1, 3, and 12 months, and then processed for spectrophotometric hydroxyproline quantitation. A 2 mm longitudinal strip from each sample was processed for histologic evaluation by light and electron microscopy. Results showed more extensive collagen deposition within the prosthesis/tissue complexes of both PG910 and PDS continuing throughout 3 months, as compared to less collagen deposition in Dacron grafts at all time points. Differences between PG910 and Dacron, and between PDS and Dacron at each time point were statistically significant. When correlated with previous related studies done in our laboratory, data showed that in resorbable grafts the rate of collagen deposition parallels the kinetics of cellular proliferation, tissue thickening, and graft resorption.

Effects of class I heparin binding growth factor and fibronectin on platelet adhesion and aggregation

Fibronectin and heparin binding growth factor-type 1 have been affixed to vascular graft surfaces to enhance the attachment and the proliferation of transplanted endothelial cells, respectively. The current study examines the effect of fibronectin and heparin binding growth factor-type 1 on platelet adhesion and activation in vivo and on platelet aggregation in vitro. Expanded polytetrafluoroethylene prostheses (5 cm x 4 mm internal diameter) were treated either with fibronectin (n = 9), fibronectin/heparin/heparin binding growth factor-type 1/heparin (n = 12), or neither (n = 13) and were interposed into canine aortoiliac systems bilaterally. Autogenous radiolabeled (Indium 111 oxine, 650 microCi) platelets were injected intravenously before reestablishment of circulation. Perfusion was maintained for 30 minutes, and prostheses were removed with segments of native aorta and distal iliac arteries bilaterally. Specimens were examined for thrombus-free surface area, by gamma well counting for adherent radiolabeled platelets, and by light microscopy and transmission and scanning electron microscopic techniques. Results showed that both the fibronectin and fibronectin/heparin/heparin binding growth factor-type 1/heparin pretreated prostheses contained significantly greater numbers of platelets and adherent radioactivity than did control graft segments when normalized to their ipsilateral iliac arteries. Fibronectin/heparin/heparin binding growth factor-type 1/heparin pretreated prostheses contained 27 +/- 16 times more radioactivity per square millimeter than ipsilateral iliac arteries, fibronectin pretreated prostheses had 13 +/- 8 times more radioactivity per square millimeter than ipsilateral iliac arteries, and untreated expanded polytetrafluoroethylene had 4 +/- 3 times more radioactivity per square millimeter than ipsilateral iliac arteries. Fibronectin/heparin/heparin binding growth factor-type 1/heparin was more radioactive than fibronectin alone (p = 0.056). Histologic evaluation and thrombus-free surface area determinations corroborated the gamma well counting data. Platelet aggregation in vitro was not activated by either fibronectin (1 to 100 micrograms/100 microliters) or heparin binding growth factor-type 1 (25 to 2500 ng/100 microliters). These data suggest that fibronectin and heparin binding growth factor-type 1 promote platelet adhesion not aggregation.