Determinants of cervical spine disorders in military pilots: a systematic review.

BACKGROUND: Neck pain and cervical spine disorders are widespread among military cockpit aircrew pilots and are often recognized as occupational stressors. AIMS: This systematic review aimed to identify significant determinants for military pilot neck pain and cervical spine disorders determined through multivariable logistic regression studies. METHODS: This systematic review was conducted according to the recommendations of the Statement of Systematic Review and Meta-analysis Protocols (Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA]-P). The following databases were searched for literature: Medline and Embase. We included studies that studied neck pain, cervical spine disorders, and/or radiological abnormalities and associated exposures (adjusted odds ratios, ORadj) in military cockpit aircrew. The trustworthiness, relevance and results of the published papers were evaluated using the Joanna Briggs Institute critical checklist. RESULTS: A total of three studies quantified the strength of the correlations between exposures and outcomes. Significant determinants/risk factors of neck pain, cervical spine disorders and radiological abnormalities were identified as age (ORadj: 1.092 [95% CI 1.054, 1.132]), fighter type (ORadj: 3.9 [95% CI 1.1, 13.9]) and absolute rotation angle of C2-7 (ARA) (ORadj: 0.91 [CI 0.85, 0.98]). The following variables were unable to demonstrate statistical significance: flying hours, body height and body mass index. CONCLUSIONS: Military cockpit aircrew's frequent neck pain after a flight raises concerns about cervical spine disorders. Age, fighter type and ARA C2-7 are strong predictors of neck pain and cervical spine disorders. More research is needed on occupational determinants and risk factors for neck pain and cervical spine disorders in military cockpit aircrew.

Sex-dependent differences in renal angiotensinogen as an early marker of diabetic nephropathy.

AIM: The renal renin-angiotensin system (RAS) has been implicated in the pathogenesis of diabetic nephropathy. The aim of this study was to investigate sex differences in renal renin-angiotensin system (RAS) and the roles of androgens in diabetes-associated renal injury. METHODS: Renal injury and fibrosis were studied in streptozotocin-induced diabetic rats by albuminuria and by gene expression of collagen I and fibronectin. RAS was investigated by analysing the plasma angiotensinogen (AOGEN) and renin activity (PRA) and their renal gene expression. Also, a group of diabetic rats was treated with the anti-androgen flutamide. RESULTS: Albuminuria was significantly lower in diabetic females than in males (1.2 [0.8-1.5] versus 4.4 [2.2-6.1] mg/24 h, data are median [IQR] values, P < 0.05). Renal AOGEN mRNA levels were increased by diabetes in males (8.1 ± 0.8% in diabetes versus 0.8 ± 0.2% in control, P < 0.001) but not in females (1.0 ± 0.1% in diabetes versus 0.8 ± 0.1% in control, P > 0.05), as were collagen I and fibronectin mRNAs. Furthermore, AOGEN mRNA levels were strongly correlated with albuminuria (Spearman r = 0.64, 95% [CI] 0.36-0.81, P < 0.0001). Diabetes decreased PRA, renal renin mRNA and plasma AOGEN in both females and males. Anti-androgen treatment decreased albuminuria only in diabetic males without affecting the endocrine or renal RAS. CONCLUSIONS: These data indicate that renal but not hepatic AOGEN or renin is positively associated with diabetic albuminuria and contribute to the sex-dependent differences in renal injury. Androgens may contribute to albuminuria in male independently of the RAS.

Genetic targeting of the brain renin-angiotensin system in transgenic rats: impact on stress-induced renin release.

The advance of genetic technologies to permit tissue-specific targeted gene manipulation allowed the development of transgenic models with alterations of the renin-angiotensin (RAS) solely in the brain. We have used such methodology to develop a transgenic rat with a brain specific alteration of the RAS [TGR(ASrAOGEN)], in order to elucidate a causative role for the brain RAS and its relevance in different pathophysiological processes. The TGR(ASrAOGEN) rats have decreased levels of angiotensinogen (AOGEN) throughout the brain because of an antisense inhibition of the astroglial AOGEN synthesis. In this review we aimed at summarizing the experience obtained from utilizing the TGR(ASrAOGEN) rat model to study the brain RAS and present novel results providing evidence for the involvement of this system in stress-induced renin release.

Tissue renin-angiotensin systems: new insights from experimental animal models in hypertension research.

Renin was first isolated in the kidney by Tigerstedt and Bergman over 100 years ago. Almost 50 additional years were necessary to isolate the renin substrate angiotensinogen and to show its cleavage to angiotensin (Ang). Further studies were then needed to demonstrate that Ang I is converted via an angiotensin-converting enzyme to Ang II. The circulating renin-angiotensin system, with blood pressure regulatory and aldosterone stimulatory roles, served well for decades. However, more recent information on Ang II and its action in terms of cell proliferation, hypertrophy, and hyperplasia as well as immune-modulatory and even intracellular functions, have focused attention on local Ang II generation and effects. These investigations necessarily began in the kidney, but quickly moved to other organs including the brain, heart, adrenal gland, and vessel wall and formed the basis for the concept of independent tissue renin-angiotensin systems. Both renin and Ang II have even been implicated in intracellular activities. This review presents some selected aspects of the historical development of this concept and summarizes discoveries relying primarily on animal models which demonstrate that Ang II is generated locally and acts in tissues as a local peptidergic system. Comprehensiveness in such an endeavor is not possible. We focus largely on work from our own group, not because the work is necessarily worthy of such scrutiny but rather because of our own familiarity with the contents.

Alterations in blood pressure and heart rate variability in transgenic rats with low brain angiotensinogen.

To study whether the brain renin-angiotensin system plays a role in the long-term and short-term control of blood pressure and heart rate variability, we examined in transgenic rats [TGR(ASrAOGEN)] with low brain angiotensinogen levels the 24-hour variation of blood pressure and heart rate. Telemetry recordings were made during basal and hypertensive conditions induced by a low-dose subcutaneous infusion of angiotensin II for 7 days. Short-term blood pressure and heart rate variability were evaluated by spectral analysis, and as a measure of baroreflex sensitivity, the average transfer gain between the pressure and heart rate variations was calculated. During the angiotensin II infusion in control but not TGR(ASrAOGEN) rats, the 24-hour rhythm of blood pressure was inverted (5.8+/-2 versus -0.4+/-1.8 mm Hg/group of day-night differences of blood pressure, P<0.05, respectively). In both the control and TGR(ASrAOGEN) rats, the 24-hour heart rate rhythms remained unaltered and paralleled those of locomotor activity. The transfer gain between 0.3 to 0.6 Hz was significantly higher in TGR(ASrAOGEN) than in control rats during control (0.71+/-0.1 versus 0.35+/-0.06, P<0.05) but not during angiotensin II infusion (0.6+/-0.07 versus 0.4+/-0.1, P>0.05). These results demonstrate that the brain renin-angiotensin system plays an important role in mediating the effects of angiotensin II on the circadian variation of blood pressure. Furthermore, these data indicate that a permanent deficiency in the brain renin-angiotensin system alters the reflex control of heart rate in rats.

Alterations of the renin-angiotensin system at the RVLM of transgenic rats with low brain angiotensinogen.

The transgenic rats TGR(ASrAOGEN) (TGR) with low levels of brain angiotensinogen were analyzed for cardiovascular reactivity to microinjections of ANG II and angiotensin receptor (AT(1)) antagonists [CV-11974, AT(1) specific; A-779, ANG-(1--7) selective; sarthran, nonspecific] into the rostral ventrolateral medulla (RVLM) of conscious rats. Microinjection of ANG II resulted in a significantly higher increase in the mean arterial pressure (MAP) of TGR than control [Sprague-Dawley (SD)] rats, suggesting an upregulation of ANG II receptors in TGR. CV-11974 produced an increase in MAP of SD but not in TGR rats. A-779 produced a depressor response in SD but not in TGR rats. Conversely, sarthran produced a similar decrease of MAP in both rat groups. The pressor effect of the AT(1) antagonist may indicate an inhibitory role of AT(1) receptors in the RVLM. On the other hand, ANG-(1--7) appears to have a tonic excitatory role in this region. The altered response to specific angiotensin antagonists in TGR further supports the functionally relevant decrease in angiotensins in the brains of TGR and corroborates the importance of the central renin-angiotensin system in cardiovascular homeostasis.

Reduced cardiac hypertrophy and altered blood pressure control in transgenic rats with the human tissue kallikrein gene.

To evaluate the cardiovascular actions of kinins, we established a transgenic rat line harboring the human tissue kallikrein gene, TGR(hKLK1). Under the control of the zinc-inducible metallothionein promoter, the transgene was expressed in most tissues including the heart, kidney, lung, and brain, and human kallikrein was detected in the urine of transgenic animals. Transgenic rats had a lower 24-h mean arterial pressure in comparison with control rats, which was further decreased when their diet was supplemented with zinc. The day/night rhythm of blood pressure was significantly diminished in TGR(hKLK1) animals, whereas the circadian rhythms of heart rate and locomotor activity were unaffected. Induction of cardiac hypertrophy by isoproterenol treatment revealed a marked protective effect of the kallikrein transgene because the cardiac weight of TGR(hKLK1) increased significantly less, and the expression of atrial natriuretic peptide and collagen III as markers for hypertrophy and fibrosis, respectively, were less enhanced. The specific kinin-B2 receptor antagonist, icatibant, abolished this cardioprotective effect. In conclusion, the kallikrein-kinin system is an important determinant in the regulation of blood pressure and its circadian rhythmicity. It also exerts antihypertrophic and antifibrotic actions in the heart.

Angiotensin peptides acting at rostral ventrolateral medulla contribute to hypertension of TGR(mREN2)27 rats.

We have previously demonstrated that microinjections of the selective angiotensin-(1-7) [ANG-(1-7)] antagonist, A-779, into the rostral ventrolateral medulla (RVLM) produces a significant fall in mean arterial pressure (MAP) and heart rate (HR) in both anesthetized and conscious rats. In contrast, microinjection of angiotensin II (ANG II) AT(1) receptor antagonists did not change MAP in anesthetized rats and produced dose-dependent increases in MAP when microinjected into the RVLM of conscious rats. In the present study, we evaluated whether endogenous ANG-(1-7) and ANG II acting at the RVLM contribute to the hypertension of transgenic rats harboring the mouse renin Ren-2 gene, TGR(mREN2)27. Unilateral microinjection of A-779 (0.1 nmol) produced a significant fall in MAP (-25 +/- 5 mmHg) and HR (-57 +/- 20 beats/min) of awake TGR rats. The hypotensive effect was greater than that observed in Sprague-Dawley (SD) rats (-9 +/- 2 mmHg). Microinjection of the AT(1) antagonist CV-11974 (0.2 nmol) produced a fall in MAP in TGR rats (-14 +/- 4 mmHg), contrasting with the pressor effect observed in SD rats (33 +/- 9 mmHg). These results indicate that endogenous ANG-(1-7) exerts a significant pressor action in the RVLM, contributing to the hypertension of TGR(mREN2)27 transgenic rats. The role of ANG II at the RVLM seems to be dependent on its endogenous level in this area.

The brain renin-angiotensin system modulates angiotensin II-induced hypertension and cardiac hypertrophy.

The potential involvement of the brain renin-angiotensin system in the hypertension induced by subpressor doses of angiotensin II was tested by the use of newly developed transgenic rats with permanent inhibition of brain angiotensinogen synthesis [TGR(ASrAOGEN)]. Basal systolic blood pressure monitored by telemetry was significantly lower in TGR(ASrAOGEN) than in Sprague-Dawley rats (parent strain) (122.5+/-1.5 versus 128.9+/-1.9 mm Hg, respectively; P<0.05). The increase in systolic blood pressure induced by 7 days of chronic angiotensin II infusion was significantly attenuated in TGR(ASrAOGEN) in comparison with control rats (29.8+/-4.2 versus 46. 3+/-2.5 mm Hg, respectively; P<0.005). Moreover, an increase in heart/body weight ratio was evident only in Sprague-Dawley (11.1%) but not in TGR(ASrAOGEN) rats (2.8%). In contrast, mRNA levels of atrial natriuretic peptide (ANP) and collagen III in the left ventricle measured by ribonuclease protection assay were similarly increased in both TGR(ASrAOGEN) (ANP, x2.5; collagen III, x1.8) and Sprague-Dawley rats (ANP, x2.4; collagen III, x2) as a consequence of angiotensin II infusion. Thus, the expression of these genes in the left ventricle seems to be directly stimulated by angiotensin II. However, the hypertensive and hypertrophic effects of subpressor angiotensin II are at least in part mediated by the brain renin-angiotensin system.

Blood pressure reduction and diabetes insipidus in transgenic rats deficient in brain angiotensinogen.

Angiotensin produced systemically or locally in tissues such as the brain plays an important role in the regulation of blood pressure and in the development of hypertension. We have established transgenic rats [TGR(ASrAOGEN)] expressing an antisense RNA against angiotensinogen mRNA specifically in the brain. In these animals, the brain angiotensinogen level is reduced by more than 90% and the drinking response to intracerebroventricular renin infusions is decreased markedly compared with control rats. Blood pressure of transgenic rats is lowered by 8 mmHg (1 mmHg = 133 Pa) compared with control rats. Crossbreeding of TGR(ASrAOGEN) with a hypertensive transgenic rat strain exhibiting elevated angiotensin II levels in tissues results in a marked attenuation of the hypertensive phenotype. Moreover, TGR(ASrAOGEN) exhibit a diabetes insipidus-like syndrome producing an increased amount of urine with decreased osmolarity. The observed reduction in plasma vasopressin by 35% may mediate these phenotypes of TGR(ASrAOGEN). This new animal model presenting long-term and tissue-specific down-regulation of angiotensinogen corroborates the functional significance of local angiotensin production in the brain for the central regulation of blood pressure and for the pathogenesis of hypertension.

Functional evidence for alternative ANG II-forming pathways in hamster cardiovascular system.

Like human chymase, hamster chymase is an ANG II-forming enzyme, but pathophysiological roles of chymase are still unknown. We determined the functional conversion of ANG I and [Pro11, D-Ala12]ANG I, a chymase-selective substrate, to ANG II in the hamster cardiovascular system. ANG I and [Pro11, D-Ala12]ANG I produced similar dose-dependent pressor responses in conscious hamsters. Captopril and CV-11974, an ANG II type 1 (AT1)-receptor antagonist, inhibited the responses to ANG I; in contrast, the pressor responses to [Pro11, D-Ala12]ANG I were suppressed only by CV-11974. In the isolated aorta, captopril suppressed ANG I-induced contraction by 84%; administration of captopril with either chymostatin or aprotinin eliminated the contraction. [Pro11, D-Ala12]ANG I-induced contraction was not affected by captopril but was attenuated by chymostatin (71%) and aprotinin (57%). CV-11974 abolished the responses to both substrates, whereas PD-123319, an AT2-receptor antagonist, had no effect. In homogenates of the aorta and heart, soybean trypsin inhibitor-inhibitable ANG II formation predominated over captopril- or aprotinin-inhibitable ANG II formation. These data suggest that [Pro11,D-Ala12]ANG I and part of ANG I were functionally converted to ANG II by chymase and other serine protease(s) in hamster vessels, inducing AT1-receptor-mediated vasoconstriction. Biochemical data supported a role for chymase in the alternative pathway.

Local renin-angiotensin system in the pineal gland.

Besides the classical endocrine renin-angiotensin system (RAS), a local RAS has been described also in the brain. We attempted to clarify the existence of a local RAS in the pineal gland. Through the use of a ribonuclease protection assay, it proved possible to detect the mRNA for angiotensinogen (AOGEN), for the angiotensin receptor type 1A (AT1a) and 1B (AT1b) and for the angiotensin-converting enzyme (ACE) in pineal glands from rats. Renin mRNA, however, could not be found by this method. By in situ hybridization and immunocytochemistry, AOGEN mRNA was co-localized with the astrocyte marker glial fibrillary acidic protein. AT1b mRNA expression exceeded the expression of AT1a mRNA and was co-localized with the pinealocyte-specific tryptophan hydroxylase. Thus, in the mammalian pineal gland there is a local formation of the components of the RAS. The presence of angiotensin II receptors further substantiates a role for angiotensins and the pineal RAS in the physiology of this gland.

High levels of human chymase expression in the pineal and pituitary glands.

The brain renin-angiotensin system plays a role in both cardiovascular homeostasis and neurosecretory functions. Since the mechanisms of angiotensin (Ang) II formation in the human brain have not been clarified, the aims of the present study were to determine the presence of human chymase and angiotensin I-converting enzyme (ACE) in human and non-human brains. In the human brain, the total Ang II-forming activity was significantly higher in the pineal and pituitary glands than those in other regions. In other species (rat, bovine and porcine), the level of chymase as well as total Ang II-forming activities in pineal glands were significantly lower than those in human glands. High levels of chymase-like immunoreactivity (ir) were found in the arteriolar endothelial cells, adventitial mesenchymal cells and in parenchymal cells of the human pineal and pituitary glands while ACE-ir was mostly observed in the endothelial cells and occasionally found in parenchymal cells. Our study provides the first evidence that human chymase exists in the pineal and pituitary glands. The remarkable regional and species differences in mechanisms of Ang II formation suggest a specific role of chymase or ACE in the human brain.

Angiotensin I converting enzyme and chymase in cardiovascular tissues.

Recent studies have provided evidence that the human cardiovascular tissues contain components of the renin-angiotensin system: angiotensinogen, renin, angiotensin I converting enzyme (ACE), chymase and angiotensin II (Ang II) receptors. In addition to ACE, a cardiac Ang II forming serine proteinase, human heart chymase, has been identified in the human left ventricle. Unlike rat heart, only a minor (approximately 11%) component of Ang II forming activity in the human left ventricle was due to ACE, since the majority (approximately 80%) of activity was due to chymase. Human heart chymase has been purified to homogeneity and characterized. Recently, the cDNA and gene for this enzyme have been cloned. Biochemical characterization revealed that heart chymase is the most efficient and specific Ang II forming enzyme described thus far. The different cellular and regional distribution of ACE and heart chymase in the heart as well as in blood vessels implies distinct pathophysiological roles for these two Ang II forming enzymes. Several reports indicate that ACE-independent Ang II formation appears to take place in hypoxic or ischemic heart or blood vessel in vivo and to be involved in vascular remodeling after balloon injury. Therefore, it is very important to clarify the detailed mechanisms of the tissue Ang II formation in humans and its contribution to the pathophysiological changes in cardiovascular disease. In this review, we review the pathophysiological roles of the two main Ang II forming enzymes, ACE and chymase, in cardiovascular homeostasis.

Modulatory role of nitric oxide on angiotensins vasoconstriction.

Using aortic rings from male Wistar rats, we studied the influence of nitric oxide (NO) on the vascular reactivity to angiotensins. The inhibition of NO-synthesis by L-NAME produced on both intact and desendothelised rings an augmentation of vascular reactivity to angiotensins. NO inhibition did not affect the blocking effects of Saralasin to angiotensins vasoconstriction, suggesting that NO cannot act directly on angiotensin II receptor. Nifedipin inhibited the stimulatory effect of L-NAME on angiotensins vasoconstriction. The results of our study provide functional evidence that NO production can interfere with vascular RAS at two levels: 1. by modulating the activity of Ang II-forming enzymes; 2. at intracellular level, by modulating the concentration of calcium. Also, our results suggest the existence of an alternative pathway on Ang II formation, that become more evident with removal of endothelium.

Effects of alpha-trinositol administered extra- and intracellularly (using liposomes) on rat aorta rings.

The effects of alpha-trinositol, a D-myo-inositol [1,2,6]trisphosphate derivative, were studied on de-endothelised rat aorta rings. The substance was applied extracellularly as well as intracellularly (by using liposomes as drug carriers). Upon extracellular administration, the drug reduced the level of contraction induced by 40 mM K+ or by phenylephrine (10(-5) M). No effects were observed on relaxed preparations. Liposomes containing alpha-trinositol induced a dose-dependent contraction of the preparations under resting tension with a threshold of 10(-5) M in the aqueous phase. These contractions were heparin-insensitive but were significantly blocked by D-600 (10(-5) M) (an L-type Ca2+ channel blocker) or in Ca(2+)-free medium. Our data suggest that alpha-trinositol has a plasmalemmal mechanism of action which could involve Ca2+ influx from the extracellular space.

Multiple effects of tyrosine kinase inhibitors on vascular smooth muscle contraction.

The effects of three tyrosine kinase inhibitors: genistein, quercetin and psi-tectorigenin, were investigated on contractions evoked in de-endothelised rat aortic rings, either by phenylephrine or 70 mM K+. A dose-dependent inhibition of both contractions by all three compounds was observed, the phenylephrine-mediated contractions being more sensitive to genistein. No differences between genistein or quercetin effects in pre-treatment or post-treatment protocols were found. Ca2+ store refilling, expressed in terms of phenylephrine-induced tension in Ca(2+)-free medium, was dose-dependently blocked by quercetin and genistein. Sodium orthovanadate, an inhibitor of tyrosine phosphatase, contracted the rat aortic rings with an IC50 of 0.66 microM. Its presence during the refilling period after exposure to Ca(2+)-free medium completely prevented the subsequent response to phenylephrine. One can conclude that the use of the above-mentioned protein tyrosine kinase inhibitors in the rat aorta blocks a step involved in Ca2+ entry and Ca2+ store refilling. A definite conclusion regarding the vanadate effects is not possible due to the fact that this compound also affects Ca2+ ATP-ases.

Effects of liposome-entrapped platelet-activating factor in the isolated rat trachea.

The effects of platelet-activating factor (PAF, 1-O-alkyl-2-acetyl-sn-glycero-3-phosphocholine)-filled liposomes upon rat tracheal rings in vitro were examined. The capture of liposomes by the smooth muscle cells of the isolated tracheal rings as well as the release of their content into the cytoplasm was shown by using Evans blue (5 x 10(-4) M)-loaded liposomes. Administration of PAF (10(-3) M)-filled liposomes contracted the preparations, in contrast with extracellular administration of PAF and control liposomes, which had no effect. Administration during the plateau or pretreatment with liposomes containing BN 52021 (3-t-butylhexahydro-4,7b-trihydroxy-8-methyl-9H-1,7a-epoxymethano- 1H,6aH- cyclopenta[c]furo(2,3-b)furo[3',2':3,4]cyclopental [1,2-d]furan-5,9,12(4H)-trione) ((10(-3) M, a selective PAF receptor antagonist) or heparin (5 x 10(-5) M) blocked this contraction. BN 52021 and heparin, not entrapped in liposomes, had no such effect. Our data suggest an intervention of PAF in the mechanisms of contraction of tracheal smooth muscle, involving a direct or indirect intervention (intracellular receptors for PAF cannot be excluded). At the same time, the rat trachea contraction induced by PAF-loaded liposomes could be linked to the PtdIns(1,4,5)P3-dependent Ca2+ channels from the endoplasmic reticulum and/or to the interaction with G proteins, as shown by the blocking effects of heparin-containing liposomes.

Cardiovascular effects of L-arginine as physiological precursor of nitric oxide.

In this study the cardiovascular effects of L-arginine were investigated. Perfusion with sorbitol L-arginine 5% solution induced a significant decrease of the systolic blood pressure in the human arterial hypertension. The hypotensive effects of L-arginine are accompanied by an increase of the ventricular ejection fraction. In vitro, L-arginine as physiologic precursor of nitric oxide induced a smooth muscle relaxation more evident in the coronary vessels than in the thoracic aorta rings. Selective inhibition of NO-synthetise with L-NAME reduced the L-arginine vasodilation and intensified the vasoconstrictor effect of phenylephrine.