The International Consolidated Venous Ulcer Guideline Update 2015: Process Improvement, Evidence Analysis, and Future Goals.

In 2015, members of the Association for the Advancement of Wound Care (AAWC), Wound Healing Society, and the Canadian Association for Enterostomal Therapy formed the International Consolidated Guidelines Taskforce to update the AAWC Venous Ulcer Guidelines to the collaborative, intersociety, endorsed International Consolidated Venous Ulcer Guideline. This "guideline of guidelines" integrates recommendations from all relevant, published evidence-based guidelines on venous ulcer care and prevention. The update process was conducted in accordance with the National Guideline Clearinghouse inclusion criteria and was informed by a systematic review of the evidence, with additional content validation of each venous ulcer management recommendation. Twenty-three (23) wound experts participated. Compared to the 2010 version of the guideline, A-level recommendations increased from 62% to 77%, 31 recommendations were removed, and new recommendations included quality of life evaluations and surgical treatment options. Gaps in the evidence and needed areas for research include surgical, topical, and pharmaceutical interventions. Collaboration among societies and stakeholders and rigorous guideline development processes may expedite the implementation of evidence-based practices, fill in research gaps, and provide a powerful unified voice to regulatory and reimbursement agencies with the ultimate goal of improving outcomes for persons with a venous ulcer.

Pressure Injury in a Community Population: A Descriptive Study.

PURPOSE: The purpose of this study was to describe present-on-admission pressure injuries (POA-PIs) in community-dwelling adults admitted to acute care. The specific aims of the study were to (1) measure the prevalence of POA-PIs during a 1-year period; (2) determine prehospital location of patients with POA-PIs; and (3) describe demographics, pressure injury (PI) characteristics, risk factors, and posthospital outcome of community-dwelling adults with PIs admitted to hospital. DESIGN: Retrospective descriptive study. SUBJECTS AND SETTING: The study sample was identified from a PI registry, a database maintained for quality improvement, at an 860-bed urban academic medical center in New England. The majority (n = 1022, 76.1%) were admitted to hospital from the community; and the remaining (23.9%) were admitted from long-term care facilities. METHODS: All subjects were assessed by certified wound nurses. Data were extracted electronically from selected standardized electronic health record (EHR) fields, representing variables of interest. Descriptive statistics were analyzed using percentages, means, and medians. RESULTS: The prevalence of patients admitted to acute care with a POA-PI was 7.4%. Community-dwelling subjects with POA-PIs had a mean age of 72.7 ± 15.4 years; 52.4% were male, 80.3% white, 30.9% lived alone, 99.2% were insured, and 30.6% were college educated. They presented with a mean of 1.46 PIs; 37.5% were full thickness. Admission Braden Scale for Pressure Sore Risk scores indicated that 77% were at risk for PI; subscores indicated mobility limitations in 90.8% and inadequate/poor nutrition in 41.3%. Subjects had multiple comorbid conditions (mean 18.4 ± 5.3 admission diagnoses). Only 21.4% were receiving home care services prior to admission. More than half (51.5%) were discharged to a healthcare facility, 33% to home, and 14% died or received hospice care. The 30-day readmission rate was 15.5%. CONCLUSION: The overall prevalence of POA-PIs on hospital admission in this study was higher than previous published reports. The majority arrived from community-dwelling locations. The severity of community-dwelling POA-PIs was higher than known benchmarked hospital-acquired PI severity. This real-world profile of community-dwelling patients with PI suggests that these individuals are considerably vulnerable and underserved by home care services. Opportunities exist for community PI screening, prevention, and intervention.

The Association for the Advancement of Wound Care (AAWC) venous and pressure ulcer guidelines.

Guidelines based on best available evidence to support pressure ulcer (PU) or venous ulcer (VU) management decisions can improve outcomes. Historically, such guidelines were consensus-based and differed in content and development methods used. Since 2002, the Association for the Advancement of Wound Care (AAWC) Guideline Task Force has used a systematic approach for developing "guidelines of guidelines" that unify and blend recommendations from relevant published guidelines while meeting Institute of Medicine and Agency for Healthcare Research and Quality standards. In addition to establishing the literature-based strength of each recommendation, guideline clinical relevance is examined using standard content validation procedures. All final recommendations included are clinically relevant and/or supported by the highest level of available evidence, cited with every recommendation. In addition, guideline implementation resources are provided. The most recent AAWC VU and PU guidelines and ongoing efforts for improving their clinical relevance are presented. The guideline development process must be transparent and guidelines must be updated regularly to maintain their relevance. In addition, end-user results and research studies to examine their construct and predictive validity are needed.

Exploring the concept of a team approach to wound care: Managing wounds as a team.

Background - The growing prevalence and incidence of nonhealing acute and chronic wounds is a worrying concern. A major challenge is the lack of united services aimed at addressing the complex needs of individuals with wounds. However, the WHO argues that interprofessional collaboration in education and practice is key to providing the best patient care, enhancing clinical and health-related outcomes and strengthening the health system. It is based on this background that the team approach to wound care project was conceptualised. The project was jointly initiated and realised by the Association for the Advancement of Wound Care (AAWC-USA), the Australian Wound Management Association (AWMA) and the European Wound Management Association (EWMA). Aim - The aim of this project was to develop a universal model for the adoption of a team approach to wound care. Objective The overarching objective of this project was to provide recommendations for implementing a team approach to wound care within all clinical settings and through this to develop a model for advocating the team approach toward decision makers in national government levels. Method An integrative literature review was conducted. Using this knowledge, the authors arrived at a consensus on the most appropriate model to adopt and realise a team approach to wound care. Results - Eighty four articles met the inclusion criteria. Following data extraction, it was evident that none of the articles provided a definition for the terms multidisciplinary, interdisciplinary or transdisciplinary in the context of wound care. Given this lack of clarity within the wound care literature, the authors have here developed a Universal Model for the Team Approach to Wound Care to fill this gap in our current understanding. Conclusion - We advocate that the patient should be at the heart of all decision-making, as working with the Universal Model for the Team Approach to Wound Care begins with the needs of the patient. To facilitate this, we suggest use of a wound navigator who acts as an advocate for the patient. Overall, we feel that the guidance provided within this document serves to illuminate the importance of a team approach to wound care, in addition to providing a clear model on how to achieve such an approach to care. We look forward to gathering evidence of the impact of this model of care on clinical and financial outcomes and will continue to share updates over time.

What Do Patients Want? Patient Preference in Wound Care.

Patient preferences are statements made or actions taken by consumers that reflect their desirability of a range of health options. The concept occupies an increasingly prominent place at the center of healthcare reform, and is connected to all aspects of healthcare, including discovery, research, delivery, outcome, and payment. Patient preference research has focused on shared decisions, decisional aids, and clinical practice guideline development, with limited study in acute and chronic wound care populations. The wound care community has focused primarily on patient focused symptoms and quality of life measurement. With increasing recognition of wound care as a medical specialty and as a public health concern that consumes extensive resources, attention to the preferences of end-users with wounds is necessary. This article will provide an overview of related patient-centered concepts and begin to establish a framework for consideration of patient preference in wound care.

An evaluation of the association for the advancement of wound care venous ulcer guideline and recommendations for further research.

OBJECTIVE: The goals of this study were to analyze the 2010 update of the Association for the Advancement of Wound Care (AAWC) Venous Ulcer Guideline (VUG) and examine recommendations with less than A-level evidence to identify important research questions. DATA SOURCES: The AAWC VUG may be found at http://aawconline.org/professional-resources/resources and at the National Guideline Clearinghouse, http://www.guideline.gov. Supporting references for each recommendation, compiled by the AAWC Guideline Task Force from MEDLINE, CINAHL, and EMBASE databases, may be viewed at the first website. STUDY SELECTION: The literature identified in support of the AAWC VUG recommendations with less than A-level evidence was evaluated and is summarized below. DATA EXTRACTION: Questions requiring further research in venous ulcer (VU) care were developed from recommendations having less than A-level support and that fall under the following topics: diagnosis, documentation, prevention, wound care, adjunctive interventions, and palliation. DATA SYNTHESIS: Practitioners lack strong evidence for several generally accepted recommendations of this synthesis of VU guidelines concerning the following: diagnostic or screening validity of varicosities, timing of biopsies for differential diagnosis, clinic visit frequency, criteria for changing VU care plans, and effective VU preventive parameters. Bedside surgical debridement, several biologic interventions, certain types of grafting, and the comparative efficacy of intravascular surgical procedures also require rigorous examination. Adjunctive interventions to be investigated include systemic pain management, topical biophysical treatments, novel devices, pharmaceuticals, timing, methods and procedures for some surgical interventions. CONCLUSIONS: Better evidence for recommendations with less than A-level support may improve the quality and consistency of VU care, reduce costs, and improve resource use.

Wound Care Nursing: Professional Issues and Opportunities.

As the field of wound care advances and seeks validity as a distinctive healthcare specialty, it becomes imperative to define practice competencies for all related professionals in the arena. As such, the myriad nurses practicing wound care in settings across the continuum should be understood for their unique contribution to the wound care team. Furthermore, the hierarchy of wound care nursing with varying levels of licensure, certification, and scope of practice can be clarified to delineate leadership and reimbursement issues to meet current health care challenges. A review of the role of nursing in wound care from a historical and evolutionary perspective helps to characterize the trend towards advanced practice nursing in the wound care specialty.

Expression of prostaglandin E synthases in periodontitis immunolocalization and cellular regulation.

The inflammatory mediator prostaglandin E(2) (PGE(2)) is implicated in the pathogenesis of chronic inflammatory diseases including periodontitis; it is synthesized by cyclooxygenases (COX) and the prostaglandin E synthases mPGES-1, mPGES-2, and cPGES. The distribution of PGES in gingival tissue of patients with periodontitis and the contribution of these enzymes to inflammation-induced PGE(2) synthesis in different cell types was investigated. In gingival biopsies, positive staining for PGES was observed in fibroblasts and endothelial, smooth muscle, epithelial, and immune cells. To further explore the contribution of PGES to inflammation-induced PGE(2) production, in vitro cell culture experiments were performed using fibroblasts and endothelial, smooth muscle, and mast cells. All cell types expressed PGES and COX-2, resulting in basal levels of PGE(2) synthesis. In response to tumor necrosis factor (TNF-α), IL-1ß, and cocultured lymphocytes, however, mPGES-1 and COX-2 protein expression increased in fibroblasts and smooth muscle cells, accompanied by increased PGE(2), whereas mPGES-2 and cPGES were unaffected. In endothelial cells, TNF-α increased PGE(2) production only via COX-2 expression, whereas in mast cells the cytokines did not affect PGE(2) enzyme expression or PGE(2) production. Furthermore, PGE(2) production was diminished in gingival fibroblasts derived from mPGES-1 knockout mice, compared with wild-type fibroblasts. These results suggest that fibroblasts and smooth muscle cells are important sources of mPGES-1, which may contribute to increased PGE(2) production in the inflammatory condition periodontitis.

Transcriptional regulation of monocyte chemotactic protein-1 release by endothelin-1 in human airway smooth muscle cells involves NF-kappaB and AP-1.

BACKGROUND AND PURPOSE: Endothelin-1 (ET-1) is implicated in airway inflammation in asthma, but the mechanisms of its effects are poorly understood. We studied the effect of ET-1 on expression of the chemokine, monocyte chemotactic protein-1 (MCP-1), in primary cultures of human airway smooth muscle cells. EXPERIMENTAL APPROACH: MCP-1 release was measured by elisa. Pharmacological antagonists/inhibitors, reverse transcriptase-polymerase chain reaction (RT-PCR) and Western blotting were used to study ET receptors and kinase cascades. Transcriptional regulation was studied by real-time RT-PCR, transient transfection studies and chromatin immunoprecipitation assay. Major findings were confirmed in cells from three donors and mechanistic studies in cells from one donor. KEY RESULTS: ET-1 increased MCP-1 release through an ET(A) and ET(B) receptor-dependent mechanism. ET-1 increased MCP-1 mRNA levels but not mRNA stability suggesting it was acting transcriptionally. ET-1 increased the activity of an MCP-1 promoter-reporter construct. Serial deletions of the MCP-1 promoter mapped ET-1 effects to a region between -213 and -128 base pairs upstream of the translation start codon, containing consensus sequences for activator protein-1 (AP-1) and nuclear factor-kappaB (NF-kappaB). ET-1 promoted binding of AP-1 c-Jun subunit and NF-kappaB p65 subunit to the MCP-1 promoter. Blocking the inhibitor of kappaB kinase-2 with 2-[(aminocarbonyl)amino]-5-[4-fluorophenyl]-3-thiophenecarboxamide (TPCA-1) decreased ET-1-stimulated MCP-1 production. p38 and p44/p42 mitogen-activated protein kinases were involved in upstream signalling. CONCLUSIONS AND IMPLICATIONS: ET-1 regulated MCP-1 transcriptionally, via NF-kappaB and AP-1. The upstream signalling involved ET(A), ET(B) receptors, p38 and p44/p42 mitogen-activated protein kinases. These may be targets for novel asthma therapies.

PKCbetaII augments NF-kappaB-dependent transcription at the CCL11 promoter via p300/CBP-associated factor recruitment and histone H4 acetylation.

The transcription factor NF-kappaB plays a pivotal role in regulating inflammatory gene expression. Its effects are optimized by various coactivators, including histone acetyltransferases (HATs) such as CREB-binding protein/p300 and p300/CBP-associated factor (p/CAF). The molecular mechanisms regulating cofactor recruitment are poorly understood. In this study, we describe a novel role for protein kinase C (PKC) betaIotaIota in augmenting NF-kappaB-mediated TNF-alpha-induced transcription of the target gene CCL11 in human airway smooth muscle cells by phosphorylating the HAT p/CAF. Studies using reporters, overexpression strategies, kinase-dead and HAT-defective mutants, and chromatin immunoprecipitation showed that PKCbetaII activation was not involved in NF-kappaB translocation, but facilitated NF-kappaB-mediated CCL11 transcription by colocalizing with and phosphorylating p/CAF, and thereby acetylating histone H4 and promoting p65 association with the CCL11 promoter. The effect was dependent on p/CAF's HAT activity. Furthermore, mouse embryonic fibroblasts from PKCbeta knockout mice showed markedly reduced TNF-alpha-induced CCL11 expression and NF-kappaB reporter activity that was restored on PKCbetaII overexpression, suggesting a critical role for this pathway. These data suggest a novel important biological role for PKCbetaIotaIota in NF-kappaB-mediated CCL11 transcription by p/CAF activation and histone H4 acetylation.

Development of a content-validated venous ulcer guideline.

Evidence-based practice for venous ulcers may improve healing and reduce costs of care. The Association for the Advancement of Wound Care Government and Regulatory Task Force developed a content-validated venous ulcer guideline based on best available evidence supporting each aspect of venous ulcer care. After compiling all-inclusive lists of elements in venous ulcer algorithms published before August 2002, the Task Force objectively rated and summarized up to five best references from MEDLINE, CINAHL, and EMBASE literature searches covering each aspect of care. Sixteen multidisciplinary wound care professionals and educators used judgment quantification to content validate all steps. A 2004 email survey of AAWC members (N = 1,514) clarified effects of under-reimbursement on evidence-based venous practice. The Venous Ulcer Guideline containing all elements with A-level evidence plus those with a Content Validity Index >0.75 now resides on the AAWC and the Agency for Healthcare Research and Quality National Guideline Clearinghouse websites. However, a review of US healthcare environment components, including reimbursement policies, and the results of the survey identified many barriers to implementation of A-level evidence supported steps (sustained graduated high compression, autolytic debridement, and moist wound environments) in practice. Sufficient evidence supports improved venous ulcer care in the US but inadequate and/or inconsistent reimbursement policies impede quality evidence-based venous ulcer practice, delaying healing and increasing the burden of venous ulcers on society.

Mast cell beta-tryptase selectively cleaves eotaxin and RANTES and abrogates their eosinophil chemotactic activities.

Recent studies have shown that a lack of eosinophils in asthmatic airway smooth muscle (ASM) bundles in contrast to the large number of mast cells is a key feature of asthma. We hypothesized that this is caused by beta-tryptase, the predominant mast cell-specific protease, abrogating the eosinophil chemotactic activities of ASM cell-derived eosinophil chemoattractants such as eotaxin and RANTES. We studied the effect of beta-tryptase on the immunoreactivities of human ASM cell-derived and recombinant eotaxin and other recombinant chemokines that are known to be produced by human ASM cells. We report in this study that purified beta-tryptase markedly reduced the immunoreactivity of human ASM cell-derived and recombinant eotaxin, but had no effect on eotaxin mRNA expression. The effect was mimicked by recombinant human beta-tryptase in the presence of heparin and was reversed by heat inactivation and the protease inhibitor leupeptin, suggesting that the proteolytic activity of tryptase is required. beta-Tryptase also exerted similar effects on recombinant RANTES, but not on the other chemokines and cytokines that were screened. Furthermore, a chemotaxis assay revealed that recombinant eotaxin and RANTES induced eosinophil migration concentration-dependently, which was abrogated by pretreatment of these chemokines with beta-tryptase. Another mast cell protease chymase also markedly reduced the immunoreactivity of eotaxin, but had no effect on RANTES and other chemokines and did not affect the influence of beta-tryptase on RANTES. These findings suggest that mast cell beta-tryptase selectively cleaves ASM-derived eotaxin and RANTES and abrogates their chemotactic activities, thus providing an explanation for the eosinophil paucity in asthmatic ASM bundles.

A new option in the treatment of skin tears for the institutionalized resident: formulated 2-octylcyanoacrylate topical bandage.

Skin tears are a common phenomenon in elderly institutionalized adults (EIAs). Incidence ranges from 0.92 to 2.5 per person/year. Little supportive literature exists regarding optimal treatment with many regimens reported. A convenience sample of 20 patients with Payne-Martin Category II and III skin tears of less than 8 hours' duration were prospectively evaluated with the use of a formulated 2-octylcyanoacrylate topical bandage. Patients were followed weekly until the tear healed. Complete healing occurred with 1 application of 2-OTB in 90% (18/20) of study subjects; 5% (n = 1) reported transient mild pain (less than 15 seconds), and 90% (n = 19) reported no pain. There were no incidents of cellulitis or infection. Shower and bathing routines were not interrupted. Cost averaged less than $1 per application. Clinician time averaged 1.5 minutes per application. Clinicians reported high satisfaction because repeated dressing changes were eliminated.

Vascular endothelial growth factor induction by prostaglandin E2 in human airway smooth muscle cells is mediated by E prostanoid EP2/EP4 receptors and SP-1 transcription factor binding sites.

Prostaglandin E2 (PGE2) can increase endothelial vascular endogrowth factor A (VEGF-A) production but the mechanisms involved are unclear. Here we characterized the transcriptional mechanisms involved in human airway smooth muscle cells (HASMC). PGE2 increased VEGF-A mRNA and protein but not mRNA stability. PGE2 stimulated the activity of a transiently transfected 2068-bp (-2018 to +50) VEGF-A promoter-driven luciferase construct. Functional 5' deletional analysis mapped the PGE2 response element to the 135-bp sequence (-85/+50) of the human VEGF-A promoter. PGE2-induced luciferase activity was reduced in cells transfected with a 135-bp VEGF promoter fragment containing mutated Sp-1 binding sites but not in cells transfected with a construct containing mutated EGR-1 binding sites. Electrophoretic mobility shift assay and chromatin immunoprecipitation assay confirmed binding of Sp-1 to the VEGF promoter. PGE2 increased phosphorylation of Sp-1 and luciferase activity of a transfected Sp-1 reporter construct. PGE receptor agonists EP2 (ONO-AE1 259) and EP4 (ONO-AE1 329) mimicked the effect of PGE2, and reverse transcription-PCR, Western blotting, and flow cytometry confirmed the presence of EP2 and EP4 receptors. VEGF protein release and Sp-1 reporter activity were increased by forskolin and isoproterenol, which increase cytosolic cAMP, and the cAMP analogue, 8-bromoadenosine-3',5'-cyclophosphoric acid. These studies suggest that PGE2 increases VEGF transcriptionally and involves the Sp-1 binding site via a cAMP-dependent mechanism involving EP2 and EP4 receptors.

Cytokines upregulate vascular endothelial growth factor secretion by human airway smooth muscle cells: Role of endogenous prostanoids.

Here, we report that vascular endothelial growth factor (VEGF)-A secretion by human airway smooth muscle cells was increased by interleukin 1 beta (IL-1beta) and transforming growth factor beta (TGFbeta). IL-1beta and TGFbeta induced cyclo-oxygenase (COX)-2 protein and increased prostaglandin E(2) (PGE(2)). Both IL-1beta and TGFbeta increased VEGF-A(165) mRNA and VEGF promoter luciferase construct activity, in addition VEGF-A protein was inhibited by actinomycin D suggesting transcriptional regulation. The COX inhibitors indomethacin and NS398 inhibited IL-1beta but not TGFbeta mediated VEGF-A production. Furthermore, the effect of the COX inhibitors was overcome by adding exogenous PGE(2). In conclusion, IL-1beta increases VEGF-A secretion by COX-2 derived PGE(2) production whereas TGFbeta uses COX-independent pathways.

Differential regulation of chemokine expression by peroxisome proliferator-activated receptor gamma agonists: interactions with glucocorticoids and beta2-agonists.

Chemokine-mediated inflammatory cell infiltration is a hallmark of asthma. We recently demonstrated that glucocorticoids and beta(2)-agonists additively or synergistically suppress tumor necrosis factor-alpha (TNFalpha)-induced production of chemokines eotaxin and interleukin-8 (IL-8), respectively, in human airway smooth muscle (HASM) cells, which may partly explain their combined benefits in asthma. Peroxisome proliferator-activated receptors (PPARs) also modulate inflammatory gene expression. We reported here that the PPARgamma agonists 15-deoxy-Delta(12,14)-PGJ(2) (15d-PGJ(2)) and troglitazone, but not PPARalpha agonist WY-14643, inhibited TNFalpha-induced production of eotaxin and monocyte chemotactic protein-1 (MCP-1) but not IL-8. Eotaxin inhibition was transcriptional and additively enhanced by the glucocorticoid fluticasone and the beta(2)-agonist salmeterol, whereas MCP-1 inhibition was post-transcriptional and additively and synergistically enhanced by fluticasone and salmeterol, respectively. Coimmunoprecipitation revealed that 15d-PGJ(2) induced a protein-protein interaction between PPARgamma and the glucocorticoid receptor (GR) in TNFalpha-treated HASM cells, which was enhanced by fluticasone and salmeterol. 15d-PGJ(2), fluticasone, and salmeterol all inhibited TNFalpha-induced histone H4 acetylation at the eotaxin promoter and NF-kappaB p65 binding to the eotaxin promoter and induced PPARgamma and GR association with the eotaxin promoter, as analyzed by chromatin immunoprecipitation assay. Our data suggest that chemokine expression in HASM cells is differentially regulated by PPARgamma agonists and that the interaction between PPARgamma and GR may be responsible for the additive and synergistic inhibition of chemokine expression by PPARgamma agonists, glucocorticoids, and beta(2)-agonists, particularly the chromatin-dependent suppression of eotaxin gene transcription. The interaction may have wide applications and may provide a potential target for pharmacological and molecular intervention.

Impact of antimicrobial gauze on bacterial colonies in wounds that require packing.

Heavy microbial contamination has been associated with delayed wound healing and infection in both acute and chronic wounds. A prospective, randomized, 5-week controlled, open label, multicenter study was conducted to determine whether using antimicrobial gauze containing polyhexamethylene biguanide in wounds that require packing will result in a greater reduction of bacterial colony counts than using a gauze without polyhexamethylene biguanide (the control). Twenty-one subjects were randomized to the treatment or control dressing. Wounds were evenly distributed with respect to etiology and both study groups had a median baseline wound size of 7 cm2. At baseline, 15 microbial isolates were recovered and counted in treatment group wounds and 12 were recovered in the controls. At Week 1, six isolates were recovered from subjects in the polyhexamethylene biguanide antimicrobial gauze treatment group while 10 were recovered in the control. Change in polymicrobial bioburden was most prominent during the first few weeks of the study in the polyhexamethylene biguanide group. Polymicrobial counts in the treatment group remained reduced for the following three study weeks, returning to baseline at Week 4. In the control group, the number of polymicrobial cultures rose to 60% above baseline at Week 4. Two wounds of subjects randomized to the polyhexamethylene biguanide antimicrobial gauze healed; one wound in the control group healed. Polyhexamethylene biguanide antimicrobial gauze dressing could be an important adjunct to control the polymicrobial bioburden of delayed closure surgical wounds, pressure ulcers, and diabetic foot ulcers. Additional studies seem warranted.

Cyclooxygenase-2 induction by bradykinin in human pulmonary artery smooth muscle cells is mediated by the cyclic AMP response element through a novel autocrine loop involving endogenous prostaglandin E2, E-prostanoid 2 (EP2), and EP4 receptors.

Bradykinin (BK) is an important mediator in several inflammatory and vascular diseases that acts in part via induction of cyclooxygenase-2 (COX-2). The mechanisms involved in BK-mediated COX-2 induction are unclear. Here we characterized the transcriptional mechanisms involved in human pulmonary artery smooth muscle cells. BK stimulated the activity of a transiently transfected 966-bp (-917 to + 49) COX-2 promoter luciferase reporter construct. There was no reduction in BK-induced luciferase activity in cells transfected with COX-2 promoter constructs of 674, 407, 239, and 135 bp or constructs with mutated CCAAT/enhancer-binding protein- or NF-kappaB-binding sites. In contrast luciferase activity was reduced in cells transfected with a 407-bp COX-2 promoter fragment containing a mutated cAMP response element (CRE)-binding site, suggesting that the CRE binding site is critical. Electrophoretic mobility shift assays using oligonucleotides specific for the CRE-binding region of the COX-2 promoter and consensus oligonucleotides showed strong specific binding. Furthermore BK increased consensus cAMP-responsive luciferase reporter (p6CRE/luc)-mediated luciferase expression. CRE activation occurred by BK inducing cytosolic phospholipase A2-mediated arachidonic acid release and rapid prostaglandin E2 (PGE2) production, thereby increasing cAMP. Indomethacin inhibited BK-induced PGE2 production, cAMP accumulation, and CRE/luc reporter and COX-2 promoter luciferase activity. Exogenous PGE2 and EP2 (ONO-AE1 259) and EP4 (ONO-AE1 329) PGE2 receptor agonists mimicked the effect of BK. Collectively these studies indicate that COX-2 induction by BK in human pulmonary artery smooth muscle cells is mediated by the CRE through a novel autocrine loop involving endogenous PGE2.

Cyclooxygenase-2 expression by nonsteroidal anti-inflammatory drugs in human airway smooth muscle cells: role of peroxisome proliferator-activated receptors.

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to modulate cyclooxygenase (COX)-2 expression, but the mechanisms involved are controversial and may be cell specific. We show in this study that indomethacin (Indo), flurbiprofen (Flur), and the selective COX-2 inhibitor NS-398 induced COX-2 expression and markedly enhanced IL-1beta-induced COX-2 expression in human airway smooth muscle (HASM) cells. These effects were not reversed by exogenous PGE(2), suggesting that they are prostanoid-independent. Indeed, PGE(2) also induced and enhanced IL-1beta-induced COX-2 expression. Peroxisome proliferator-activated receptor (PPAR) alpha and PPARgamma (not PPARbeta) were expressed in HASM cells. PPARgamma activators ciglitizone (Cig) and 15-Deoxy-Delta(12,14)-PGJ(2) (15d-PGJ(2)), but not the PPARalpha activator WY-14643, mimicked the effect of NSAIDs on COX-2 expression. Treatment with Flur, NS-398, Cig, and 15d-PGJ(2) alone, but not Indo and WY-14643, elevated COX activity; however, neither enhanced IL-1beta-induced COX activity. Pretreatment with dexamethasone suppressed COX-2 expression, PGE(2) release, and COX activity induced by NS-398, Cig, IL-1beta, alone or in combination. Unlike IL-1beta, NS-398 and Cig did not cause NF-kappaB (p65) nuclear translocation, nor did they further enhance IL-1beta-induced NF-kappaB translocation, but they stimulated PPARgamma translocation. Indo, NS-398, Flur, and 15d-PGJ(2), but not WY-14643, induced transcriptional activity of a COX-2 reporter construct containing the peroxisome proliferator response element (PPRE) on their own and enhanced the effect of IL-1beta, but had no effect on a COX-2 reporter construct lacking the PPRE. The results suggest that COX-2 expression by NSAIDs is biologically functional, prostanoid-independent, and involves PPARgamma activation, and provide the first direct evidence that the PPRE in the promoter is required for NSAID-induced COX-2 expression.