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1.
Eur J Pharmacol ; 723: 234-45, 2014 Jan 15.
Article in English | MEDLINE | ID: mdl-24296316

ABSTRACT

The small G protein RhoA and its downstream effector Rho-kinase play an important role in various physiopathological processes including ischemia/reperfusion (I/R) injury. Reactive oxygen and nitrogen species produced by iNOS and NADPH oxidase are important mediators of inflammation and organ injury following an initial localized I/R event. The aim of this study was to determine whether RhoA/Rho-kinase signaling pathway increases the expression and activity of MEK1, ERK1/2, iNOS, gp91(phox), and p47(phox), and peroxynitrite formation which result in oxidative/nitrosative stress and inflammation leading to hindlimb I/R-induced injury in kidney as a distant organ and gastrocnemius muscle as a target organ. I/R-induced distant and target organ injury was performed by using the rat hindlimb tourniquet model. I/R caused an increase in the expression and/or activity of RhoA, MEK1, ERK1/2, iNOS, gp91(phox), p47(phox), and 3-nitrotyrosine and nitrotyrosine levels in the tissues. Although Rho-kinase activity was increased by I/R in the kidney, its activity was decreased in the muscle. Serum and tissue MDA levels and MPO activity were increased following I/R. I/R also caused an increase in SOD and catalase activities associated with decreased GSH levels in the tissues. Y-27632, a selective Rho-kinase inhibitor, (100µg/kg, i.p.; 1h before reperfusion) prevented the I/R-induced changes except Rho-kinase activity in the muscle. These results suggest that activation of RhoA/Rho-kinase/MEK1/ERK1/2/iNOS pathway associated with oxidative/nitrosative stress and inflammation contributes to hindlimb I/R-induced distant organ injury in rats. It also seems that hindlimb I/R induces target organ injury via upregulation of RhoA/MEK1/ERK1/2/iNOS pathway associated with decreased Rho-kinase activity.


Subject(s)
MAP Kinase Kinase 1/metabolism , MAP Kinase Signaling System , Nitric Oxide Synthase Type II/metabolism , Reperfusion Injury/metabolism , rho-Associated Kinases/metabolism , rhoA GTP-Binding Protein/metabolism , Amides/pharmacology , Animals , Catalase/metabolism , Glutathione/metabolism , Inflammation/metabolism , Kidney/drug effects , Kidney/metabolism , Male , Malondialdehyde/metabolism , Muscle, Skeletal/drug effects , Muscle, Skeletal/metabolism , NADPH Oxidases/metabolism , Oxidative Stress , Peroxidase/metabolism , Peroxynitrous Acid/metabolism , Pyridines/pharmacology , Rats , Rats, Wistar , Superoxide Dismutase/metabolism , Tyrosine/analogs & derivatives , Tyrosine/metabolism
2.
Nitric Oxide ; 33: 18-41, 2013 Sep 01.
Article in English | MEDLINE | ID: mdl-23684565

ABSTRACT

We have previously demonstrated that a stable synthetic analog of 20-hydroxyeicosatetraenoic acid (20-HETE), N-[20-hydroxyeicosa-5(Z),14(Z)-dienoyl]glycine (5,14-HEDGE), prevents vascular hyporeactivity, hypotension, tachycardia, and inflammation in rats treated with lipopolysaccharide (LPS) and mortality in endotoxemic mice. These changes were attributed to decreased production of inducible nitric oxide (NO) synthase (iNOS)-derived NO, cyclooxygenase (COX)-2-derived vasodilator prostanoids, and proinflammatory mediators associated with increased cyctochrome P450 (CYP) 4A1-derived 20-HETE and CYP2C23-dependent antiinflammatory mediator formation. The aim of this study was to determine whether decreased expression and activity of iNOS, soluble guanylyl cyclase (sGC), protein kinase G (PKG), COX-2, gp91(phox) (NOX2; a superoxide generating NOX enzyme), and peroxynitrite production associated with increased expression of COX-1 and CYP4A1 and 20-HETE formation in renal and cardiovascular tissues of rats contributes to the effect of 5,14-HEDGE to prevent vasodilation, hypotension, tachycardia, and inflammation in response to systemic administration of LPS. Mean arterial pressure fell by 28mmHg and heart rate rose by 47beats/min in LPS (10mg/kg, i.p.)-treated rats. Administration of LPS also increased mRNA and protein expression of iNOS and COX-2 associated with a decrease in COX-1 and CYP4A1 mRNA and protein expression. Increased NOS activity, iNOS-heat shock protein 90 complex formation (an index for iNOS activity), protein expression of phosphorylated vasodilator stimulated phosphoprotein (an index for PKG activity), gp91(phox), p47(phox) (NOXO2; organizer subunit of gp91(phox)), and nitrotyrosine (an index for peroxynitrite production) as well as cGMP (an index for sGC activity), 6-keto-PGF1α (a stable metabolite PGI2) and PGE2 levels (indexes for COX activity), and nitrotyrosine levels by LPS were also associated with decreased CYP hydroxylase activity as measured by 20-HETE formation from arachidonic acid in renal microsomes of LPS-treated rats. These effects of LPS, except iNOS mRNA and COX-1 protein expression, were prevented by 5,14-HEDGE (30mg/kg, s.c.; 1h after LPS). A competitive antagonist of vasoconstrictor effects of 20-HETE, 20-hydroxyeicosa-6(Z),15(Z)-dienoic acid (30mg/kg, s.c.; 1h after LPS) reversed the effects of 5,14-HEDGE, except iNOS and COX-1 mRNA and protein expression as well as expression of CYP4A1 mRNA. These results suggest that increased CYP4A1 expression and 20-HETE formation associated with suppression of iNOS/sGC/PKG pathway, COX-2, and gp91(phox) participate in the protective effect of 5,14-HEDGE against vasodilation, hypotension, tachycardia, and inflammation in the rat model of septic shock.


Subject(s)
Lipopeptides/pharmacology , Nitric Oxide Synthase Type II/metabolism , Protective Agents/pharmacology , Shock, Septic/drug therapy , Shock, Septic/metabolism , Signal Transduction/drug effects , Animals , Cell Adhesion Molecules/metabolism , Cyclic GMP-Dependent Protein Kinases/metabolism , Cyclooxygenase 2/genetics , Cyclooxygenase 2/metabolism , Cytochrome P-450 CYP2J2 , Cytochrome P-450 Enzyme System/genetics , Cytochrome P-450 Enzyme System/metabolism , Disease Models, Animal , Guanylate Cyclase/metabolism , HSP90 Heat-Shock Proteins/metabolism , Hydroxyeicosatetraenoic Acids/pharmacology , Lipopolysaccharides/pharmacology , Male , Membrane Glycoproteins/metabolism , Microfilament Proteins/metabolism , NADPH Oxidase 2 , NADPH Oxidases/metabolism , Nitric Oxide Synthase Type II/genetics , Organ Specificity , Peroxynitrous Acid/metabolism , Phosphoproteins/metabolism , RNA, Messenger/genetics , RNA, Messenger/metabolism , Random Allocation , Rats , Rats, Wistar , Receptors, Cytoplasmic and Nuclear/metabolism , Shock, Septic/enzymology , Shock, Septic/genetics , Soluble Guanylyl Cyclase
3.
Prostaglandins Other Lipid Mediat ; 102-103: 31-41, 2013.
Article in English | MEDLINE | ID: mdl-23454652

ABSTRACT

We have previously demonstrated that a stable synthetic analog of 20-HETE, N-[20-hydroxyeicosa-5(Z),14(Z)-dienoyl]glycine (5,14-HEDGE), restores vascular reactivity, blood pressure, and heart rate in endotoxemic rats. The aim of this study was to determine whether decreased renal expression and activity of soluble epoxide hydrolase (sEH), MEK1, ERK1/2, IKKß, IκB-α, and NF-κB as well as systemic and renal proinflammatory cytokine production associated with increased expression and activity of CYP2C23 contributes to the effect of 5,14-HEDGE to prevent hypotension, tachycardia, inflammation, and mortality in response to systemic administration of lipopolysaccharide (LPS). Blood pressure fell by 33 mmHg and heart rate rose by 57 beats/min in LPS (10 mg/kg, i.p.)-treated rats. Administration of LPS also increased mRNA and protein expression of sEH associated with a decrease in CYP2C23 mRNA and protein expression. Increased activity of sEH and p-MEK1, p-ERK1/2, p-IκB-α, NF-κB, and p-NF-κB protein levels as well as TNF-α and IL-8 production by LPS were also associated with a decreased activity of AA epoxygenases. These effects of LPS were prevented by 5,14-HEDGE (30 mg/kg, s.c.; 1 h after LPS). Treatment of endotoxemic mice with 5,14-HEDGE also raised the survival rate of animals from 84% to 98%. A competitive antagonist of vasoconstrictor effects of 20-HETE, 20-hydroxyeicosa-6(Z),15(Z)-dienoic acid, 20-HEDE (30 mg/kg, s.c.; 1 h after LPS) prevented the effects of 5,14-HEDGE on blood pressure, heart rate, expression and/or activity of sEH, CYP2C23, and ERK1/2 as well as TNF-α and IL-8 levels in rats treated with LPS. These results suggest that decreased expression and/or activity of sEH and MEK1/ERK1/2/IKKß/IκB-α/NF-κB pathway as well as proinflammatory cytokine production associated with increased CYP2C23 expression and antiinflammatory mediator formation participate in the protective effect of 5,14-HEDGE against hypotension, tachycardia, inflammation, and mortality in the rodent model of septic shock.


Subject(s)
Cytochrome P-450 Enzyme System/biosynthesis , Epoxide Hydrolases/biosynthesis , Hydroxyeicosatetraenoic Acids/administration & dosage , Inflammation/drug therapy , Lipopeptides/administration & dosage , Shock, Septic/drug therapy , Animals , Blood Pressure/drug effects , Cytochrome P-450 CYP2J2 , Disease Models, Animal , Gene Expression Regulation/drug effects , Heart Rate/drug effects , Humans , Hydroxyeicosatetraenoic Acids/chemical synthesis , Hypotension/drug therapy , Hypotension/pathology , Inflammation/metabolism , Inflammation/pathology , Lipopeptides/chemical synthesis , MAP Kinase Signaling System , Mice , NF-kappa B/metabolism , Rats , Shock, Septic/metabolism , Shock, Septic/pathology , Survival
4.
Article in English | MEDLINE | ID: mdl-23189948

ABSTRACT

Oxidative stress and apoptosis are the states that can contribute to the pathogenesis of sepsis. In this study we aimed to investigate whether mitogen-activated protein kinase kinase 1 (MEK1)/extracellular signal-regulated kinase 1/2 (ERK1/2)/inducible nitric oxide synthase (iNOS) pathway plays a role in oxidative stress and apoptosis in endotoxemic rats. Systemic total antioxidant, SOD, GPx, and GR activities as markers of oxidative stress, and tissue caspase-3 enzyme activity as a marker of apoptosis were measured in sera and thoracic aortae of male Wistar rats sacrificed 4 h after being treated with saline (vehicle) or lipopolysaccharide (LPS) (10 mg/kg, i.p.). A decrease in total antioxidant activity and caspase-3, SOD, GPx, and GR enzyme activities was occured by LPS. These changes caused by LPS were prevented when a selective iNOS inhibitor, 1,3-PBIT (10 mg/kg, i.p.) or a selective inhibitor of ERK1/2 phosphorylation by MEK1, U0126 (5 mg/kg, i.p.) were given 1 h after administration of LPS. Our results suggest that decreased activity of MEK1/ERK1/2/iNOS pathway prevents oxidative stress by increasing systemic antioxidant enzyme activities and restores decreased caspase-3 activity in thoracic aorta in endotoxemic rat.


Subject(s)
Caspase 3/metabolism , Endotoxemia/enzymology , MAP Kinase Kinase 1/physiology , Mitogen-Activated Protein Kinase 3/physiology , Nitric Oxide Synthase Type II/physiology , Oxidative Stress/physiology , Animals , Antioxidants/metabolism , Aorta, Thoracic , Apoptosis/physiology , Butadienes/pharmacology , Endotoxins/toxicity , Enzyme Inhibitors/pharmacology , Glutathione Peroxidase/metabolism , Glutathione Reductase/metabolism , Heart Rate/drug effects , MAP Kinase Signaling System/physiology , Male , Nitriles/pharmacology , Rats , Rats, Wistar , Superoxide Dismutase/metabolism , Thiourea/analogs & derivatives , Thiourea/pharmacology
5.
Basic Clin Pharmacol Toxicol ; 109(3): 186-94, 2011 Sep.
Article in English | MEDLINE | ID: mdl-21463481

ABSTRACT

Nitric oxide (NO) produced by inducible NO synthase (iNOS) is responsible for endotoxin-induced vascular hyporeactivity and hypotension resulting in multiple organ failure. Endotoxic shock is also characterized by decreased expression of constitutive cyclooxygenase (COX-1), cytochrome P450 (CYP) 4A and endothelial NOS (eNOS). Our previous studies demonstrated that dual inhibition of iNOS and COX with a selective COX-2 inhibitor, NS-398, or a non-selective COX inhibitor, indomethacin, restores blood pressure presumably because of increased production of 20-hydroxyeicosatetraenoic acid (20-HETE) derived from arachidonic acid (AA) by CYP4A in endotoxaemic rats. The aim of this study was to investigate the effects of piroxicam, a preferential COX-1 inhibitor, on the endotoxin-induced changes in blood pressure, expression of COX-1, inducible COX (COX-2), CYP4A1, eNOS, iNOS and heat shock protein 90 (hsp90), and production of PGI(2), PGE(2), 20-HETE and NO. Injection of endotoxin (10 mg/kg, i.p.) to male Wistar rats caused a fall in blood pressure and an increase in heart rate associated with elevated renal 6-keto-PGF(1α) and PGE(2) levels as well as an increase in COX-2 protein expression. Endotoxin also caused an elevation in systemic and renal nitrite levels associated with increased renal iNOS protein expression. In contrast, systemic and renal 20-HETE levels and renal expression of eNOS, COX-1 and CYP4A1 were decreased in endotoxaemic rats. The effects of endotoxin, except for renal COX-1 and eNOS protein expression, were prevented by piroxicam (10 mg/kg, i.p.), given 1 hr after injection of endotoxin. Endotoxin did not change renal hsp90 protein expression. These data suggest that a decrease in the expression and activity of COX-2 and iNOS associated with an increase in CYP4A1 expression and 20-HETE synthesis contributes to the effect of piroxicam to prevent the hypotension during rat endotoxaemia.


Subject(s)
Cyclooxygenase Inhibitors/therapeutic use , Eicosanoids/biosynthesis , Endotoxins/toxicity , Hypotension/prevention & control , Nitric Oxide/biosynthesis , Piroxicam/therapeutic use , Animals , Blood Pressure/drug effects , Cyclooxygenase 1/metabolism , Cyclooxygenase 2/metabolism , Cyclooxygenase Inhibitors/administration & dosage , Cyclooxygenase Inhibitors/pharmacology , Cytochrome P-450 CYP4A/biosynthesis , Dinoprostone/biosynthesis , Epoprostenol/biosynthesis , Hydroxyeicosatetraenoic Acids/biosynthesis , Hypotension/chemically induced , Hypotension/enzymology , Hypotension/metabolism , Male , Nitric Oxide Synthase Type II/antagonists & inhibitors , Piroxicam/administration & dosage , Piroxicam/pharmacology , Rats , Rats, Wistar , Time Factors , Vasoconstriction/drug effects , Vasodilation/drug effects
6.
Nitric Oxide ; 24(3): 160-72, 2011 Apr 30.
Article in English | MEDLINE | ID: mdl-21354320

ABSTRACT

Increased production of inducible nitric oxide (NO) synthase (iNOS)-derived NO contributes to fall in blood pressure and vascular reactivity during endotoxemia. We investigated whether an increase in protein expression and activity of the enzymes involved in mitogen-activated protein kinase kinase 1 (MEK1)/extracellular signal-regulated kinase 1/2 (ERK1/2)/iNOS/soluble guanylyl cyclase (sGC)/protein kinase G (PKG) pathway associated with peroxynitrite production would contribute to endotoxin-induced decrease in mean blood pressure (MAP) and vascular reactivity in rats. A selective iNOS inhibitor, 1,3-PBIT (10 mg/kg, i.p.), or a selective inhibitor ERK1/2 phosphorylation by MEK1, U0126 (5mg/kg, i.p.), prevented endotoxin (10mg/kg, i.p.)-induced decrease in MAP and vascular reactivity to norepinephrine (0.001-100 µM) in endothelium-intact and -denuded arteries associated with increased levels of nitrite (an index for NO production), cyclic GMP (an index for sGC activity), phosphorylated vasodilator stimulated phosphoprotein (an index for PKG activity), and nitrotyrosine (an index for peroxynitrite production). Endotoxin-induced increase in the phosphorylated MEK1 protein levels were not changed by 1,3-PBIT or U0126. U0126 prevented the endotoxin-induced increase in phosphorylated ERK1/2 and iNOS expressions. A selective sGC inhibitor, ODQ (3µM), prevented the endotoxin-induced decrease in the E(max) values and increase in the EC(50) values of norepinephrine in endothelium-intact aortic rings isolated from endotoxemic rats in vitro. ODQ also reversed the effect of endotoxin on the increase in the EC(50) values of norepinephrine in endothelium-denuded rings. A selective PKG inhibitor, KT5823 (1 µM), only prevented the endotoxin-induced decrease in the E(max) values of norepinephrine in arteries with endothelium. These results suggest that activation of MEK1/ERK1/2 pathway leading to an increase in iNOS protein expression and NO production associated with an increase in sGC and PKG activity and peroxynitrite formation results in hypotension and vascular hyporeactivity in endotoxemic rats. However, further study is needed to confirm the involvement of PKG to the fall in vascular reactivity in the rat model of endotoxemia.


Subject(s)
Aorta, Thoracic/physiopathology , Endotoxemia/metabolism , Hypotension/metabolism , Peroxynitrous Acid/biosynthesis , Signal Transduction/drug effects , Animals , Aorta, Thoracic/metabolism , Blood Pressure/drug effects , Cyclic GMP-Dependent Protein Kinases/antagonists & inhibitors , Cyclic GMP-Dependent Protein Kinases/metabolism , Endotoxemia/complications , Endotoxemia/physiopathology , Endotoxins/toxicity , Enzyme Activation/drug effects , Enzyme Inhibitors/pharmacology , Guanylate Cyclase/antagonists & inhibitors , Guanylate Cyclase/metabolism , Heart Rate/drug effects , Hypotension/etiology , Hypotension/physiopathology , MAP Kinase Kinase 1/antagonists & inhibitors , MAP Kinase Kinase 1/metabolism , Male , Mitogen-Activated Protein Kinase 3/antagonists & inhibitors , Mitogen-Activated Protein Kinase 3/metabolism , Nitric Oxide Synthase Type II/antagonists & inhibitors , Nitric Oxide Synthase Type II/metabolism , Nitrites/blood , Nitrites/metabolism , Norepinephrine/metabolism , Oxidative Stress , Rats , Rats, Wistar , Receptors, Cytoplasmic and Nuclear/antagonists & inhibitors , Receptors, Cytoplasmic and Nuclear/metabolism , Soluble Guanylyl Cyclase , Tyrosine/analogs & derivatives , Tyrosine/metabolism
7.
Basic Clin Pharmacol Toxicol ; 107(5): 877-82, 2010 Nov.
Article in English | MEDLINE | ID: mdl-22545970

ABSTRACT

Our previous studies with the use of non-selective cyclooxygenase (COX) inhibitor, indomethacin, demonstrated that prostanoids produced during endotoxaemia increase inducible nitric oxide synthase (iNOS) protein expression and nitric oxide synthesis, and decrease cyctochrome P450 (CYP) 4A1 protein expression and CYP 4A activity. The results suggest that dual inhibition of iNOS and COX by indomethacin restores blood pressure presumably due to increased production of 20-hydroxyeicosatetraenoic acid (20-HETE) derived from CYP 4A in endotoxaemic rats. The present study examined whether increased levels of vasoconstrictor eicosanoids, 20-HETE, prostaglandin F(2α) (PGF(2α) )and thromboxane A(2) (TxA(2) ), would contribute to the effect of selective COX-2 inhibition to prevent endotoxin (ET)-induced fall in blood pressure associated with an increase in the production of vasodilator prostanoids, prostaglandin I(2) (PGI(2) ) and prostaglandin E(2) (PGE(2) ) and nitric oxide synthesis. Mean arterial blood pressure fell by 31 mmHg and heart rate (HR) rose by 90 beats/min. in male Wistar rats treated with ET (10 mg/kg, i.p.). The fall in mean arterial pressure and increase in HR were associated with increased levels of 6-keto-prostaglandin F(1α) (6-keto-PGF(1α) ), PGE(2) , TxB(2) , and nitrite in the serum, kidney, heart, thoracic aorta and/or superior mesenteric artery. Systemic and renal 20-HETE and PGF(2α) levels were also decreased in endotoxaemic rats. These effects of ET were prevented by a selective COX-2 inhibitor, N-(2-cyclohexyloxy-4-nitrophenyl)methansulphonamide (10 mg/kg, i.p.), given 1 hr after injection of ET. These data suggest that an increase in 20-HETE and PGF(2α) levels associated with decreased production of PGI(2) , PGE(2) , and TxA(2) , and nitric oxide synthesis contributes to the effect of selective COX-2 inhibitor to prevent the hypotension during rat endotoxaemia.


Subject(s)
Cyclooxygenase 2 Inhibitors/therapeutic use , Eicosanoids/metabolism , Hypotension/prevention & control , Nitric Oxide/biosynthesis , Nitrobenzenes/therapeutic use , Shock, Septic/prevention & control , Sulfonamides/therapeutic use , Animals , Blood Pressure/drug effects , Cyclooxygenase 2 Inhibitors/administration & dosage , Cyclooxygenase 2 Inhibitors/pharmacology , Hypotension/chemically induced , Hypotension/immunology , Lipopolysaccharides/toxicity , Male , Nitrobenzenes/administration & dosage , Nitrobenzenes/pharmacology , Rats , Rats, Wistar , Shock, Septic/chemically induced , Shock, Septic/immunology , Sulfonamides/administration & dosage , Sulfonamides/pharmacology , Time Factors , Vasoconstriction/drug effects , Vasodilation/drug effects
8.
Basic Clin Pharmacol Toxicol ; 106(5): 378-88, 2010 May.
Article in English | MEDLINE | ID: mdl-20002062

ABSTRACT

Nitric oxide (NO) produced by inducible NO synthase (iNOS) is responsible for endotoxin (ET)-induced hypotension and vascular hyporeactivity and plays a major contributory role in the multiorgan failure. Endotoxic shock is also associated with an increase in vasodilator prostanoids as well as a decrease in endothelial NO synthase (eNOS) and cytochrome P450 4A protein expression, and production of a vasoconstrictor arachidonic acid product, 20-hydroxyeicosatetraenoic acid (20-HETE). The aim of this study was to investigate the effects of a synthetic analogue of 20-HETE, N-[20-hydroxyeicosa-5(Z),14(Z)-dienoyl]glycine (5,14-HEDGE), on the ET-induced changes in eNOS, iNOS and heat shock protein 90 (hsp90) expression as well as 20-HETE and vasodilator prostanoid (6-keto-PGF(1alpha) and PGE(2)) production. ET-induced fall in blood pressure and rise in heart rate were associated with an increase in iNOS protein expression and a decrease in eNOS protein expression in heart, thoracic aorta, kidney and superior mesenteric artery. ET did not change hsp90 protein expression in the tissues. ET-induced changes in eNOS and iNOS protein expression were associated with increased 6-keto-PGF(1alpha) and PGE(2) levels and a decrease in 20-HETE levels, in the serum and kidney. These effects of ET on the iNOS protein expression and 6-keto-PGF(1alpha), PGE(2) and 20-HETE levels were prevented by 5,14-HEDGE. Furthermore, a competitive antagonist of vasoconstrictor effects of 20-HETE, 20-hydroxyeicosa-6(Z),15(Z)-dienoic acid, prevented the effects of 5,14-HEDGE on the ET-induced changes in systemic and renal levels of these prostanoids and 20-HETE. These data are consistent with the view that an increase in systemic and renal 20-HETE levels associated with a decrease in iNOS protein expression and vasodilator prostanoid production contributes to the effect of 5,14-HEDGE to prevent the hypotension during rat endotoxemia.


Subject(s)
Hydroxyeicosatetraenoic Acids/metabolism , Hypotension/drug therapy , Lipopeptides/therapeutic use , Nitric Oxide Synthase Type II/metabolism , Prostaglandins/metabolism , Animals , Blood Pressure/drug effects , Cytochrome P-450 CYP4A/metabolism , Endotoxins , Heart Rate/drug effects , Hypotension/chemically induced , Hypotension/metabolism , Rats , Rats, Sprague-Dawley , Shock, Septic/chemically induced , Vasodilation
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