Jeffrey E. Gotts

Lineage-negative progenitors mobilize to regenerate lung epithelium after major injury

Broadly, tissue regeneration is achieved in two ways: by proliferation of common differentiated cells and/or by deployment of specialized stem/progenitor cells. Which of these pathways applies is both organ- and injury-specific. Current models in the lung posit that epithelial repair can be attributed to cells expressing mature lineage markers. By contrast, here we define the regenerative role of previously uncharacterized, rare lineage-negative epithelial stem/progenitor (LNEP) cells present within normal distal lung. Quiescent LNEPs activate a ΔNp63 (a p63 splice variant) and cytokeratin 5 remodelling program after influenza or bleomycin injury in mice. Activated cells proliferate and migrate widely to occupy heavily injured areas depleted of mature lineages, at which point they differentiate towards mature epithelium. Lineage tracing revealed scant contribution of pre-existing mature epithelial cells in such repair, whereas orthotopic transplantation of LNEPs, isolated by a definitive surface profile identified through single-cell sequencing, directly demonstrated the proliferative capacity and multipotency of this population. LNEPs require Notch signalling to activate the ΔNp63 and cytokeratin 5 program, and subsequent Notch blockade promotes an alveolar cell fate. Persistent Notch signalling after injury led to parenchymal ‘micro-honeycombing’ (alveolar cysts), indicative of failed regeneration. Lungs from patients with fibrosis show analogous honeycomb cysts with evidence of hyperactive Notch signalling. Our findings indicate that distinct stem/progenitor cell pools repopulate injured tissue depending on the extent of the injury, and the outcomes of regeneration or fibrosis may depend in part on the dynamics of LNEP Notch signalling.

Sepsis: pathophysiology and clinical management

Sepsis, severe sepsis, and septic shock represent increasingly severe systemic inflammatory responses to infection. Sepsis is common in the aging population, and it disproportionately affects patients with cancer and underlying immunosuppression. In its most severe form, sepsis causes multiple organ dysfunction that can produce a state of chronic critical illness characterized by severe immune dysfunction and catabolism. Much has been learnt about the pathogenesis of sepsis at the molecular, cell, and intact organ level. Despite uncertainties in hemodynamic management and several treatments that have failed in clinical trials, investigational therapies increasingly target sepsis induced organ and immune dysfunction. Outcomes in sepsis have greatly improved overall, probably because of an enhanced focus on early diagnosis and fluid resuscitation, the rapid delivery of effective antibiotics, and other improvements in supportive care for critically ill patients. These improvements include lung protective ventilation, more judicious use of blood products, and strategies to reduce nosocomial infections.

Migration and fate of newly born cells after focal cortical ischemia in adult rats

Neural cell migration and differentiation may participate in neural repair after adult brain injury; however, the survival and differentiation of newly born cells after different brain lesions are poorly understood. We have examined the migration and fate of bromodeoxyuridine (BrdU)‐labeled cells after a highly reproducible focal ischemic lesion restricted to the frontoparietal cortex in adult rats. Thermocoagulation of pial blood vessels induces a circumscribed degeneration of all cortical layers while sparing the corpus callosum and striatum and increases cell proliferation in the subventricular zone (SVZ) and rostral migratory stream (RMS) within 7 days. We now show that, although the rostral migration of the newly born SVZ cells and their differentiation into neurons in the olfactory bulb were not affected by the lesion, numerous cells expressing the neuroblast marker doublecortin migrated laterally in the striatum and corpus callosum 5 days postinjury. In addition to the SVZ, BrdU‐labeled cells were seen in the striatum, in the corpus callosum, and around the lesion. One month later, BrdU‐labeled cells in the corpus callosum expressed transferrin and the π isoform of glutathione‐S‐transferase (GST‐π), markers of oligodendrocytes. Other BrdU+ cells expressed a marker of astrocytes, but none expressed neuronal markers, suggesting that new neurons do not form or survive under these conditions. Numerous BrdU‐labeled cells were still observed in the SVZ and RMS. The data show that focal cortical ischemia does not lead to the long‐term survival of new neurons in the striatum or cortex but induces long‐term alterations in the SVZ and the production of new oligodendrocytes that may contribute to neural repair.

Mesenchymal Stem Cells and Acute Lung Injury

Acute respiratory distress syndrome (ARDS) is a clinical syndrome of acute respiratory failure presenting with hypoxemia and bilateral pulmonary infiltrates, most often in the setting of pneumonia, sepsis, or major trauma. The pathogenesis of ARDS involves lung endothelial injury, alveolar epithelial injury, and the accumulation of protein-rich fluid and cellular debris in the alveolar space. No pharmacologic therapy has so far proved effective. A potential strategy involves cell-based therapies, including mesenchymal stem cells (MSCs). Herein we review basic properties of MSCs, their use in preclinical models of lung injury and ARDS, and potential therapeutic mechanisms.

Vascular changes in the subventricular zone after distal cortical lesions

One of the effects of cortical lesions is to produce cell proliferation in the subventricular zone (SVZ), a neurogenic zone of the adult brain distal from the lesion. The mechanisms of these effects are unknown. Recent evidence points to a relationship between the vasculature and neurogenesis both in vitro and in vivo. In the present study, we asked whether cortical lesions induced vascular modifications in the distal SVZ in vivo. Lesions of the frontoparietal cortex were produced by thermocoagulation of pial blood vessels, a method that leads to highly reproducible loss of all cortical layers, sparing the corpus callosum and underlying striatum. These lesions induced increased immunoreactivity for vascular endothelial growth factor (VEGF) around the walls of SVZ vessels, at a considerable distance from the lesion. Vascular permeability was markedly increased in both the SVZ and RMS by 3 days after the injury. A dramatic increase in endothelial proliferation was followed by expansion of the local SVZ vascular tree 7 days after the injury. This time course corresponded to the proliferative changes in the SVZ, and a tight correlation was observed between the number of blood vessels and the increase in SVZ cell number. The data demonstrate that thermocoagulatory cortical lesions induce distal vascular changes that could play a role in lesion-induced SVZ expansion.

Mechanisms of subventricular zone expansion after focal cortical ischemic injury.

The rodent subventricular zone (SVZ) contains neural precursor cells that divide and then die in place or migrate to the olfactory bulb through the rostral migratory stream (RMS) to become new neurons. Despite the normally tight control in cell numbers in this region in adults, previous work from our laboratory and others has shown that SVZ cell number increases after a variety of brain injuries. The relative contribution of changes in rostral migration, cell proliferation, and cell death to increased cell number is poorly understood. We examined these parameters after focal cortical ischemic lesions distal from the SVZ in adult rats. Stereological analysis revealed that cell numbers remain constant in the SVZ and RMS until 5 days postinjury but then rapidly expanded by 150,000 cells by day 7 in each region. Rostral migration of SVZ cells was unaffected by the injury. Both cell death and proliferation increased in the SVZ as early as day 5. However, these two mechanisms became uncoupled when cell number increased, indicating that a distant brain injury expands the SVZ by disrupting the balance between cell death and proliferation in this adult neurogenic zone. J. Comp. Neurol. 488:201–214, 2005.

Pulmonary toxicity of e-cigarettes

Electronic cigarettes (e-cigarettes or e-cigs) are designed to heat and aerosolize mixtures of vegetable glycerin, propylene glycol, nicotine, and flavoring additives, thus delivering nicotine by inhalation in the absence of combustion. These devices were originally developed to facilitate smoking cessation and have been available in the United States for over a decade. Since 2010, e-cig use has expanded rapidly, especially among adolescents, despite a paucity of short- and long-term safety data. Patterns of use have shifted to include never smokers and many dual users of e-cigs and combustible tobacco products. Over the last several years, research into the potential toxicities of e-cig aerosols has grown exponentially. In the interim, regulatory policymakers across the world have struggled with how to regulate an increasingly diverse array of suppliers and products, against a backdrop of strong advocacy from users, manufacturers, and tobacco control experts. Herein we provide an updated review of the pulmonary toxicity profile of these devices, summarizing evidence from cell culture, animal models, and human subjects. We highlight the major gaps in our current understanding, emphasize the challenges confronting the scientific and regulatory communities, and identify areas that require more research in this important and rapidly evolving field.

Design and implementation of the START (STem cells for ARDS Treatment) trial, a phase 1/2 trial of human mesenchymal stem/stromal cells for the treatment of moderate-severe acute respiratory distress syndrome

BackgroundDespite advances in supportive care, moderate-severe acute respiratory distress syndrome (ARDS) is associated with high mortality rates, and novel therapies to treat this condition are needed. Compelling pre-clinical data from mouse, rat, sheep and ex vivo perfused human lung models support the use of human mesenchymal stem (stromal) cells (MSCs) as a novel intravenous therapy for the early treatment of ARDS.MethodsThis article describes the study design and challenges encountered during the implementation and phase 1 component of the START (STem cells for ARDS Treatment) trial, a phase 1/2 trial of bone marrow-derived human MSCs for moderate-severe ARDS. A trial enrolling 69 subjects is planned (9 subjects in phase 1, 60 subjects in phase 2 treated with MSCs or placebo in a 2:1 ratio).ResultsThis report describes study design features that are unique to a phase 1 trial in critically ill subjects and the specific challenges of implementation of a cell-based therapy trial in the ICU.ConclusionsExperience gained during the design and implementation of the START study will be useful to investigators planning future phase 1 clinical trials based in the ICU, as well as trials of cell-based therapy for other acute illnesses.Trial registrationClinical Trials Registration: NCT01775774 and NCT02097641.

Mesenchymal stem cells and the stem cell niche: a new chapter

BONE MARROW-DERIVED mesenchymal stem/stromal cells (MSCs) are self-renewing multipotent cells with therapeutic effects in diverse models of tissue injury (27). In the rodent lung, MSCs reduce collagen deposition in the bleomycin model of pulmonary fibrosis (26) and reduce lung injury and improve survival following intrapulmonary delivery of endotoxin or Escherichia coli (10, 11) and following severe gram-negative peritonitis (18). In the hyperoxia model of bronchopulmonary dysplasia, exposure to high concentrations of oxygen during early postnatal life in rats and mice causes simplification of alveolar and lung capillary structure and reduced pulmonary capillary surface area, leading to pulmonary hypertension. Two groups reported simultaneously in 2009 that MSCs given by airway to rats (12) or by blood to mice (2) during prolonged hyperoxia in early postnatal life prevented arrested alveolar growth. However, engraftment of MSCs during hyperoxia and in other models has not accounted for the therapeutic effects, thus prompting a search for other mechanisms. MSCs are potent immunomodulators, suppressing several functions of lymphocytes, natural killer cells, and monocytes (1), and reduce inflammatory cell lung infiltrates and cytokines during sepsis and acute lung injury (11, 23, 25). In addition, MSCs have direct antibacterial effects (19), secrete epithelial growth factors (21), and can rescue epithelial cellular bioenergetics with mitochondrial transfer (14). MSCs and the Stem Cell Niche

Endogenous and Exogenous Cell-Based Pathways for Recovery from Acute Respiratory Distress Syndrome

Regenerative medicine has entered a rapid phase of discovery, and much has been learned in recent years about the lungs response to injury. This article first summarizes the cellular and molecular mechanisms that damage the alveolar-capillary barrier, producing acute respiratory distress syndrome (ARDS). The latest understanding of endogenous repair processes is discussed, highlighting the diversity of lung epithelial progenitor cell populations and their regulation in health and disease. Finally, the past, present, and future of exogenous cell-based therapies for ARDS is reviewed.