Chemoprophylaxis, diagnosis, treatments, and discharge management of COVID-19: An evidence-based clinical practice guideline (updated version).

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, coronavirus disease 2019 (COVID-19), affecting more than seventeen million people around the world. Diagnosis and treatment guidelines for clinicians caring for patients are needed. In the early stage, we have issued "A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version)"; now there are many direct evidences emerged and may change some of previous recommendations and it is ripe for develop an evidence-based guideline. We formed a working group of clinical experts and methodologists. The steering group members proposed 29 questions that are relevant to the management of COVID-19 covering the following areas: chemoprophylaxis, diagnosis, treatments, and discharge management. We searched the literature for direct evidence on the management of COVID-19, and assessed its certainty generated recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Recommendations were either strong or weak, or in the form of ungraded consensus-based statement. Finally, we issued 34 statements. Among them, 6 were strong recommendations for, 14 were weak recommendations for, 3 were weak recommendations against and 11 were ungraded consensus-based statement. They covered topics of chemoprophylaxis (including agents and Traditional Chinese Medicine (TCM) agents), diagnosis (including clinical manifestations, reverse transcription-polymerase chain reaction (RT-PCR), respiratory tract specimens, IgM and IgG antibody tests, chest computed tomography, chest x-ray, and CT features of asymptomatic infections), treatments (including lopinavir-ritonavir, umifenovir, favipiravir, interferon, remdesivir, combination of antiviral drugs, hydroxychloroquine/chloroquine, interleukin-6 inhibitors, interleukin-1 inhibitors, glucocorticoid, qingfei paidu decoction, lianhua qingwen granules/capsules, convalescent plasma, lung transplantation, invasive or noninvasive ventilation, and extracorporeal membrane oxygenation (ECMO)), and discharge management (including discharge criteria and management plan in patients whose RT-PCR retesting shows SARS-CoV-2 positive after discharge). We also created two figures of these recommendations for the implementation purpose. We hope these recommendations can help support healthcare workers caring for COVID-19 patients.

Exosomal miR-25-3p from mesenchymal stem cells alleviates myocardial infarction by targeting pro-apoptotic proteins and EZH2.

Mesenchymal stem cell (MSC) therapy is a promising approach against myocardial infarction (MI). Studies have demonstrated that MSCs can communicate with other cells by secreting exosomes. In the present study, we aimed to identify exosomal microRNAs that might contribute to MSC-mediated cardioprotective effects. Primary cardiomyocytes were deprived of oxygen and glucose to mimic MI in vitro. For the animal model of MI, the left anterior descending artery was ligated for 1 h, followed by reperfusion for 12 h. MSC-derived exosomes were used to treat primary cardiomyocytes or mice. Cardioprotection-related microRNAs were determined, followed by target gene identification and functional studies with quantitative PCR, western blotting, MTT assay, flow cytometry assay, chromatin immunoprecipitation and dual-luciferase assay. We found that MSC co-culture reduced OGD-induced cardiomyocyte apoptosis and inflammatory responses. Cardioprotection was also observed upon treatment with MSC-derived exosomes in vitro and in vivo. In line with this, exosome uptake led to a significant increase in miR-25-3p in cardiomyocytes. Depletion of miR-25-3p in MSCs abolished the protective effects of exosomes. Mechanistically, miR-25-3p directly targeted the pro-apoptotic genes FASL and PTEN and reduced their protein levels. Moreover, miR-25-3p decreased the levels of EZH2 and H3K27me3, leading to derepression of the cardioprotective gene eNOS as well as the anti-inflammatory gene SOCS3. Inhibition of EZH2 or overexpression of miR-25-3p in cardiomyocytes was sufficient to confer cardioprotective effects in vitro and in vivo. We concluded that exosomal miR-25-3p from MSCs alleviated MI by targeting pro-apoptotic proteins and EZH2.

A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version).

In December 2019, a new type viral pneumonia cases occurred in Wuhan, Hubei Province; and then named "2019 novel coronavirus (2019-nCoV)" by the World Health Organization (WHO) on 12 January 2020. For it is a never been experienced respiratory disease before and with infection ability widely and quickly, it attracted the world's attention but without treatment and control manual. For the request from frontline clinicians and public health professionals of 2019-nCoV infected pneumonia management, an evidence-based guideline urgently needs to be developed. Therefore, we drafted this guideline according to the rapid advice guidelines methodology and general rules of WHO guideline development; we also added the first-hand management data of Zhongnan Hospital of Wuhan University. This guideline includes the guideline methodology, epidemiological characteristics, disease screening and population prevention, diagnosis, treatment and control (including traditional Chinese Medicine), nosocomial infection prevention and control, and disease nursing of the 2019-nCoV. Moreover, we also provide a whole process of a successful treatment case of the severe 2019-nCoV infected pneumonia and experience and lessons of hospital rescue for 2019-nCoV infections. This rapid advice guideline is suitable for the first frontline doctors and nurses, managers of hospitals and healthcare sections, community residents, public health persons, relevant researchers, and all person who are interested in the 2019-nCoV.

Downregulation of exosome-encapsulated miR-548c-5p is associated with poor prognosis in colorectal cancer.

The role of circulating exosomal microRNAs (miRNAs) in colorectal cancer (CRC) has drawn more and more attention during the past few years. Previously, we have identified several specific miRNAs in serum exosomes as potential CRC biomarkers. However, little is known about the association between exosome-encapsulated miR-548c-5p and outcomes of patients with CRC. In the current study, the expression of serum exosomal miR-548c-5p was investigated by quantitative real-time polymerase chain reaction. Its correlation with CRC prognosis was estimated by Kaplan-Meier survival and log-rank tests. Cox regression analysis based on uni- and multivariate analyses was performed to estimate the relationship of exosome-encapsulated miR-548c-5p with the clinicopathological factors of patients with CRC. Reduced levels of serum exosomal miR-548c-5p were more significant in CRC patients with liver metastasis and at later TNM stage (III/IV tumor stages). Serum exosomal miR-548c-5p could inhibit the proliferation of CRC cells, while the precise molecular mechanisms warranted further elucidation. In addition, decreased levels of serum exosomal miR-548c-5p were independently associated with shorter overall survival in CRC adjusted by age, sex, tumor grade vascular infiltration, TNM stage (III/IV tumor stages) and metastasis (hazard ratio = 3.40, 95% confidence interval 1.02-11.27; P = 0.046). The downregulation of exosomal miR-548c-5p in serum predicts poor prognosis in patients with CRC. Exosomal miR-548c-5p may be a critical biomarker for CRC diagnosis and prognosis.

Incomplete intestinal obstruction as the possible main complaint in Behcet's disease after surgery for recurrent abdominal aortic pseudoaneurysms: a case report and literature review.

BACKGROUND: Behcet's disease (BD) is a systemic vasculitis characterized by oral and genital aphthosis, and ocular and skin lesions. The disease is involved in vascular, gastrointestinal, and central nervous systems. Vasculitis may exacerbate fatal problems, such as anastomotic pseudoaneurysms. If the mesenteric vessels are involved, severe abdominal symptoms such as intestinal obstruction may occur. CASE PRESENTATION: This case report describes a young female patient who suffered from BD with recurrent abdominal aortic pseudoaneurysms, as well as deep venous thrombosis and subsequent complications of incomplete intestinal obstruction. This patient first underwent stent grafting, which was followed by rupture of two newly formed anastomotic pseudoaneurysms within six months. Emergency open surgical repair (OSR) was then performed on the ruptured pseudoaneurysms. Thrombosis and incomplete ileus occurred five months after surgery. This case was unique due to the presence of incomplete intestinal obstruction being the possible main complaint for a patient with Behcet's disease, and it is the first ever case to be reported. CONCLUSION: Intestinal obstruction may present as the possible main complaint in BD. Careful and attentive strategy should be carried out to prevent fatal outcomes.

Cross-species validation of cell cycle arrest markers for acute kidney injury in the rat during sepsis.

BACKGROUND: The recent discovery of cell cycle arrest biomarkers, tissue inhibitor of metalloproteinases (TIMP)-2 and insulin-like growth factor binding protein 7 (IGFBP7), has led to a newly available clinical test for acute kidney injury. The performance of these markers in preclinical studies has not been established. Therefore, we sought to evaluate the performance of TIMP-2 and IGFBP7 in rats undergoing cecal ligation and puncture. METHODS: In this secondary analysis, we analyzed banked urine samples from 60 Sprague-Dawley rats undergoing cecal ligation and puncture (CLP). Samples were obtained from baseline, 18 h after CLP, at the end of fluid resuscitation (22 h after CLP), and again 24 h later. We measured TIMP-2 and IGFBP7 and compared the results to acute kidney injury by RIFLE criteria for creatinine using area under the receiver operating characteristic curve (AUC). The primary endpoint was moderate-to-severe acute kidney injury (AKI) (I or F criteria), and the primary time point was immediately after fluid resuscitation. Secondary outcomes included mortality and comparisons with other biomarkers: cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) in both urine and plasma. RESULTS: After fluid resuscitation, urine [TIMP-2] and [IGFBP7] were significantly higher in animals developing moderate-to-severe AKI (p = 0.002 and p = 0.01). AUC of [TIMP-2]·[IGFBP7] for AKI was 0.89 (95 % CI 0.80-0.98). By contrast, the next best AUC was seen with plasma cystatin C (0.78; 95 % CI 0.65-0.90). [TIMP-2]·[IGFBP7] also predicted mortality (AUC 0.69; 95 % CI 0.53-0.85). CONCLUSIONS: In this experimental model of sepsis in the rat, cell cycle arrest biomarkers TIMP-2 and IGFBP7 are valid predictors of acute kidney injury.

Honokiol induces cell cycle arrest and apoptosis in human gastric carcinoma MGC-803 cell line.

OBJECTIVE: Gastric carcinoma is a malignant tumor that responds poorly to both chemotherapy and radiation therapy. In our study, we investigated the anti-cancer effect of honokiol, an active component isolated and purified from the Magnolia officinalis, in human gastric carcinoma MGC-803 cell line. METHODS: The cell viability was detected by the CCK8 assay. The cell apoptosis and cell cycle arrest were assessed by flow cytometer. The protein expression of cell cycle regulators and tumor suppressors were analyzed by western blotting. RESULTS: Treatment of human gastric carcinoma cells with honokiol induced cell death in a dose-and time-dependent manner by using CCK8 assay. Consistent with the CCK8 assay, the flow cytometry results showed that the proportion of apoptosis cells had gained when the cells were exposed to honokiol. Moreover, Cyclin B1, CDC2 and cdc25C were downregulated, and the expression of p-CDC2 and p-cdc25c was significantly upregulated upon honokiol treatment. P53 and p21 were significantly upregulated by honokiol treatment. Treatment of MGC-803 cells with honokiol significantly increased the pro-apoptotic Bax level and decreased the anti-apoptotic Bcl-2 level. CONCLUSIONS: These results confirmed that honokiol could induce apoptosis and cell cycle arrest, the underlying molecular mechanisms, at least partially, through activation p53 signaling and downregulation CDC2/cdc25C expression.

Effects of fluid resuscitation with 0.9% saline versus a balanced electrolyte solution on acute kidney injury in a rat model of sepsis*.

OBJECTIVE: To compare the acute effects of 0.9% saline versus a balanced electrolyte solution on acute kidney injury in a rat model of sepsis. DESIGN: Controlled laboratory experiment. SETTING: University laboratory. SUBJECTS: Sixty adult, male Sprague-Dawley rats. INTERVENTIONS: We induced sepsis by cecal ligation and puncture and randomized animals to receive fluid resuscitation with either 0.9% saline or Plasma-Lyte solution for 4 hours after 18 hours of cecal ligation and puncture (10 mL/kg in the first hour and 5 mL/kg in the next 3 hr). Blood and urine specimens were obtained from baseline, 18 hours after cecal ligation and puncture, immediately after 4 hours fluid resuscitation, and 24 hours later. We measured blood gas, plasma electrolytes, creatinine, interleukin-6, cystatin C, and neutrophil gelatinase-associated lipocalin concentrations. We also analyzed urine for cystatin C and neutrophil gelatinase-associated lipocalin. We used Risk, Injury, Failure, Loss and End-stage criteria for creatinine to assess severity of acute kidney injury. We observed all animals for survival up to 1 day after resuscitation. Surviving animals were killed for kidney histology. Finally, we carried out an identical study in 12 healthy animals. MEASUREMENTS AND MAIN RESULTS: Compared with Plasma-Lyte, 0.9% saline resuscitation resulted in significantly greater blood chloride concentrations (p < 0.05) and significantly decreased pH and base excess. Acute kidney injury severity measured by RIFLE criteria was increased with 0.9% saline compared with Plasma-Lyte resuscitation (p < 0.05), and these results were consistent with kidney histology and biomarkers of acute kidney injury. Twenty-four-hour survival favored Plasma-Lyte resuscitation (76.6% vs 53.3%; p = 0.03). Finally, in healthy animals, we found no differences between fluids and no evidence of acute kidney injury. CONCLUSION: Volume resuscitation with Plasma-Lyte resulted in less acidosis and less kidney injury and improved short-term survival when compared with 0.9% saline in this experimental animal model of sepsis.

Development of venovenous extracorporeal blood purification circuits in rodents for sepsis.

BACKGROUND: Unlike pharmacologic interventions in sepsis, extracorporeal blood purification, which is widely used in septic patients, is not typically studied in experimental rodents. Most of the previous studies have performed extracorporeal blood purification in larger animals and typically use arteriovenous (AV) vascular access. We developed a venovenous (VV) purification model in the rat as an adjunct for the treatment of sepsis. METHODS: Using adult male Sprague-Dawley rats, we cannulated the femoral artery or vein and the jugular vein with P50 tubing and created an AV or VV circuit. Blood flow was maintained by arterial pressure in the AV circuit, whereas in the VV circuit the blood flow was regulated using a rotary pump. The safety of this circuit was evaluated using the changes of blood interleukin 6, rectal temperature, and 7-d survival with sham extracorporeal circulation (circuit connection without treatment) compared with the control (without circuit). The main side complications of this VV circuit were compared with those of the AV circuit. RESULTS: The differences in interleukin 6, body temperature, and cumulative survival were not statistically significant after extracorporeal circulation. The main complications of extracorporeal circulation occurred less often with VV compared with AV therapy: massive bleeding (2.5% versus 15%, P = 0.04); clot formation (2.5% versus 15%, P = 0.04). This VV circuit has been successfully used in different septic rodent models with different techniques (hemoadsorption and hemofiltration). CONCLUSIONS: VV blood purification in a rodent model appears to be effective and is safer than AV circuit.

The anti-oxidant effects are not the main mechanism for glutamine's protective effects on acute kidney injury in mice.

Acute kidney injury (AKI) is a common problem characterized by an inflammatory response in the kidney and oxidative stress. However, there are no interventions to prevent AKI. Glutamine is an important precursor of glutathione and has also been shown to induce heat shock proteins (HSP). Thus, glutamine may affect both oxidative stress and inflammation. This study was to explore the effects of glutamine pretreatment on nephrotoxic AKI and to investigate the underlying mechanisms. First, the effects of alternate doses of glutamine were compared in CD-1 mice with AKI induced with folic acid intra-peritoneal injection. Then the effects of glutamine quercetin (an HSP inhibitor), and quercetin+glutamine, were compared in the same AKI model. AKI were assessed with plasma creatinine, urine neutrophil gelatinase-associated lipocalin, and renal histology. Inflammatory response was monitored with renal tumor necrosis factor (TNF-α), chemkines (CXCL1 and CCL2) contents, and neutrophil infiltration. Oxidative injury was detected with reduced glutathione, malondialdehyde, and protein thiol. Glutamine provided dose-dependent renal protection. Pretreatment with quercetin, which was showed to inhibit HSP-70 expression, abolished glutamine's renal-protective effects. Quercetin also abrogated glutamine's beneficial effects on renal TNF-α, chemokines, and neutrophil infiltration. However, quercetin did not affect glutamine's anti-oxidative effects. These results suggest that glutamine's renal-protective effects are mainly related to its activation of HSP-70, which mitigates inflammatory response, renal neutrophil infiltration and subsequent AKI. Regulating neutrophil infiltration might be a potential therapeutic target for AKI.

Acute removal of common sepsis mediators does not explain the effects of extracorporeal blood purification in experimental sepsis.

The effect of extracorporeal blood purification on clinical outcomes in sepsis is assumed to be related to modulation of plasma cytokine concentrations. To test this hypothesis directly, we treated rats that had a cecal ligation followed by puncture (a standard model of sepsis) with a modest dose of extracorporeal blood purification that did not result in acute changes in a panel of common cytokines associated with inflammation (TNF-α, IL-1ß, IL-6, and IL-10). Pre- and immediate post-treatment levels of these cytokines were unchanged compared to the sham therapy of extracorporeal circulation without blood purifying sorbent. The overall survival to 7 days, however, was significantly better in animals that received extracorporeal blood purification compared to those with a sham procedure. This panel of common plasma cytokines along with alanine aminotransferase and creatinine was significantly lower 72 h following extracorporeal blood purification compared to sham-treated rats. Thus, the effects of this procedure on organ function and survival do not appear to be due solely to immediate changes in the usual measured circulating cytokines. These results may have important implications for the design and conduct of future trials in sepsis including defining alternative targets for extracorporeal blood purification and other therapies.

N-acetylcysteine is effective for prevention but not for treatment of folic acid-induced acute kidney injury in mice.

OBJECTIVES: There is controversy regarding the benefits of N-acetylcysteine in acute kidney injury. This study was to compare three commonly used regimens and explore which regimen is best for the protection of acute kidney injury. DESIGN: Prospective experimental study. SETTING: University research laboratory. INTERVENTIONS: Acute kidney injury was induced with folic acid intraperitoneal injection in mice. Mice in pretreatment were treated with a subcutaneous injection of N-acetylcysteine before the folic acid injection. Mice in posttreatment were treated with N-acetylcysteine after folic acid. Mice in pre- + posttreatment were treated with N-acetylcysteine before folic acid and after folic acid. Placebo mice received vehicle only using the pre- + posttreatment protocol. Fourteen healthy animals were given N-acetylcysteine to evaluate for toxicity and the other 24 mice subjected to folic acid were killed for kidney histology and analysis for oxidative injury. The same studies were also carried out in milder acute kidney injury (lower folic acid) model. MEASUREMENTS AND MAIN RESULTS: Plasma concentrations of creatinine, cystatin C, and reduced glutathione were measured. Survival time was assessed up to 7 days. The survival rates in N-acetylcysteine pretreatment mice were significantly better (73.33% vs. 46.67%, p < .04) and acute kidney injury was significantly less compared with placebo. However, mice with posttreatment exhibited significantly worse survival and more severe acute kidney injury. Histologic findings were consistent with functional parameters. Glutathione levels decreased less in N-acetylcysteine pretreatment but also increased beginning on day 2 compared with placebo (11.5 vs. 8.1 µg/mL, p < .05). Glutathione levels did not increase in N-acetylcysteine posttreatment. However, three different N-acetylcysteine interventions neither significantly improved nor worsened renal function in the milder acute kidney injury model. CONCLUSION: N-acetylcysteine pretreatment was effective in reducing the incidence and severity of acute kidney injury as well as in increasing survival. However, N-acetylcysteine posttreatment worsened folic acid toxicity. Only pretreatment was effective in increasing glutathione. These data may help explain the variation from clinical studies of N-acetylcysteine use.

Effects of hemoadsorption on cytokine removal and short-term survival in septic rats.

OBJECTIVE: A broad-spectrum immune-regulating therapy could be beneficial in the treatment of sepsis. Our previous studies have shown that a hemoadsorption device (CytoSorb) removes both pro- and anti-inflammatory cytokines and improves survival in experimental endotoxemia. We sought to determine whether hemoadsorption can also be effective in the treatment of sepsis. DESIGN: Randomized controlled laboratory experiment. SETTING: University laboratory. INTERVENTIONS: Rats were subjected to cecal ligation and puncture (CLP) and 20 hrs later were randomized to receive either hemoadsorption or sham treatment using an arterial-venous circuit. Hemoadsorption was accomplished using a cartridge containing Cytosorb beads. Blood was drawn for cytokine measurements and mean arterial pressure (MAP) was continuously monitored. Cytokines were measured via multiplex bead immunoassays. Survival time was observed for 9 hours after the intervention and assessed by Kaplan-Meier statistics. The overall survival in each group was compared using Fisher's exact test. Finally, we used a Cox proportional-hazards model to examine the effects of cytokine removal on survival time. MEASUREMENTS AND MAIN RESULTS: Baseline plasma cytokine concentrations and MAP were similar between hemoadsorption and sham-treated groups. However, the concentrations of tumor necrosis factor, interleukin (IL)-1beta, IL-6, and IL-10 were significantly lower after hemoadsorption compared to the sham group. Six hours after treatment ended, IL-6 and IL-10 concentrations were still lower in hemoadsorption group. MAP was significantly better in hemoadsorption compared to sham-treated animals (p < .05). Finally, mean survival time was significantly longer (720 vs. 381 min, p < .05, Mann-Whitney test), and overall survival was significantly better (11/17 vs. 2/16, p < .01) with hemoadsorption compared to sham. Combined reduction in both IL-6 and IL-10 was associated with a significantly decreased risk of death (hazard ratio, .11, p = .005). CONCLUSION: Hemoadsorption reduced circulating cytokines, improved MAP, and resulted in better short-term survival in CLP-induced septic rats.

Glutamine-mediated attenuation of cellular metabolic dysfunction and cell death after injury is dependent on heat shock factor-1 expression.

BACKGROUND: Cellular metabolic dysfunction is associated with occurrence of multiple-organ failure after critical illness. Glutamine (GLN) attenuates cellular metabolic dysfunction in critical illness models. The mechanism of this protection is unclear. We previously demonstrated that GLN's benefit in critical illness might be due to enhanced heat shock protein (HSP) expression. We hypothesize that GLN's attenuation of cellular metabolic dysfunction is dependent on presence of heat shock factor-1 (HSF-1). METHODS: HSF-1 wild-type and knockout mouse embryonic fibroblasts (HSF-1+/+ and HSF-1-/-) were used in all experiments. Cells were not treated, or were treated with 8 mmol/L GLN and immediately exposed to heat stress injury (45 degrees C for 45 minutes). Cells were harvested for metabolic analysis by nuclear magnetic resonance (NMR) at 24 hours postinjury. Cell survival was assessed using the MTS assay. RESULTS: GLN treatment in HSF-1+/+ cells led to significant attenuation of decreases in adenosine triphosphate (ATP)/adenosine diphosphate (ADP) ratio, phosphomonoester/phosphodiester (PME/PDE) ratio, and cell survival observed in non-GLN-treated HSF-1+/+ cells. In HSF-1-/- cells, the beneficial effect of GLN on preservation of ATP/ADP ratio, PME/PDE proliferation, and cell survival was lost. GLN-treated HSF-1-/- cells had a significant increase in extracellular lactate concentrations vs GLN-treated HSF+/+ cells. CONCLUSIONS: GLN treatment attenuated cellular metabolic dysfunction and improved cell membrane recovery only in HSF-1+/+ cells. Cellular injury, as measured by lactate release and cell survival assay, was improved by GLN treatment in HSF-1+/+ cells alone. Thus, GLN's beneficial effect on cellular metabolic dysfunction and cell survival appears to be dependent on HSF-1 expression.

Glutamine attenuation of cell death and inducible nitric oxide synthase expression following inflammatory cytokine-induced injury is dependent on heat shock factor-1 expression.

BACKGROUND: Glutamine (GLN) has been shown to improve outcome after experimental and clinical models of critical illness. Enhanced expression of heat shock protein (HSP) has been hypothesized to be responsible for this protection. The heat shock response has been shown to inhibit inducible nitric oxide synthase (iNOS) gene expression and nitric oxide (NO) production. This study tested the hypothesis that GLN-mediated activation of the HSP pathway is responsible for improved survival and attenuation of iNOS expression after an inflammatory cytokine-induced injury. METHODS: Heat shock factor-1 (HSF-1) wild-type and knockout mouse embryonic fibroblasts (HSF-1+/+ and HSF-1-/-) were used in all experiments. Cells were treated with 0 mmol/L or 8 mmol/L GLN and cytomix (tumor necrosis factor-alpha, lipopolysaccharide, and interferon-gamma) in a concurrent treatment model once they had reached confluence. Cell viability was assayed with MTS/PMS mixture. Apoptosis and necrosis were assayed via immunohistochemistry. iNOS and HSP-70 expression were detected via Western blotting. NO production was measured using the Griess reagent. RESULTS: GLN treatment significantly attenuated inflammatory cytokine-induced cell death and apoptosis in HSF-1+/+ cells vs 0 mmol/L GLN treatment; however, GLN's cellular protection was lost in HSF-1-/- cells. GLN supplementation attenuated cytomix-induced iNOS expression and NO production only in HSF-1+/+ cells. Further, GLN induced HSP-70 expression only in HSF-1+/+ cells. CONCLUSIONS: This is the first demonstration that GLN-mediated cellular protection after inflammatory cytokine injury is due to HSF-1 expression and cellular capacity to activate an HSP response.