Reliability and clinical correlations of semi-quantitative lung ultrasound on BLUE points in COVID-19 mechanically ventilated patients: The 'BLUE-LUSS'-A feasibility clinical study.

INTRODUCTION: Bedside lung ultrasound has gained a key role in each segment of the treatment chain during the COVID-19 pandemic. During the diagnostic assessment of the critically ill patients in ICUs, it is highly important to maximize the amount and quality of gathered information while minimizing unnecessary interventions (e.g. moving/rotating the patient). Another major factor is to reduce the risk of infection and the workload of the staff. OBJECTIVES: To serve these significant issues we constructed a feasibility study, in which we used a single-operator technique without moving the patient, only assessing the easily achievable lung regions at conventional BLUE points. We hypothesized that calculating this 'BLUE lung ultrasound score' (BLUE-LUSS) is a reasonable clinical tool. Furthermore, we used both longitudinal and transverse scans to measure their reliability and assessed the interobserver variability as well. METHODS: University Intensive Care Unit based, single-center, prospective, observational study was performed on 24 consecutive SARS-CoV2 RT-PCR positive, mechanically ventilated critically ill patients. Altogether 400 loops were recorded, rated and assessed off-line by 4 independent intensive care specialists (each 7+ years of LUS experience). RESULTS: Intraclass correlation values indicated good reliability for transversal and longitudinal qLUSS scores, while we detected excellent interrater agreement of both cLUSS calculation methods. All of our LUS scores correlated inversely and significantly to the P/F values. Best correlation was achieved in the case of longitudinal qLUSS (r = -0.55, p = 0.0119). CONCLUSION: Summarized score of BLUE-LUSS can be an important, easy-to-perform adjunct tool for assessing and quantifying lung pathology in critically ill ventilated patients at bedside, especially for the P/F ratio. The best agreement for the P/F ratio can be achieved with the longitudinal scans. Regarding these findings, assessing BLUE-points can be extended with the BLUE-LUSS for daily routine using both transverse and longitudinal views.

Heterologous phosphorylation-induced formation of a stability lock permits regulation of inactive receptors by ß-arrestins.

ß-Arrestins are key regulators and signal transducers of G protein-coupled receptors (GPCRs). The interaction between receptors and ß-arrestins is generally believed to require both receptor activity and phosphorylation by GPCR kinases. In this study, we investigated whether ß-arrestins are able to bind second messenger kinase-phosphorylated, but inactive receptors as well. Because heterologous phosphorylation is a common phenomenon among GPCRs, this mode of ß-arrestin activation may represent a novel mechanism of signal transduction and receptor cross-talk. Here we demonstrate that activation of protein kinase C (PKC) by phorbol myristate acetate, Gq/11-coupled GPCR, or epidermal growth factor receptor stimulation promotes ß-arrestin2 recruitment to unliganded AT1 angiotensin receptor (AT1R). We found that this interaction depends on the stability lock, a structure responsible for the sustained binding between GPCRs and ß-arrestins, formed by phosphorylated serine-threonine clusters in the receptor's C terminus and two conserved phosphate-binding lysines in the ß-arrestin2 N-domain. Using improved FlAsH-based serine-threonine clusters ß-arrestin2 conformational biosensors, we also show that the stability lock not only stabilizes the receptor-ß-arrestin interaction, but also governs the structural rearrangements within ß-arrestins. Furthermore, we found that ß-arrestin2 binds to PKC-phosphorylated AT1R in a distinct active conformation, which triggers MAPK recruitment and receptor internalization. Our results provide new insights into the activation of ß-arrestins and reveal their novel role in receptor cross-talk.

Angiotensin type 1A receptor regulates ß-arrestin binding of the ß2-adrenergic receptor via heterodimerization.

Heterodimerization between angiotensin type 1A receptor (AT1R) and ß2-adrenergic receptor (ß2AR) has been shown to modulate G protein-mediated effects of these receptors. Activation of G protein-coupled receptors (GPCRs) leads to ß-arrestin binding, desensitization, internalization and G protein-independent signaling of GPCRs. Our aim was to study the effect of heterodimerization on ß-arrestin coupling. We found that ß-arrestin binding of ß2AR is affected by activation of AT1Rs. Costimulation with angiotensin II and isoproterenol markedly enhanced the interaction between ß2AR and ß-arrestins, by prolonging the lifespan of ß2AR-induced ß-arrestin2 clusters at the plasma membrane. While candesartan, a conventional AT1R antagonist, had no effect on the ß-arrestin2 binding to ß2AR, TRV120023, a ß-arrestin biased agonist, enhanced the interaction. These findings reveal a new crosstalk mechanism between AT1R and ß2AR, and suggest that enhanced ß-arrestin2 binding to ß2AR can contribute to the pharmacological effects of biased AT1R agonists.

Mutations in the 'DRY' motif of the CB1 cannabinoid receptor result in biased receptor variants.

The role of the highly conserved 'DRY' motif in the signaling of the CB1 cannabinoid receptor (CB1R) was investigated by inducing single-, double-, and triple-alanine mutations into this site of the receptor. We found that the CB1R-R3.50A mutant displays a partial decrease in its ability to activate heterotrimeric Go proteins (∼80% of WT CB1R (CB1R-WT)). Moreover, this mutant showed an enhanced basal ß-arrestin2 (ß-arr2) recruitment. More strikingly, the double-mutant CB1R-D3.49A/R3.50A was biased toward ß-arrs, as it gained a robustly increased ß-arr1 and ß-arr2 recruitment ability compared with the WT receptor, while its G-protein activation was decreased. In contrast, the double-mutant CB1R-R3.50A/Y3.51A proved to be G-protein-biased, as it was practically unable to recruit ß-arrs in response to agonist stimulus, while still activating G-proteins, although at a reduced level (∼70% of CB1R-WT). Agonist-induced ERK1/2 activation of the CB1R mutants showed a good correlation with their ß-arr recruitment ability but not with their G-protein activation or inhibition of cAMP accumulation. Our results suggest that G-protein activation and ß-arr binding of the CB1R are mediated by distinct receptor conformations, and the conserved 'DRY' motif plays different roles in the stabilization of these conformations, thus mediating both G-protein- and ß-arr-mediated functions of CB1R.

Differential ß-arrestin2 requirements for constitutive and agonist-induced internalization of the CB1 cannabinoid receptor.

CB1 cannabinoid receptor (CB1R) undergoes both constitutive and agonist-induced internalization, but the underlying mechanisms of these processes and the role of ß-arrestins in the regulation of CB1R function are not completely understood. In this study, we followed CB1R internalization using confocal microscopy and bioluminescence resonance energy transfer measurements in HeLa and Neuro-2a cells. We found that upon activation CB1R binds ß-arrestin2 (ß-arr2), but not ß-arrestin1. Furthermore, both the expression of dominant-negative ß-arr2 (ß-arr2-V54D) and siRNA-mediated knock-down of ß-arr2 impaired the agonist-induced internalization of CB1R. In contrast, neither ß-arr2-V54D nor ß-arr2-specific siRNA had a significant effect on the constitutive internalization of CB1R. However, both constitutive and agonist-induced internalization of CB1R were impaired by siRNA-mediated depletion of clathrin heavy chain. We conclude that although clathrin is required for both constitutive and agonist-stimulated internalization of CB1R, ß-arr2 binding is only required for agonist-induced internalization of the receptor suggesting that the molecular mechanisms underlying constitutive and agonist-induced internalization of CB1R are different.

Regulation of endocannabinoid release by G proteins: a paracrine mechanism of G protein-coupled receptor action.

In the past years, the relationship between the endocannabinoid system (ECS) and other hormonal and neuromodulatory systems has been intensively studied. G protein-coupled receptors (GPCRs) can stimulate endocannabinoid (eCB) production via activation of G(q/11) proteins and, in some cases, G(s) proteins. In this review, we summarize the pathways through which GPCR activation can trigger eCB release, as well as the best known examples of this process throughout the body tissues. Angiotensin II-induced activation of AT(1) receptors, similar to other G(q/11)-coupled receptors, can lead to the formation of 2-arachidonoylglycerol (2-AG), an important eCB. The importance of eCB formation in angiotensin II action is supported by the finding that the hypertensive effect of angiotensin II, injected directly into the hypothalamic paraventricular nucleus of anaesthetized rats, can be abolished by AM251, an inverse agonist of CB(1) cannabinoid receptors (CB(1)Rs). We conclude that activation of the ECS should be considered as a general consequence of the stimulation of G(q/11)-coupled receptors, and may mediate some of the physiological effects of GPCRs.

Paracrine transactivation of the CB1 cannabinoid receptor by AT1 angiotensin and other Gq/11 protein-coupled receptors.

Intracellular signaling systems of G protein-coupled receptors are well established, but their role in paracrine regulation of adjacent cells is generally considered as a tissue-specific mechanism. We have shown previously that AT(1) receptor (AT(1)R) stimulation leads to diacylglycerol lipase-mediated transactivation of co-expressed CB(1)Rs in Chinese hamster ovary cells. In the present study we detected a paracrine effect of the endocannabinoid release from Chinese hamster ovary, COS7, and HEK293 cells during the stimulation of AT(1) angiotensin receptors by determining CB(1) cannabinoid receptor activity with bioluminescence resonance energy transfer-based sensors of G protein activation expressed in separate cells. The angiotensin II-induced, paracrine activation of CB(1) receptors was visualized by detecting translocation of green fluorescent protein-tagged beta-arrestin2. Mass spectrometry analyses have demonstrated angiotensin II-induced stimulation of 2-arachidonoylglycerol production, whereas no increase of anandamide levels was observed. Stimulation of G(q/11)-coupled M(1), M(3), M(5) muscarinic, V(1) vasopressin, alpha(1a) adrenergic, B(2) bradykinin receptors, but not G(i/o)-coupled M(2) and M(4) muscarinic receptors, also led to paracrine transactivation of CB(1) receptors. These data suggest that, in addition to their retrograde neurotransmitter role, endocannabinoids have much broader paracrine mediator functions during activation of G(q/11)-coupled receptors.

The role of diacylglycerol lipase in constitutive and angiotensin AT1 receptor-stimulated cannabinoid CB1 receptor activity.

The cannabinoid CB1 receptor (CB1R) is a G protein-coupled receptor, which couples to the Gi/o family of heterotrimeric G proteins. The receptor displays both basal and agonist-induced signaling and internalization. Although basal activity of CB1Rs is attributed to constitutive (agonist-independent) receptor activity, studies in neurons suggested a role of postsynaptic endocannabinoid (eCB) release in the persistent activity of presynaptic CB1Rs. To elucidate the role of eCBs in basal CB1R activity, we have investigated the role of diacylglycerol lipase (DAGL) in this process in Chinese hamster ovary (CHO) cells, which are not targeted specifically with eCBs. Agonist-induced G protein activation was determined by detecting dissociation G protein subunits expressed in CHO cells with bioluminescence resonance energy transfer (BRET), after labeling the alpha and beta subunits with Renilla luciferase and enhanced yellow fluorescent protein (EYFP), respectively. Preincubation of the cells with tetrahydrolipstatin (THL), a known inhibitor of DAGLs, caused inhibition of the basal activity of CB1R. Moreover, preincubation of CHO and cultured hippocampal neurons with THL increased the number of CB1Rs on the cell membrane, which reflects its inhibitory action on CB1R internalization in non-simulated cells. In CHO cells co-expressing CB1R and angiotensin AT1 receptors, angiotensin II-induced Go protein activation that was blocked by both a CB1R antagonist and THL. These data indicate that cell-derived eCB mediators have a general role in the basal activity of CB1Rs in non-neural cells and neurons, and that this mechanism can be stimulated by AT1 receptor activation.