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The Journal of Immunology, 1998, 161: 957-962.
Copyright © 1998 by The American Association of Immunologists

The IL-1ß-Converting Enzyme (Caspase-1) Inhibits Apoptosis of Inflammatory Neutrophils Through Activation of IL-1ß1

R. William, G. Watson, Ori D. Rotstein, Jean Parodo, Richard Bitar and John C. Marshall2

Department of Surgery, Toronto Hospital, and University of Toronto, Toronto, Ontario, Canada


    Abstract
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
IL-1ß-converting enzyme (ICE), also known as caspase-1, subserves two dichotomous biologic roles. It processes newly synthesized pro-IL-1ß to yield the active cytokine and, as the human homologue of the Caenorhabditis elegans gene product, ced-3, it also induces cellular apoptosis through the cleavage of key intracellular structural and regulatory proteins and through the catalytic activation of other caspase family members. We show here that two different proinflammatory stimuli, LPS and granulocyte-macrophage-CSF, up-regulate the expression of both ICE and IL-1ß in human polymorphonuclear neutrophils, and that the ICE-dependent cleavage of pro-IL-1ß results in delayed expression of the constitutive cell death program. The apoptotic delay can be blocked by inhibiting tyrosine kinases or NF-{kappa}B activation and by inhibiting protein synthesis. Since an antisense oligonucleotide for IL-1ß, a blocking Ab to IL-1ß, and preincubation with the IL-1R antagonist all prevent the delay in apoptosis, we conclude that IL-1ß acts in an autocrine manner to inhibit granulocyte programmed cell death. We conclude that caspase-1 (ICE) subserves both pro- and antiapoptotic roles; the latter role is evident during inflammation as an inhibition of spontaneous neutrophil apoptosis through the processing of IL-1ß. The ICE-dependent activation of IL-1ß may represent a common autocrine pathway for the divergent stimuli that inhibit the constitutive expression of neutrophil programmed cell death during inflammation.


    Introduction
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Programmed cell death (apoptosis) is effected through the activation of a cascade of intracellular proteases, collectively known as caspases (1, 2). The IL-1ß-converting enzyme (ICE),3 alternatively known as caspase-1, was the first such protein identified on the basis of its sequence homology to the proapoptotic Caenorhabditis elegans gene product, ced-3 (3). At least 10 members of the caspase family have been identified to date (2). Each is capable not only of degrading key cytostructural and reparative proteins but also of activating other caspase family members by cleaving the pro forms of the enzymes at aspartic acid residues.

Caspase-1, however, also processes pro-IL-1ß to yield active IL-1ß (4), a cytokine which plays a pivotal role in inflammatory cell activation (5) and is known to inhibit the expression of apoptosis (6). Thus, ICE may have divergent effects on cell survival, depending upon which of its substrates is preferentially processed.

Apoptosis in the mature polymorphonuclear neutrophil is a constitutive process that results in a rapid turnover of the circulating neutrophil population with a t1/2 of 5 to 6 h in vivo (7) and 24 to 36 h in vitro (7, 8). However, the expression of neutrophil apoptosis can be regulated by inflammatory mediators. It can be accelerated by IL-6 (9), TNF (10), IL-10 (11), and by the ingestion of Escherichia coli (8). Conversely, it is inhibited by such bacterial products as LPS and FMLP (7), by proinflammatory cytokines such as granulocyte-macrophage (GM)-CSF, granulocyte CSF (12), and IL-1ß (13), and by the engagement of cell surface ß2 integrins (14). Some stimuli, in particular TNF and IL-6, have been variously reported to accelerate or delay apoptosis, depending upon the experimental circumstances and the cells studied. The mechanism through which these divergent inflammatory mediators delay neutrophil apoptosis is unknown. The Bcl-2 family of antiapoptotic proteins is not expressed in quiescent mature neutrophils (15) nor is it expressed in cells in which apoptosis has been inhibited by LPS or GM-CSF (16). However both LPS and GM-CSF are known to induce the neutrophil synthesis of IL-1ß, which itself decreases spontaneous neutrophil apoptosis (17).

Therefore, we evaluated the expression and activities of IL-1ß and caspase-1 in neutrophils that had been activated by a bacterial product, LPS, and a host-derived cytokine, GM-CSF, both of which are known inhibitors of neutrophil apoptosis. Here, we show that these two activational stimuli up-regulate the expression of both caspase-1 and its substrate, pro-IL-1ß, and also that newly synthesized IL-1ß inhibits the expression of the constitutive neutrophil cell death program. These results demonstrate that the prototypical proapoptotic enzyme, caspase-1, can inhibit the expression of neutrophil apoptosis. In addition, they establish a role for neutrophil IL-1ß as an autocrine regulator of cell survival during acute inflammation.


    Materials and Methods
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Reagents

DMEM, penicillin/streptomycin solution, L-glutamine, PBS, and FCS were purchased from Life Technologies (Burlington, Ontario, Canada). YVAD-CMK, an irreversible inhibitor of caspase-1, was purchased from Calbiochem (San Diego, CA). Dihydrorhodamine 123 was purchased from Molecular Probes (Eugene, OR). All other chemicals were supplied by Sigma (St. Louis, MO) unless otherwise stated. A phosphorothioate-modified antisense oligonucleotide to IL-1ß was purchased from Life Technologies. rIL-1R antagonist (rIL-1RA) was a gift of Amgen (Boulder, CO).

Antibodies

Polyclonal antiphosphotyrosine Ab and horseradish peroxidase-conjugated anti-rabbit Ig were purchased from Serotec (Hornby, Ontario, Canada). A blocking mAb to IL-1ß was supplied by Genzyme (Cambridge, MA).

Probes

cDNA for human caspase-1 was kindly donated by Immunex (Seattle, WA). IL-1ß cDNA was supplied by the American Type Culture Collection (Manassas, VA).

Neutrophil isolation

Neutrophils were isolated from healthy volunteers by dextran sedimentation and centrifugation through a discontinuous Ficoll gradient (8). Isolated neutrophils were resuspended in polypropylene tubes at a concentration of 1 x 106 cells/ml in DMEM supplemented with 10% FCS, 1% glutamine, and 1% penicillin/streptomycin solution. Neutrophil purity as assessed by size and granularity on flow cytometry was consistently >95%.

Quantification of apoptosis

Neutrophil apoptosis was quantified by flow cytometry as the percent of cells with hypodiploid DNA (18). Cells were centrifuged at 200 x g for 10 min, gently resuspended in 500 µl of hypotonic fluorochrome solution (50 µg/ml propidium iodide, 3.4 mM sodium citrate, 1 mM Tris, 0.1 mM EDTA, and 0.1% Triton X-100), and stored in the dark at 4°C for 3 to 4 h before analysis using a Coulter Epics XL-MCL cytofluorometer (Hialeah, FL). A minimum of 5000 events were collected and analyzed. Apoptotic nuclei were distinguished from normal neutrophil nuclei by their hypodiploid DNA; neutrophil debris was excluded from analysis by raising the forward threshold. Apoptosis was assessed at 24 h after experimental manipulations unless otherwise stated.

Electrophoretic mobility shift assay

Nuclear extracts were prepared from 20 x 106 isolated neutrophils (19). A total of 5 µg of protein from the extracts was preincubated with the nonspecific DNA competitor poly(dI-dC) (5 mg) for 10 min at room temperature. A [32P]-radiolabeled probe that contained two NF-{kappa}B sites and was derived from the HIV-1 enhancer was added for an additional 20 min at room temperature. DNA/protein complexes were resolved on a 5% nondenaturing polyacrylamide (60:1 cross-link)/Tris glycine gel, and autoradiographs were prepared by exposure at -70°C using Kodak X-OMAT film. To demonstrate the specificity of the protein/DNA complex, either a 125 M excess of the unlabeled probe or a mutated HIV enhancer probe was added to the nuclear extract before the addition of the radiolabeled probe (19). The sequence of the plus strand of the oligonucleotide used was as follows: HIV-1 enhancer 5'-AGG GAC TTT CCG CTG GGA CTT TCC-3'.

Inhibition of IL-1ß translation using an antisense oligodeoxynucleotide

Neutrophils (1 x 105) were preincubated with 5 µM of a phosphorothioate-modified (20) oligodeoxynucleotide antisense probe to IL-1ß mRNA (5'-CTC AGG TAC TTC TGC CAT-3'), which was complementary to six bases starting at the translation initiation codon, ATC (21), or were preincubated with a sense probe as a control for 6 h; the neutrophils were then incubated with LPS (1 µg/ml) or GM-CSF (100 U/ml).

Northern blot analysis

Total RNA was extracted using the guanidinium-isothiocyanate method. Briefly, 50 x 106 neutrophils were lysed in a 4 M guanidinium-isothiocyanate solution containing 25 mM sodium citrate, 0.5% sarcosyl, and 100 mM ß-mercaptoethanol. RNA was denatured, electrophoresed through a 1.3% formaldehyde-agarose gel, and transferred to nylon membrane. Hybridization was performed at 42°C for 18 h with an [{alpha}-32P]dCTP-labeled, random-primed cDNA probe for either human ICE or IL-1ß cDNA. Membranes were stripped and hybridized to an 18S ribosomal subunit cDNA probe to correct for variability in gel loading. mRNA expression was quantified using a PhosphorImager with accompanying ImageQuant software (Molecular Dynamics, Sunnyvale, CA).

IL-1ß ELISA

Supernatants were collected at the times indicated and stored at -80°C. Concentrations of mature IL-1ß in the medium were measured by ELISA using a commercially available assay (Genzyme).

Assay of caspase-1 activity

Cell lysates were prepared from the membrane fraction of 20 x 106 neutrophils following experimental manipulation. Aliquots of the lysates (10 µl) were diluted in assay buffer (100 mM HEPES (pH 7.5), 10% sucrose, and 0.1% 3-([3-cholamidopropyl]dimethylammonio)-1-propanesulfonate) containing 20 µM Ac-Tyr-Val-Ala-Asp-7-amino-4-methylcoumarin (Calbiochem, Hornby, Ontario, Canada) and then incubated for 45 min at room temperature. The release of 7-amino-4-methylcoumarin was detected by continuous measurement using a Perkin-Elmer LS50 luminescence spectrometer (London, England) with an excitation of 380 nm and an emission slit at 460 nm. Specific ICE (caspase-1) activity is measured as pmol/s per milligram of protein.

Statistical analysis

Individual experiments were repeated a minimum of four times; results are expressed as the mean ± SD. Analysis was performed using the Student t test or ANOVA with Scheffe’s correction. The {alpha} level for statistical significance was set at p < 0.05.


    Results
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Inhibition of polymorphonuclear neutrophil apoptosis by LPS or GM-CSF is dependent upon cellular activation and protein synthesis

Preincubating resting neutrophils with either LPS or GM-CSF resulted in a significant inhibition of the constitutively expressed cell death program. The antiapoptotic effects of both could be blocked either by tyrosine kinase inhibition with herbimycin A or by the inhibition of NF-{kappa}B activation with pyrrolidine dithiocarbamate (PDTC) (Fig. 1GoA). Inhibiting protein synthesis with cycloheximide (CHX) blocked the apoptotic delay resulting from exposure to LPS or GM-CSF (Fig. 1GoA). Both herbimycin and PDTC inhibited NF-{kappa}B activation in response to LPS (Fig. 1GoB), suggesting that tyrosine phosphorylation is an upstream event to NF-{kappa}B activation in the cascade which leads to the inhibition of the LPS-induced apoptotic delay. CHX itself had no effect on NF-{kappa}B activation (Fig. 1GoC). Similar results were obtained for GM-CSF (data not shown). Taken together, these results suggested that delayed apoptosis in LPS- or GM-CSF-treated neutrophils was mediated by an inducible protein or proteins whose expression was signaled through a tyrosine kinase-dependent pathway and was dependent on activation of the transcription factor, NF-{kappa}B.



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FIGURE 1. Inhibition of constitutive neutrophil apoptosis by LPS or GM-CSF. A, Preincubating neutrophils (1 x 106/ml) from healthy volunteers for 2 h with an inhibitor of tyrosine kinases (herbimycin A (1 µg/ml)), an inhibitor NF-{kappa}B activation (PDTC (100 nM)), or an inhibitor of protein synthesis (CHX (2 µg/ml) for 1 h), blocked the inhibition of apoptosis resulting from stimulation with either LPS (1 µg/ml) or GM-CSF (8 ng/ml = 100 U/ml). Rates of apoptosis were assessed at 24 h. *p < 0.05 vs control; {ddagger}p < 0.05 vs LPS. B, The electrophoretic mobility shift assay showed both an activation of NF-{kappa}B by LPS and its inhibition by herbimycin and PDTC but not by CHX (C). Comp indicates the competitive inhibition of binding by the unlabeled probe; Mut indicates the addition of mutated probe as described in Materials and Methods. Blots represent one of four experiments.

 
LPS and GM-CSF up-regulate the expression of pro-IL-1ß

Neutrophils exposed to either LPS or GM-CSF released IL-1ß into the culture medium, an effect that could be inhibited by herbimycin A, PDTC, and CHX (Fig. 2Go). IL-1ß is synthesized and released as a 31-kDa precursor that is activated through cleavage at an aspartic acid residue by ICE (13). Exposing resting neutrophils to LPS (Fig. 3GoA) or GM-CSF (Fig. 3GoB) induced significant increases in the expression of mRNA for pro-IL-1ß, an effect that could be reduced by tyrosine kinase inhibition with herbimycin and by the inhibition of NF-{kappa}B activation with PDTC (Fig. 3GoA).



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FIGURE 2. Release of mature IL-1ß by LPS-stimulated neutrophils. Herbimycin A (1 µg/ml), PDTC (100 nM), and CHX (2 µg/ml) prevented the LPS- or GM-CSF-induced increase in IL-1ß release following 4 h of incubation with LPS or GM-CSF. *p < 0.05 vs resting cells; {ddagger}p < 0.05 vs LPS and GM-CSF-stimulated release (NS vs resting controls).

 


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FIGURE 3. Up-regulation of message for ICE (caspase-1) and pro-IL-1ß. mRNA was isolated from neutrophils stimulated with either LPS (A) or GM-CSF (B). Membranes were probed with ICE and IL-1ß probes and also with 18S to confirm equal loading. Each blot represents one of four experiments. C, ICE activity in cell lysates was increased by both LPS and GM-CSF.

 
ICE message is up-regulated by LPS and GM-CSF

ICE message was expressed at low levels in resting neutrophils, despite the fact that ~35% of these cells showed flow cytometric evidence of apoptosis after 18 h in culture (Fig. 1GoA). Both LPS (Fig. 3GoA) and GM-CSF (Fig. 3GoB) up-regulated message for ICE, although the functional consequence was the inhibition of spontaneous neutrophil apoptosis (Fig. 1GoA). The increased expression of ICE mRNA was associated with an increase in specific ICE activity (Fig. 3GoC) but was not associated with an increase in caspase 3 (CPP32) proteolytic activity (data not shown).

Increased ICE-dependent IL-1ß processing prevents the activation-induced apoptotic delay

Inhibiting ICE activity with the irreversible tetrapeptide inhibitor YVAD-CMK, largely prevented the LPS- or GM-CSF-induced release of IL-1ß (Fig. 4GoA) and blocked the corresponding apoptotic delay (Fig. 4GoB). Three separate strategies were used to confirm the necessary role of newly processed IL-1ß in the observed apoptotic delay. Preincubating neutrophils with a phosphorothioate-modified antisense oligodeoxynucleotide to IL-1ß mRNA (21) blocked the LPS- or GM-CSF-stimulated increases in IL-1ß release (Fig. 5GoA) and prevented the apoptotic delay associated with exposure to these stimuli (Fig. 5GoB). The addition of rIL-1ß to cells treated with the antisense probe restored the apoptotic delay (Fig. 5GoC). Similarly, adding a specific blocking mAb to IL-1ß also inhibited the antiapoptotic effects of LPS, GM-CSF, and rIL-1ß (Fig. 6Go). Finally, preincubating neutrophils with human rIL-1RA restored the rates of apoptosis to near normal levels following exposure to LPS or GM-CSF, although this effect could be overcome by the addition of rIL-1ß (Fig. 7Go). An inhibition of IL-1ß activation or cellular binding by any of the strategies described above had no effect on the functional priming activities of LPS or GM-CSF, and respiratory burst activity was normal (data not shown).



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FIGURE 4. Effects of ICE inhibition with YVAD.CMK. The effects of the specific ICE inhibitor, YVAD.CMK on IL-1ß release (A) and apoptosis (B) following exposure to LPS or GM-CSF are shown. Supernatants were collected at 4 h after cell stimulation; apoptosis was assessed after 18 h of culture in vitro. *p < 0.05 vs control; {ddagger}p < 0.05 vs control LPS and GM-CSF.

 


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FIGURE 5. Effects of an IL-1ß antisense oligodeoxynucleotide. The effects of an IL-1ß antisense probe on the LPS- and GM-CSF-induced delay in neutrophil apoptosis are shown. Supernatants were assayed for IL-1ß after 4 h; apoptosis was assessed at 18 h. The antisense probe inhibited the release of IL-1ß (A) and prevented the corresponding apoptotic delay (B). Adding rIL-1ß (50 pg/ml) to cells treated with the antisense probe restored the apoptotic delay.

 


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FIGURE 6. Effects of a blocking Ab to IL-1ß on LPS-, GM-CSF-, and IL-1ß-induced delays in neutrophil apoptosis. Neutrophils (1 x 106/ml) were preincubated for 1 h with Ab to IL-1ß (50 ng/ml) or to an irrelevant control (1 µg/ml anti-rat CD11b IgG), and subsequently cultured with LPS (1 µg/ml), GM-CSF (100 U/ml), or IL-1ß (50 pg/ml). *p < 0.05 vs control; {ddagger}p < 0.05 vs control plus anti-IL-1ß Ab.

 


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FIGURE 7. Effects of rIL-1RA on the apoptotic delay resulting from LPS, GM-CSF, or IL-1ß. Cells were preincubated with or without IL-1RA (100 ng/ml) for 1 h, and subsequently cultured with LPS (1 µg/ml), GM-CSF (100 U/ml), or IL-1ß (50 pg/ml). *p < 0.05 vs control; {ddagger}p < 0.05 vs control plus IL-1RA.

 
In summary, the de novo generation of mature IL-1ß by an ICE-dependent pathway results in an inhibition of the expression of the constitutive apoptotic program of the normal neutrophil. Since inhibiting ICE activity (Fig. 4Go), IL-1ß synthesis (Fig. 5Go), or IL-1ß binding (Figs. 6Go and 7Go) to cells does not completely reverse the delay, other autocrine factors may be involved.


    Discussion
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
In aggregate, these studies demonstrate that ICE (caspase-1) serves an important role in the regulation of neutrophil apoptosis in addition to its well-described role as an effector of programmed cell death, inhibiting the expression of the constitutive cell death program through activation of the antiapoptotic cytokine, IL-1ß.

After 24 h in culture, ~30 to 40% of quiescent neutrophils exhibit morphologic features of apoptosis, a consequence of the execution of a constitutively expressed cell death program. The expression of apoptosis is accelerated following the ligation of cell surface Fas with its physiologic ligand, Fas ligand (22), or with an agonistic anti-Fas Ab (23). In contrast, the constitutive apoptotic program can be inhibited by a variety of signals that are associated with the expression of an inflammatory response, including exposure to bacterial LPS (7) or an array of proinflammatory cytokines (12); the program can also be inhibited by the process of transmigration into an inflammatory focus (14). As shown here, the inhibition of apoptosis is an active process, dependent upon the tyrosine phosphorylation of as yet unidentified intracellular proteins, the activation of the nuclear transcription factor NF-{kappa}B, and the synthesis of new protein by the neutrophil.

There is growing consensus that progression to apoptosis is the normal default state for many cells, and that survival is contingent upon the rescue of cells from programmed cell death by signals from the environment. For the neutrophil, prolonged survival is intimately linked to functional activation. Activational regulation of the expression of neutrophil apoptosis has been suggested by previous studies. Thus, the inhibitory effects of GM-CSF are mediated through the tyrosine phosphorylation of lyn, and can be blocked by inhibitors of tyrosine kinases (16). Moreover, neutrophil activation by LPS is associated with a dissociation of inhibitor-{kappa}B and the release of NF-{kappa}B; NF-{kappa}B, in turn, can render lymphocytes, fibroblasts, and macrophages refractory to the proapoptotic effects of TNF (24, 25). Additionally, NF-{kappa}B is known to regulate the transcription of IL-1ß in U937 cells (26). Finally the inhibitory effects of GM-CSF are known to be dependent upon new protein synthesis, since they can be blocked by inhibitors of protein synthesis (11). The results of the present study suggest that these regulatory effects are mediated by ICE-dependent processing of pro-IL-1ß, and establish a novel role for caspase-1 in the inhibition of the expression of apoptosis under conditions of cellular activation.

Whether the ICE-dependent generation of IL-1ß represents a single final common pathway for the multiple signals that inhibit the constitutive cell death program of the neutrophil is unknown. The surface receptors for LPS and GM-CSF are distinct. Moreover, LPS binds to the neutrophil CD14R (27), leading to the activation of a p38 mitogen-activated protein kinase but not to the activation of extracellular signal-related kinase (ERK)-1 (p42) or ERK-2 (p44) (28); the ligation of CD14 with an agonistic Ab, RM052, triggers a comparable apoptotic delay (our unpublished observations). The receptor for GM-CSF comprises two chains, an {alpha}- and a ß-chain (29). GM-CSF binding to its receptor on the neutrophil appears to preferentially activate ERK-1 and ERK-2 (30). Both receptors are linked to intracellular signaling cascades that are dependent upon tyrosine phosphorylation and the activation of the transcription factor NF-{kappa}B. Although the inhibition of early events following receptor engagement (tyrosine kinase and NF-{kappa}B activation) or protein synthesis was able to completely block the activation-induced apoptotic delay, interventions targeting ICE (YVAD-CMK) or IL-1ß (antisense oligonucleotide, blocking Ab, or IL-1RA) alone only partially inhibited this effect. Thus, we cannot exclude the possibility that a second caspase and protein mediator is implicated in the inhibition of the constitutive apoptotic program during cellular activation.

Contrary to what has been observed in other cells, we found no evidence that ICE induces apoptosis in activated neutrophils. Thus the enzyme was expressed at lower levels in spontaneously apoptotic cells; both increased expression and activity, measured as cleavage of the tetrapeptide, YVAD, were associated with the inhibition rather than the activation of apoptosis. Moreover, even when the processing of pro-IL-1ß was blocked by the use of an antisense oligonucleotide, there was no observed shift in ICE activity to an enhanced expression of apoptosis. Whether this lack of proapoptotic activity reflects intrinsic alterations in the ICE molecule or altered activity in the inflammatory intracellular milieu of the neutrophil merits further investigation. The suppression of apoptosis by a truncated version of the ICE homologue, Ich-1, has previously been reported (31), and mice with a targeted deletion of the ICE gene demonstrate apparently normal development and normal expression of macrophage and thymocyte apoptosis (32). It is intuitively apparent that inhibiting the proapoptotic activity of ICE is a prerequisite for the ongoing generation of IL-1ß by a cell.

IL-1 is a pleiotropic cytokine that exerts multiple paracrine and endocrine influences on cellular homeostasis during acute inflammation (5). By virtue of its effects on neutrophil functional survival, it can also be considered an autocrine cell survival factor that promotes cellular longevity by inhibiting the expression of programmed cell death. Regulating its activity by the targeting of signaling cascades, gene transcription, or IL-1 binding to cell surface receptors provides a novel option for the regulation of inflammatory cell survival, and consequently for the therapy of a broad group of disease processes characterized by a dysregulated inflammatory response, from arthritis to inflammatory bowel disease to sepsis.


    Footnotes
 
1 This work was supported by the physicians of Ontario through a grant from the Physician’s Services Incorporated Foundation. Back

2 Address correspondence and reprint requests to Dr. John C. Marshall, Eaton North 9–234, Toronto Hospital, General Division, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4. E-mail address: Back

3 Abbreviations used in this paper: ICE, IL-1ß-converting enzyme; GM-CSF, granulocyte-macrophage CSF; IL-1RA, IL-1R antagonist; CHX, cycloheximide; ERK, extracellular signal-related kinase; PDTC, pyrrolidine dithiocarbamate. Back

Received for publication January 8, 1998. Accepted for publication March 16, 1998.


    References
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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