Aims Cyclic adenosine monophosphate (cAMP) is the predominant intracellular second messenger that transduces signals from Gs-coupled receptors. Intriguingly, there is evidence from various cell types that an extracellular cAMP pathway is active in the extracellular space. Herein, we investigated the role of extracellular cAMP in the lung and examined whether it may act on pulmonary vascular cell proliferation and pulmonary vasculature remodelling in the pathogenesis of pulmonary hypertension (PH). Methods and results The expression of cyclic AMP-metabolizing enzymes was increased in lungs from patients with PH as well as in rats treated with monocrotaline and mice exposed to Sugen/hypoxia. We report that inhibition of the endogenous extracellular cAMP pathway exacerbated Sugen/hypoxia-induced lung remodelling. We found that application of extracellular cAMP induced an increase in intracellular cAMP levels and inhibited proliferation and migration of pulmonary vascular cells in vitro. Extracellular cAMP infusion in two in vivo PH models prevented and reversed pulmonary and cardiac remodelling associated with PH. Using protein expression analysis along with luciferase assays, we found that extracellular cAMP acts via the A2R/PKA/CREB/p53/Cyclin D1 pathway. Conclusions Taken together, our data reveal the presence of an extracellular cAMP pathway in pulmonary arteries that attempts to protect the lung during PH, and suggest targeting of the extracellular cAMP signalling pathway to limit pulmonary vascular remodelling and PH.

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Children with cerebral palsy (CP) often have changes in proximal femoral geometry. Neck-shaft angle (NSA), Hilgenreiner epiphyseal angle (HEA) and head-shaft angle (HSA) are used to measure these changes. The impact of femoral rotation on HEA/HSA and of ab/adduction on HEA/HSA/NSA is not well known. This study aimed to determine and compare the effect of rotation, ab/adduction and flexion/extension on HEA/HSA/NSA. Radiographic measurements from 384 patients with Gross Motor Function Classification System (GMFCS) levels I–V were utilized. NSA/HSA for affected hips were used with femoral anteversion averages to create three-dimensional models of 694 hips in children with CP. Each hip was rotated, ab/adducted and flexed/extended to simulate malpositioning. HEA/HSA/NSA of each model were measured in each joint position, and differences from correct positioning were determined. Mean HEA error at 20° of internal/external rotations were −0.60°/3.17°, respectively, with the NSA error of −6.56°/9.94° and the HSA error of −3.69°/1.21°. Each degree of ab/adduction added 1° of the HEA error, with no NSA/HSA error. NSA was most sensitive to flexion. Error for all measures increased with increasing GMFCS level. HEA/HSA were minimally impacted by rotation. NSA error was much higher than HEA/HSA in internal rotation and flexion whereas HEA was sensitive to changes in ab/adduction. Given abduction is more easily detectable on imaging than rotation, HEA may be less affected by positioning errors that are common with children with CP than NSA. HSA was least affected by position changes. HEA/HSA could be robust, complementary measures of hip deformities in children with CP.

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Pulmonary arterial hypertension (PAH) is an uncommon, progressive, life-threatening and often fatal disease. Despite advances in PAH therapy, there is no cure for PAH, and new therapies need to be developed. Activation of G-protein-coupled receptors stimulates adenylyl cyclase, leading in vascular smooth muscle cells to an increase in intracellular cyclic adenosine monophosphate (cAMP) formation and reduced cell proliferation in vitro and in vivo . Yet, the last two decades of research have shown that there is more to the role of cAMP than ever expected from this molecule. Stimulated cells transport cAMP outside the cells, a process that is mediated by the multidrug resistance-associated proteins (MRPs). Herein, we investigated the role of extracellular cAMP in the lung and asked whether it may act on pulmonary vascular remodeling. By employing a fluorescence resonance energy transfer (FRET)-based sensor, we found that extracellular cAMP activates intracellular cAMP formation in human pulmonary artery smooth muscle cells (hPASMC) and endothelial cells (hPAEC). Extracellular cAMP, via binding of its metabolite adenosine to the type A2 receptor, reduced hPASMC and hPAEC proliferation and migration by controlling the PKA/CREB pathway. To test for a role of extracellular cAMP in the pulmonary vasculature, we used rat-monocrotaline and mouse-hypoxia as in vivo models of PAH. Rats treated with monocrotaline developed PAH with increased pulmonary artery pressures (PAP) and right ventricular (RV) hypertrophy. Extracellular cAMP infusion significantly prevented and reversed these structural changes. Extracellular-cAMP-treated rats displayed lower RV systolic pressure and Fulton index, as well as decreased PAP. In line with these observations, we found infused cAMP to potently repress RV hypertrophy, RV systolic pressure, perivascular lung fibrosis and pulmonary arteries remodeling in mice exposed to Sugen5416 and chronic hypoxia. Together, our results assign extracellular cAMP a potent regulatory role in pulmonary vascular cells, and suggest targeting the extracellular cAMP signaling pathway to limit pulmonary vascular remodeling and PAH.