Friday, February 28, 2020

Anti-Epileptic Drugs, Would They be the Cause of Heterotopic Ossification

Anti-Epileptic Drugs, Would They be the Cause of Heterotopic Ossification

Abstract

Etiopathogenesis of Heterotopic ossification or paraosteoarthropathy is unknown, all speculations remain open. Epilepsy and anti-epileptic drugs have never been mentioned as a risk factor. We report the case of an epileptic patient operated several times for fracture of the right humeral head. He was treated by anti-epileptic (Valproic Acid). He developed a stiffness of the right shoulder. Imaging showed a heterotopic ossification. Through this observation, we have tried to answer the question of the origin of the appearance of the heterotopic ossification; this genesis is multifactorial with a role of the anti-epileptic whose Valproic Acid.
Keywords: Heterotopic Ossification; Anti-Epileptic Drugs; Valproic Acid; Shoulder; Epilepsy
Abbreviations: HO: Heterotopic Ossification; AEDs: Anti-Epileptic Drugs; CT: Computed Tomography; BM: Bone Marrow; MSC: Mesenchymal Stromal Cells

Introduction

Heterotopic ossification (HO) or paraosteoarthropathy is called neurogenic when it occurs as a result of central or peripheral nervous system involvement. A HO may also occur in a context of bone trauma or burns or in an orthopedic context [1]. Epilepsy and anti-epileptic drugs (AEDs) have never been mentioned as a risk factor.

Case Description

Figure 1a: X-ray of the face with posterior dislocation of the shoulder.
A 30 years old patient with no antecedent had a painful posterior dislocation of the right shoulder, due to an initial epileptic seizure (Figure 1a). Neurological examination and cerebral Computed tomography (CT) showed no abnormality; he was treated by an anti-epileptic (Valproic Acid). The reduction of the posterior dislocation with sedation caused a fracture of the head without neurological injury (Figure 1b). The patient was operated on three occasions: he was operated on day one for the initial fracture (anterior approach, Figure 1c). The postoperative was marked on day seven by a superficial cutaneous infection (C-reactive protein at 54 mg / L, normal complete blood count, and preservation of the general state). The sampling showed an enterobacter clouaca complex. He was treated by antibiotherapy based on gentamicin 160mg / L for five days and ciprofloxacin for two months, the evolution was remarkable after one month. He was operated at day 7 for insufficient reduction of the humeral head (removal of material and introduction of new material (Figure 1d, anterior and posterior approach). There was no sign of deep infection. The progress was marked by the absence of recurrence of epilepsy since the first crisis and stiffness. At day 30 of dislocation, there was an appearance of periarticular ossification compromising the function of the shoulder (Figures 1e & 1f). Computed tomography (CT) of the shoulder showed the localization of ossification (Figures 2a-2c). At day 45, Rehabilitation sessions were done but without improvement. He was operated at day 60 of the last act for the removal of the material without sign of infection (anterior approach). Currently, the patient always keeps stiffness on the activities of the daily life, the hand-mouth is possible but the limitation of the abduction and the external rotation makes difficult hand-neck. Scintigraphic evaluation of osteoblastic activity would be realized to decide on a possible arthrolysis of the shoulder.
Figure 1b: Fracture of the head of the shoulder after reduction with sedation.

Discussion

We distinguish metastatic calcification, dystrophic calcification, and ectopic ossification. In ectopic ossification, there is: progressive myositis (congenital disease), post-traumatic ossification myositis, sequelae of burns, complications of surgery, and neurological lesion. The etiopathogenesis of HO is not yet known exactly, although there are several models of HO induction in animals [1], like the technique of injecting bone marrow into a muscle [2]. Among the factors of the formation of the HO, some authors have evoked vascular changes related to a dysfunction of the autonomic nervous system [3]; the existence of a prolonged immobilization, it is responsible for a bone demineralization resulting in a release of calcium which can participate in the calcification of the neighboring soft tissues [4]; bone microtrauma, due to repeated passive kinesitherapic manipulations and going beyond the articular amplitudes, are responsibles for a local inflammatory state, favoring the release of humoral factors that stimulate osteogenesis [4]; the existence of sepsis, or a pressure ulcer leads to the appearance of a inflammatory syndrome, which also promotes the onset a HO [4]; spastic hypertonia would act by inducing bone micro-traumas linked to the stresses exerted by muscle contractures on the articulation [5].
In our case, we note several factors whose connection is unknown: the various surgical procedures, kinesitherapic manipulations, prolonged immobilization and a local inflammatory state such as sepsis. We eliminated the role of kinesitherapy that began after the onset of HO, we doubt about the role of infection because it was cutaneous and superficial; there was no damage to the central nervous system to incriminate spasticity. Could Epilepsy as a central neurological disorder promote HO with the intervention of other factors? We wonder what role the anti-epileptic drugs (AEDs), could play. Epilepsy is a common neurological disorder worldwide and AEDs are always the first choice for treatment, the treatment of our patient was Valproic Acid. However, more than 50% of patients with epilepsy who take AEDs have reported bone abnormalities [6]. In our observation, we believe that the multiple surgeries have favored HO by release of bone tissue and the intervention of anti-epileptic drugs as Valproic Acid. We wonder about the role of mesenchymal stromal cells in the genesis of OH after the fracture of the humerus. The mesenchymal stromal cells of adipose tissue were initially isolated from the bone marrow (BM-MSC) [7]. BM-MSC are multipotent, that is, they can differentiate into various types of cells derived from the mesoderm [8] (bone, cartilage, adipose tissue); these cells have great potential for cellular therapies as they can be directed to differentiate into certain lineages [9].
Recent studies have reported that Valproic Acid influences osteogenesis in vivo and in vitro [10,11], the study indicates that Valproic Acid increase the recruitment of Mesenchymal stromal cells (MSC) to sites of injury without compromising their ability to proliferate or differentiate [12]. Valproic Acid promoted osteoblastic differentiation [10]. Etiopathogenesis of HO is unknown, all speculations remain open, and the links that can exist between several clinical entities deserve clarification. In the case of a stiff shoulder post traumatic or postoperative consider making radiography and do not hastily think of a capsulate. Further investigation is warranted with regard to the predisposing a factor of HO.

The Treatment of Female Pattern Hair Loss with Long Acting Platelet Rich Plasma - https://biomedres01.blogspot.com/2020/02/the-treatment-of-female-pattern-hair.html


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Regulatory Effects of Mesenchymal Stem Cells in Brain

Regulatory Effects of Mesenchymal Stem Cells in Brain 

Abstract

The question on various functional effects of mesenchymal stem cells (MSCs) during different pathological processes development in brain was considered. Attention was paid to ability of MSCs to be involved in control of reparative processes in nerve tissue due to expression of many neurotrophic factors. Such feature of MSCs enhances their positive effects by realization of another potential - ability to progress in neuron-like direction. They also have an impressive ability to interact with immune competent cells in brain tissue to increase antitumor effect. It was shown that MSCs are able to synthesize and express lots of regulatory factors which inhibit growth of glioma cells. Therefore, vision of MSCs functional heterogeneity was expanded and their various regulatory effects were combined in realization of protective function both in health and disease.
Keywords: Antitumor Effects; Brain Plasticity; Defensive Reactions; Neurotrophic Factors; Reparative Processes; Stem Cells; Transcription Factors
Abbreviations: Ad-HMSCs: Adipose Human Mesenchymal Stem Cells; BDNF: Brain Derived Neurotrophic Factor; GDNF: Glial Cell Derived Neurotrophic Factor; NGF: Nerve Growth factor; NGFR: Nerve Growth Factor Receptor; MSCs: Mesenchymal Stem Cells; SCs: Stem Cells; Sox: (Sry-Related HMG Box) Genes Encode Transcription Factors

Introduction

Cellular technologies are being widely implemented into many spheres of practical medicine recently. The number of advanced technologies involving stem cells (SCs) progressively increases in treatment of brain diseases. Specialists think SCs are able to grow in neuron-like direction in damaged brain regions showing various regulatory effects in health and disease (Alzheimer’s disease, stroke, brain trauma, glioma, glioblastoma) [1-6]. Mesenchymal stem cells (MSCs) seem the most promising besides residential brain cells. MSCs are administered mainly systemically for correction of impaired brain functions in the development of pathological processes. For example, MSCs have wide potential for the treatment of Alzheimer’s disease [1,7]. It has been suggested that reparative processes in the brain are activated by secretion of nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and vascular endothelial growth factor (VEGF) from neural SCs [8].The search for “Neurotrophic Effect Stem Cells Brain” and “Neurotrophic Effect Mesenchymal Stem Cells Brain” in PubMed on November 7th, 2018 showed 491 and 153 articles, respectively, and the interest started to grow only eight-nine years ago. Scientists and physicians are interested in two aspects of MSCs functional role in brain: reparative potential of MSCs, and antitumor potential of MSCs.

Reparative Potential of MSCs

First of all, enhancement of reparative potential of residential stem cells in patient’s brain by autologous MSCs is a promising field. Only 27 articles have been found in PubMed while searching for “Neurotrophic Effect Mesenchymal Stem Cells Brain repair”. Their authors stress that despite of low amount of publications cellular technologies of MSCs use are promising addition to current methods of neurodestructive processes treatment [3,4,6,9-11]. According to range of authors, intravenous injection of allogeneic MSCs from adipose tissue in patients with acute stroke can be safe therapy and increase recovery of nerve tissue and blood flow in cerebral vessels [8]. Brain-derived neurotrophic factor (BDNF) is mentioned as one of the key trophic factors which MSCs express in damaged brain area [8,9]. It was assumed, following experimental modeling of neonatal stroke in rats, that intranasal administration of MSCs could be useful in brain functions recovery after stroke [3,4,6]. The technique of intranasal administration of MSCs after modeling of neurodestructive processes in different parts of brain and spinal cord was thoroughly substantiated [2-4]. Somatotopic principle of MSCs migration to damaged brain region was established for the first time: MSCs move along chosen cranial nerve to anterior or posterior cranial fossae depending on damage localization [4].

Antitumor Potential of MSCs

Secondly, recent results showed that MSCs have potential for inhibition of glioma cells growth [12,13]. It was based on revealed MSCs taxis to tumor cells [6]. PubMed search for “Neurotrophic Effect Mesenchymal Stem Cells Brain glioma” and “Mesenchymal Stem Cells Brain glioma” on November 7th, 2018 revealed one and 386 articles, respectively. Articles demonstrate how MSCs actively interact with components of immune system and show both antiinflammatory and antitumor effects [13].
MSCs serve as attractive instrument for cellular therapy of cancer due to their ability to migrate to tumors and express bioactive molecules. However, influence of MSCs on tumor growth was not completely established. Authors [2,7,13] performed systemic injection of MSCs to femoral vein, or carotid artery. Same authors [14] showed that intracerebral injection of Ad-hMSC significantly improved survival rate of rats with heterotransplants U87MG. This effect was associated with decrease of tumor growth due to limitation of tumor cells proliferation and decrease of microvessel density. Fetal injection of Ad-hMSC lowered population of tumor cells and initiated migration of residential microglia cells in GSC1 heterotransplants. It is known that Sox21 inhibits glioma progression, because Sox21 decrease the stem-like cell properties of the tumor cells [15]. Induction of Sox21 in the glioma resulted in a significant smaller tumor size [15]. But, still there is no clarity in the answer to the question of how the intercellular, perineural and perivascular spaces of the brain create conditions for the migration of stem cells [16].
Gathered data can say for broadening of MSCs antitumor potential use in combination with standard surgical, radio- and chemotherapeutical, and especially with such methods which are aimed at activation of immune system [17,18], delivery of metabolizing genes and/or oncolytic viruses [19].

Conclusion

Functional heterogeneity of MSCs which is demonstrated in various regulatory effects is the basis for extension of stem cells use in guidelines dedicated to treatment of socially important diseases. It should be mentioned that lots of MSCs effects are still underexplored. For example, we don’t know all of side effects, including possibility of MSCs to transform to cancerogenic cells. Deepening of knowledge on fundamental and applied aspects of MSCs use in experiments and practice will allow reasonable use of protective function of MSCs in health and disease.

Acknowledgement

Our research project was partially sponsored by SSTP “New methods of medical care”, section “Transplantation of cells, tissues and organs” (2016-2020), and by grant OOO “Synergy”.

The Possibility of Urinary Tract Infection in Primary School Students with A Diagnosis of Febrile Pharyngotonsillitis - https://biomedres01.blogspot.com/2020/02/the-possibility-of-urinary-tract.html

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Thursday, February 27, 2020

The Possibility of Urinary Tract Infection in Primary School Students with A Diagnosis of Febrile Pharyngotonsillitis

The Possibility of Urinary Tract Infection in Primary School Students with A Diagnosis of Febrile Pharyngotonsillitis 

Abstract

Background: Urinary tract infection (UTI) is one of the commonest bacterial infection seen in children, ranking second only to those of the respiratory tract.
Material & Methods: One hundred and five 6-12 years old school children with pharyngotonsillitis visit our outpatient clinic were recruited in this study. Urinalysis and mid-stream urine collection culture after disinfection of the private area were performed in all children. Serum procalcitonin, CRP and DMSA were performed in student with significant positive urine culture.
Results: The urine culture results showed positive rate in 48.6%, negative rate in 39% and contamination urine culture was 12.4%. Urinalysis did not indicate the possibility of positive urine culture. Also, the procalcitonin and CRP could not indicate upper UTI when compared with the results of DMSA.
Conclusion: This study indicates that urine tract evaluation is important and should be performed in children who are suspected with pharyngotonsillitis.
Keywords: UTI; Pharyngitis; Tonsillitis; E.Coli; Children

Introduction

Urinary tract infections are common in children. They may present with a range of severity form cystitis to febrile UTI or pyelonephritis. The presentation may be vague and have nonspecific symptoms. The younger the child is the more symptoms are atypical. Therefore, a UTI should be considered in all children with a fever and it is even possible associated with febrile pharyngotonsillitis [1,2]. In Scholer SJ study (1996) stated that an acute complaint of abdominal pain in children occurs in 5.1% nonscheduled visits. Close follow-up will identify the 1% to 2% who proceeds to have a more serious disease process including UTI [3]. The clinical prediction rules for UTI was developed. Its sensitivity and specificity were 0.95 and 0.31 respectively if patient confirm to have 2 or more of the following 5 variables: less than 12 months old, white race, temperature of 39 °C or higher, fever for 2 days or more, and absence of another source of fever on examination [4]. The gold standard for UTI diagnosis is significant colony counts of a single organism in urine obtained in a sterile manner. Positive urine culture was defined as 50,000 or more colony-forming units per milliliter of a urinary tract pathogen [5]. The most common uropathogens were E. coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Proteus mirabilis [6].
However, children with Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa were significantly less likely to exhibit pyuria, positive leukocyte esterase on dipstick urinalysis than children with [7]. Moreover, high prevalence of Staphylococcus saprophyticus is in patients > 10 years and Proteus mirabilis is predominant in males [8]. Acute UTIs are relatively common in children, with 8% of girl and 2% of boys having at least one episode by seven years of age. Renal parenchymal defect are present in 3% to 15% of children within one to two years of their first diagnosed UTI. Evaluation of older children may depend on the clinical presentation and symptoms that toward a urinary source (leukocyte esterase or nitrite present on dipstick testing; pyuria of at least 10 WBC/HPF and bacteriuria on microscopy) [9]. Delay in treatment of febrile UTIs and permanent renal scarring are associated. In febrile children, clinicians should not delay testing for UTI.

Material and Methods

One hundred and five primary school children (Male=47, female=58) who were diagnosed with pharyngotonsillitis in outpatient clinic were involved in this study. Their common symptoms were fever, emesis, decreased appetite, sore throat, headache and abdominal pain. Urinalysis and mid-stream urine collection cultures were done in all participants. Serum procalcitonin, CRP and DMSA were also performed in students with significant positive urine culture (50,000 or more colony-forming units per milliliter of a single urinary tract pathogen).

Results

The urinalysis results including esterase, nitrite, proteinuria, occult blood, white blood cells and red blood cells were not significant, it cannot predict the possibility of urine culture. Culture of urine showed uropathgen positive rate 48.6% (n=51), negative rate 39% (n=41) and the contamination rate 12.4% (n=13) respectively. was the only bacteria showed in culture. Also, the procalcitonin and CRP levels were mostly lower than their cutoff levels (0.5ng/ml and 20mg/L) respectively. Even the higher levels could not indicate upper UTI when compared with the results of DMSA.

Discussion

Twenty percent of febrile children have fever without an apparent source of infection after history and physical examination. Of these, a small proportion may have an occult bacterial infection, including bacteremia, UTI, occult pneumonia. Also, in children with fever without source, occult UTIs occur 3% to 4% of boy younger than 1 year and 8% to 9% of girls younger than 2 years of age [10]. In this current study, the absolute number of WBCs or red blood cells in the urine and the presence of proteinuria, leukocyte esterase and nitrite were not associated with positive culture or urinary infection as proposed by Hooker JB (2014) study [11]. In review of literature, routine urinalysis had limited sensitivity, but moderate specificity, in predicting UTI in children. The composite urinalysis and moderate or large leukocyte esterase both had good negative predictive values for the outcome of UTI [12]. According to the procalcitonin, CRP against the results of acute-phase DMSA scan in children aged 0 to 18 years with culture confirmed episode of UTI, the cutoff values were used for the primary analysis of UTI: 0.5mg/mL for procalcitonin, 20mg/L for CRP [13]. Moreover, certain unopathogens: Enterococcus species, Klebsiella species, and Psiudomonas aeruginosa were less likely to exhibit pyuria (>/=5 WBCs per high power field or >/=10 WBCs per cubic millimeter) [14]. Therefore, the definitive diagnosis of UTI is based on the urine culture but clinicians should remember a higher contamination rate was found in the early stream (51%) and midstream sample (16%). The benefit of catching midstream urine samples for the diagnosis of UTI is most important [15,16]. In conclusion, collecting a viable urine sample for urine culture for diagnosis of UTI using clean voided methods in primary school students with fibril pharyngotonsillitis is feasible.

Development of Activity of Labour and Occupational Therapies in University Hospital, Pleven, Bulgaria - https://biomedres01.blogspot.com/2020/02/development-of-activity-of-labour-and.html 
 
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The Treatment of Female Pattern Hair Loss with Long Acting Platelet Rich Plasma

The Treatment of Female Pattern Hair Loss with Long Acting Platelet Rich Plasma 

Opinion

Female Pattern Hair Loss (FPHL), also referred to as Androgenic Alopecia (AGA), is the most common type of non-scarring hair loss and, affects up to 40% of women [1]. Classically, FPHL presents as thinning over the top of the head and patients are concerned with a widened part. Unlike male pattern hair loss, the hairline is commonly retained. In the areas of thinning, the terminal, healthy hairs are fewer in number and there are many miniaturized and/or vellus hairs. The pathogenesis of FPHL is complex and likely is triggered by an underlying genetic predisposition and environmental influence. Originally, it was believed that androgens were responsible for FPHL hence the term androgenic alopecia. This notion has been challenged recently as there are reports of women with FPHL that are androgen insensitive. Thus, in this subset of patients, the appearance of FPHL is due to factors other than androgens [2]. On hair shaft biopsy of FPHL, there is often evidence of a microfolliculitis surrounding the hair bulge of the miniaturized hairs and this finding is not found surrounding the terminal hairs, suggesting that inflammation plays a role in FPHL [3].

These findings may explain why some women do not respond to hormonal therapy such as finasteride but do respond to treatments that target inflammation, such as platelet rich plasma (PRP) therapy. PRP therapy involves the use of a patient’s own growth factors to influence and support the growth of hair. PRP is made through centrifugation of a patient’s blood during an office visit. The least dense layer is the platelets within plasma. Within the platelets are granules that contain more than 20 different growth factors including platelet-derived growth factor, fibroblast growth factor, transforming growth factor, and vascular endothelial growth factor [4]. These growth factors are released into solution by adding calcium chloride or citrate in a process called “activation”. Once in solution, the growth factors are concentrated to a level the body never routinely experiences. The growth factor rich solution (PRP) is then injected into areas of thinning at the level of the follicle in the sub-dermis. There are many kits available to physicians to aid in the production of PRP. Some kits link the growth factors to fibrin, known as Platelet Rich Fibrin Matrix or Long-Acting PRP (LA-PRP). In hair loss, I believe this is very advantageous as hair grows slowly and the scalp is vascular. There are studies showing that traditional PRP is washed away in as little as 24 hours where as PRFM may last many weeks if not months slowly releasing growth factors [5]. I believe the duration of effect is the single most important variable in achieving growth when treating hair loss with PRP.

In my practice, I only use LA-PRP and I will pretreat the target area of thinning scalp with a ring block with local anesthesia prior to LA-PRP injection. The LA-PRP session is routinely completed in a single office visit lasting less than 30 minutes, and patients have no downtime from work. The results from a treatment take 2-4 weeks to begin and last for 6 months. Patients will describe first a reduction in shedding, a thickening of the shaft diameter, and possibly new hair growth. After 6 months, the improvement from PRP wanes. Patients are comforted in knowing that all the blood products in this treatment come from their own blood, eliminating the risk of viral infection, allergy, and growth-factor rejection. In my experience in over 500 patients, there has not been an increase in shedding or acute telogen effluvium from treatment at any point in the treatment course. I have also noted that increased frequency of sessions of PRP lead to improved results. There are likely patients who have a genetic predisposition to FPHL and show both a sensitivity to hormonal as well as inflammatory insult. In these patients, combined therapy with minoxidil as well as LA-PRP has been very valuable. There are many reports of shedding upon starting and stopping minoxidil. This effect seems to be blunted in females when combining treatment with LA-PRP. The current literature is becoming populated with various levels of evidence showing the benefit of PRP for women with FPHL. I would encourage more research into PRFM as an ideal form of LA-PRP for FPHL, as this treatment has been invaluable for my patients.

Integrated in Silico Docking and MOMA Simulation Methods Reveal Rottlerin as a Potent Janus kinase 2 (JAK2) Inhibitor - https://biomedres01.blogspot.com/2020/02/integrated-in-silico-docking-and-moma.html

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Wednesday, February 26, 2020

Integrated in Silico Docking and MOMA Simulation Methods Reveal Rottlerin as a Potent Janus kinase 2 (JAK2) Inhibitor

Integrated in Silico Docking and MOMA Simulation Methods Reveal Rottlerin as a Potent Janus kinase 2 (JAK2) Inhibitor 

Abstract

Janus kinase 2 (JAK2) is a prospective drug target for myeloproliferative neoplasms, mainly polycythemia Vera, essential thrombocythemia and primary myelofibrosis disorders. JAK2 abnormalities are mainly identified in myeloid neoplasms. Multiple type I ATP-competitive JAK inhibitors with various specificities displayed potent anti-inflammatory activity with minimum hematologic toxicity in clinical trials. Therefore, only two tyrosine kinase inhibitors have been approved by Food and Drug Administration (FDA) as follows: first tyrosine kinase inhibitor is JAK2/JAK1 inhibitor (ruxolitinib 1) in intermediate-2 and high-risk myelofibrosis and hydroxyurea-resistant or -intolerant polycythemia Vera. Second tyrosine kinase inhibitor is JAK1/JAK3 inhibitor (tofacitinib. 2) in methotrexate-resistant rheumatoid arthritis. However, the potent-antiinflammatory effects of JAK inhibitors seem to be logical therapeutic approach for various inflammatory and auto-immune diseases. Extensive research has identified the chemotherauperic potential of plant-derived compounds of which rottlerin (5) exhibited great potentiality since rottlerin (5) influences various cell mechanisms involved in cell survival, autophagy, apoptosis and invasion. Rottlerin (5) activity is presumed to result from a combination of signaling pathways at multiple levels. Bioinformatics’ tools were utilized to identify the specific targets for different ligands. In silico predictions, modeling and dynamic simulations based on the crystal structure of JAK2 and ligands were performed. Active molecular docking studies using AutoDock Vina software suggested that rottlerin (5) is a novel inhibitor of JAK2 with binding affinities of –9.3 kcal/mol when compared to approved drugs ruxolitinib (1) (-8.7 cal/mol and tofacitinib (2) (-7.4kcal/mol). Of these ligands investigated in this study, rottlerin (5) produced the greatest JAK2 binding affinity. The data suggests that rottlerin (5) could be explored as potent lead compound to treat myelofibrosis caused by JAK2 overexpression.
Keywords: Janus kinase 2; Myelofibrosis; Docking Studies; In Silico; Apigenin; Gandotinib; Ruxolitinib; Rottlerin; Tofacitinib; Wogonin
Abbreviations: ARG: Argenine; ASN: Aspertine; Glu: Glutathione; Gly: Glycine; LYS: Lysine; PHE: Phenylalanine, VAL: Valine; JAK 2: Janus Kinase 2; ET: Thrombocythemia; MPDs: Myeloproliferative disorders; PV: Polycythemia Vera; PMF: Primary Myelofbrosis

Introduction

Janus kinase 2 (JAK2) is a non-receptor tyrosine kinase. Janus kinase family (JAK1, JAK2, JAK3 and TYK2) was associated with signaling by members of the type II cytokine receptors (e.g. interferon receptors), gp130 receptors (e.g. IL-6R), GM-CSF receptors (IL-3R, IL-5R and GMCSF-R), and single chain receptors (e.g. Epo-R, Tpo-R, GH-R, PRL-R) [1,2]. JAK/STAT signaling pathway plays imperative part in many physiological processes in response to various extracellular stimuli and cytokines. The Janus kinase family (JAK1, JAK2, JAK3 and TYK2) plays a crucial role in cytokine and growth factor mediated Janus kinase/signal transducers and activators of transcription (JAK/STAT) signal transduction [3]. JAK auto-phosphorylation leads to dimerization of phosphorylated STAT proteins and their translocation into the nucleus, thereby increasing cellular proliferation and resistance to apoptosis [4]. Myelofibrosis is a group of rare cancers of bone marrow and is classified as chronic leukaemia. Among the Janus kinase family, JAK2 was proved to be associated with the pathogenesis of myeloproliferative disorders (MPDs), primarily including polycythemia Vera (PV), essential thrombocythemia (ET), and primary myelofbrosis (PMF) [5-7].
In particular, the essential role in cell growth and survival makes JAK2 an important target for cancer treatment [8,9]. However, ruxolitinib (1) was the only JAK1/JAK2 inhibitor that was approved for clinical use to treat myelofibrosis and hydroxyurearesistant- moderate-2 and high risk myelofibrosis and hydroxyurearesistant or intolerant polycythemia Vera. In addition, tofacitinib (2) was approved JAK1/JAK3 inhibitor to treat methotrexateresistant rheumatoid arthritis. JAK inhibitors often exhibit potential anti-inflammatory activity and thus could be useful in chronic inflammation treatment. Therefore, research had been diverted to discover other JAK1/JAK2 inhibitors with better drug-like properties with novel structural skeleton and fewer side effects. Furthermore, non-approved JAK inhibitors displayed numerous offtarget effects leading to undesired neurological and gastrointestinal toxicities in myeloproliferative neoplasm associated clinical trials [10]. Recently, several small molecules belonging to different class of natural products were reported to regulate JAK/STAT pathway [12]. Among these, apigenin (3) and wogonin (4) have been found to inhibit IL-1-induced STAT1/2 activation via inhibition of JAK2 activation, leading to MMP-13 down-regulation in SW1353 cells (human chondrosarcoma cell line) [13].
Rottlerin (5) ((E)-1-[6-[(3-acetyl-2,4,6-trihydroxy-5- methylphenyl) methyl]-5,7-dihydroxy-2,2-dimethyl-chromen-8- yl]-3-phenyl-prop-2-en-1-one) also known as mallotoxin, is the principal phloroglucinol derivative of kamala dye obtained from Mallotus philippinensis [14]. Rottlerin (5) inhibited many other protein kinases, such as MAPKAPK5 (PRAK), MAPKAP-2, Akt/ PKB, and calmodulin-dependent protein kinase (CaMK) [15]. Rottlerin (5) uncoupled mitochondrial respiration from oxidative phosphorylation, thereby reducing adenosine triphosphate (ATP) levels and affected several cellular functions [13]. In pancreatic acinar cells, rottlerin (5) modulated several biological and biochemical processes in a PKCδ-independent pathway. In addition, rottlerin (5) (6M) depleted ATP levels, consequently averted the phosphorylation of many signaling proteins and inhibited enzymatic secretion and several intracellular pathways, in a PKCδ-independent manner. As a result, the inhibitory effects of rottlerin (5) were mimicked by the mitochondrial uncouplers carbonylcyanide m-chlorophenylhydrazone and carbonyl cyanide p-trifluoromethoxy phenylhydrazone, in pancreatic acini [16]. Cancers are caused by deregulation of hundreds of genes. An ideal anticancer agent should target multiple gene products or signaling pathways simultaneously without effecting normal cells. Recently, extensive research was focused on the chemotherapeutic potential of plant-derived compounds. Rottlerin (5) inhibited cell growth, induced apoptosis, arrested cell cycle, and retarder cell invasion as well as migration.
Furthermore, rottlerin (5) suppressed Skp2 expression and subsequently exerted its tumor suppressive function in pancreatic cancer cells, suggesting that rottlerin (5) might be a potential therapeutic target for treating pancreatic cancer [14]. Among the ever-increasing list of naturally occurring anticancer agents, rottlerin (5) was effective in chemotherapy because of its influence on several cellular machineries involved in survival, apoptosis, autophagy, and invasion [17]. In a recent study, rottlerin emerged as the most potent metastasis-associated in colon cancer 1 transcriptional (MACC1) inhibitors [18]. Rottlerin (5) anticancer activity resulted from combination of signaling pathways at multiple levels. Furthermore, the underlying mechanisms described for rottlerin (5) anticarcinogenic activity were diverse and cell-specific [14]. Molecular docking is a computer-based drug design that initiates the docking of a ligand into the active site of the receptor. The motive of receptor and ligand docking interactions can be predicted through three-dimensional visualization of the docked complexes. This research was conducted to explore the binding interactions between receptor protein and the three naturally rottlerin (5) along with JAK known inhibitors, ruxolitinib (1), tofacitinib (2) and gandotinib (6) (Figure 1).
Figure 1: Ruxolitinib (1), Tofacitinib (2), Apigenin (3), Wogonin (4), Rottlerin (5), Gandotinib (6)

Materials and Methods

Protein Preparation

Homology Modeling of the 4AGC Protein: Homology modeling methods make use of experimental protein structures (“templates”) to build receptor proteins in drug discovery. Homology (or comparative) modelling is currently the most accurate method to generate reliable three-dimensional protein structure models. SWISS-MODEL is a structural bioinformatics web-server dedicated to homology modelling to predict protein 3D structures [19,20]. Janus kinase 2 (PDB ID: 4AGC), protein structure retrieved from protein data bank (http://www.rcsb.org/) was missing some amino acid residues. The complete JAK2 protein was modelled by submitting FASTA sequence of 4AGC (chain A) protein into SWISS-MODEL Workspace through automated mode for the development of a more accurate protein model [21]. The 4AGC (Chain A) protein and its sequence were selected as the target protein and query sequence, respectively. The crystal structure of JAK2- (PDB ID: 2W1I) was also obtained from the protein data bank. The 4AGC protein model was built by using the 2W1I protein as a suitable template. In the SWISS MODEL Workspace automated mode, fifty templates of query sequence were generated. The template, 2W1I.1.A, demonstrated highest sequence identity to query sequence and was used to develop an improved model of the 4AGC protein. Global quality estimate, local quality estimate comparison and 4AGC model template alignment with 2W1I.1.A were calculated (Figure 2) [22,23].
Figure 2: Global quality estimate, local quality estimate comparison and 4AGC model template alignment with 2W1I.1. A.
biomedres-openaccess-journal-bjstr
Modeled JAK2 Protein Validation: The 4AGC-Modeled protein quality was validated by Ramachandran plot using Rampage [24] and in SPDBV (Deep View – Swiss – Pdb Viewer) version 4.10 based on the RMSD value obtained by superimposing the 4AGC protein model on its model template 2W1I [25]. 4AGC-Modeled protein was selected for molecular docking to acquire reliable prediction of ligands ability to bind with the receptor. The quality of 4AGCModeled protein was validated by comparing Ramachandran plots of 4ACC, 2W1I and modeled 4AGC using Rampage [24]. A New generation of crystallographic validation tools for the protein data bank and in SPDBV (Deep View – Swiss – Pdb Viewer) version 4.10 based on RMSD value obtained by superimposing 4AGC protein model on its model [25]. Ramachandran plot values of the 4AGC, 4AGC-Modeled protein and its template 2W1I.1.A were obtained (Table 1). In Ramachandran plot generated for 4AGC protein, 96.8% of amino acid residues were found in favored region, 2.8% residues in allowed area, and 0.4% of residues were present in outlier regions (Figure 3). Ramachandran plot of 2W1I.1.A showed 94.6% residues in favored region, 4.0% residues in allowed region, and 1.4% of residues in outlier regions. Ramachandran plot generated for 4AGC-Modeled protein displayed 97.2%, 2.1% and 0.7% of residues in the favored, the allowed, and the outlier regions, respectively. Ramachandran plot data for 4AGC-Modelled, 6FTU and 2W1I proteins suggested favorable reliability of 4AGCModelled protein for subsequent docking studies (Table 1) (Figure 3).Energy Minimization and Refinement of the Modeled 4AGC Protein (4AGC-Modeled): The modeled 4AGC (4AGC-Modelled) protein valency and chemistry were rectified using Chimera (UCSF, San Francisco, CA, USA). Energy minimization and refinement were performed by employing CHARMm force field in order to obtain a protein with least energy [26,27]. Later, polar hydrogen atoms were added to the protein model using Auto Dock tools 4.2.6 screening tool and PyRx v0.8 software (http://pyrx.sourceforge.net/).
Receptor Cavity Prediction: The cavity or the potential ligand binding site of JAK2 (PDB ID:4AGC) was predicted using MVD with volume of 174.08 A3 which was identified as active site for docking using Molegro Virtual Docker (MVD) software. The active binding cavity was further ascertained through a trail docking run of JAK2 and adenosine triphosphate (ATP) (Figure 4).

Preparation of Ligands

The structures of ruxolitinib (1) (CID: 25126798), tofacitinib (2) (CID: 9926791), rottlerin (5) (CID: 5281847) and gandotinib (6) (CID: 46213929) were initially retrieved from PubChem Compound Database (National Center for Biotechnology Information, U.S.
National Library of Medicine). Molecular geometry optimization of ligands was achieved using Avogadro (an open-source molecular builder and visualization tool. Version 1.90.0. http://avogadro.cc/). The force field MMF94 was set with number of steps 500, algorithm steepest descent and convergence of 10e-7 [28]. The structures of ligands were saved in Protein Data Bank (PDB) file format and used for docking study.

Docking Between JAK2 and Ligands

Discovery Studio visualizer and Chimera (UCSF, San Francisco, CA, USA) were chosen for visual inspection and preparations. PyRx software was employed as the virtual screening software. PyRx includes Auto Dock Vina with a Lamarckian genetic algorithm as a scoring algorithm. The ligand/protein simulated interactions of ruxolitinib (1), tofacitinib (2), rottlerin (5) and gandotinib (6) with JAK2 were determined using Auto Dock Vina (Molecular Graphics Lab, La Jolla, CA, USA) [28,29]. The docking was conducted with exhaustiveness of 8 and a grid box with the dimensions for center: 25×25×25 Ã… and box center: center_x = 31.2851, center_y = 0.4544, center_z = 2.9915 for 4AGC docking. PyMol v1.3 (Schrodinger, New York, NY, USA). Auto Dock Vina evaluated target conformation (biomacromolecule) as a rigid unit while ligands were conceded to be flexible and adoptable to the target. The software determined the lowest binding affinity by using different conformations of each ligand. AutoDock Vina searched for the lowest binding affinity conformations and determined 9 different conformations for each receptor and ligand complexes. Each receptor and ligands complex with the lowest binding energy docking poses were selected. The protein-ligand interactions were analyzed with LigPlot and Discovery Studio 4.5 (Dassault Systems BIOVIA, Discovery Studio Modelling Environment, Release 2017, San Diego, USA).
Docking simulations of target JAK2 with ruxolitinib (1), tofacitinib (2), rottlerin (5) and gandotinib (6) were performed in AutoDock Vina. (Molecular Graphics Lab, La Jolla, CA, USA). The AutoDock Vina software prepared the target in a rigid conformation while ligands were permitted to be flexible and malleable to the target. After the completion of docking, ligand conformations displaying greatest binding affinity and lowest docked energies to the target were selected. The hydrogen bonds, bond lengths and hydrophobic interactions between JAK2 and ligands ruxolitinib (1), tofacitinib (2), rottlerin (5) and gandotinib (6) were determined by using LigPlot (http://www.ebi.ac.uk/thornton-srv/software/ LIGPLOT/).

Target-Ligand Complex Unbinding Simulations

The MoMA-LigPath web server and Molecular Motion Algorithms (MoMA) were utilized to simulate ligand unbinding from the binding site to surface of the target. In addition, server discloses flexibility of protein side-chains, ligands and includes only statistical limitations. This process generates mechanistic data on the pathway of each ligand as it moves from the protein surface to the binding site or from binding site to surface of the protein. The program offers molecular interaction graphics, leading the ligands from surface of protein to the binding site. In this process, the program identifies certain residues that are crucial factors for ligand binding or driving ligands towards binding site, in spite of being away from binding site. The docked molecular complexes of JAK2 with ruxolitinib (1), tofacitinib (2), rottlerin (5) and gandotinib (6) that produced the lowest binding energies were selected for unbinding simulations by using MoMA LigPath [30,31].

Results and Discussion

Autonomous activation of the JAK/STAT pathway is an important factor in several pathologies. Genetic mutations targeting this signaling pathway are linked fundamentally with hematologic malignancies as well as diseases associated with uncharacteristic cytokine stimulation. The JAK/STAT pathway is frequently deregulated in malignant diseases caused by irregular immunological response. One of such disorder is myelofibrosis, a rare form of cancers of bone marrow where the bone marrow is replaced by scar tissue failing to produce healthy blood cells as a result of mutations. BCR-ABL1-negative myeloproliferative neoplasms initiate unusual activation of JAK2 caused by various mutations. The discovery of JAK2V617F as the driver mutation of majority of non-BCR-ABL1 myeloproliferative neoplasms encouraged the development of JAK inhibitors. Furthermore, search for JAK2 inhibitors continued following the discovery of JAK2V617F which revealed that other driver mutations like CALR and MPL also displayed tenacity in the activation of JAK2 [10].
The interpretation of the protein-ligand interactions plays an important role in structure-based drug discovery. When each ligand (1, 2, 5 and 6) was docked with JAK2, different binding energies were observed. Of these, known JAK inhibitors, tofacitinib (2) produced the lowest value (-7.4 kcal/mol), compared ruxolitinib (1) (-8.7 kcal/mol), and gandotinib (6) (-9.1 kcal/mol) whereas natural product rottlerin (5) generated the greatest binding energy (-9.3) kcal/mol) when docked with JAK2 receptor. These results suggest that rottlerin (5) might emerge as a promising candidate for the inhibition of JAK2 enzyme activity. The present docking study explored the interactions of ruxolitinib (1), tofacitinib (2), rottlerin (5) and gandotinib (6) with the receptor protein JAK2 and their binding patterns with JAK2 amino acid residues ruxolitinib (1), tofacitinib (2), rottlerin (5) and gandotinib (6) docked with the active site of JAK2.Each amino acid residue within a 4A0 distance from ligand was evaluated for the presence of any van der Waals forces or alkyl, and hydrogen bond interactions.
As a result, ruxolitinib (1), generated 11 van der Waals forces (Leu 24, Gly 25, Lys 26 , Gly 27, Lys 51, Glu 67, Val 80, Arg 149, Asn 150, Asp 163 and Phe 164) , 5 alkyl interactions (Val 32, Ala 49, Met 98, Ser 105 and Leu 152) and 1 hydrogen bond Asp 108 with JAK2; while tofacitinib (2) generated 7 van der Waals forces (Gly 25, Lys 26, Gly 27, Val 80, Arg 149, Gly 162 and Asp 163), 3 alkyl interactions (Leu 24, Val 32, Ala 49, Met 98 and Leu 152), with JAK2; gandotinib (6) generated 10 van der Waals forces (Gly 25, Lys 26, Gly 27, Ala 49, Pyr 100, Gly 104, Ser 105, Asp 108, Gly 162 and Asp 163), 5 alkyl interactions (Leu 24, Val 32, Val 80, Met 98, Arg 149 and Leu 152), 1hydrogen bond (Asn 150) with JAK2 residues whereas rottlerin (5) generated 8 van der Waals forces (Lys 26, Gly 25, Gly 27, Tyr 100, Leu 101, Gly 104, Asn 150 and Asp 163 ), 4 alkyl interactions (Leu 24, Val 32,Ala49 and Leu 152), 4 hydrogen bonds (Ser 105, Asp 108, Arg 107 and Arg 149) with JAK2 residues. Collectively, these results suggested that rottlerin (5) might function as excellent JAK2 inhibitor since it produced the highest binding energy (-9.3 Kcal) (Figure 5).

Conclusion


Myelofibrosis is a cluster of rare bone marrow cancers also known as chronic leukemia that belongs to certain type of blood disorders-myeloproliferative ailments. In case of mylofibrosis one blood stem cell inherits the capacity to reproduce without any regulation and thus generating large numbers of immature blood cells leaving little room for healthy cells. The discovery of JAK2 mutations initiated the discovery of a targeted therapy for myelofibrosis. BCR-ABL1-negative myeloproliferative neoplasms are associated with abnormal JAK2 activation. Most often, the JAK/ STAT pathway is disrupted in malignant disorders with abnormal immunological responses. The discovery of JAK2V617F as a driver mutation of majority of non-BCR-ABL1 myeloproliferative neoplasms in 2005 led to the development of JAK inhibitors. At present, ruxolitinib (1) is the sole FDA approved medication available for the treatment of myelofibrosis.
Our present in silico docking study suggested that rottlerin (5), a natural product displayed strong interactions with JAK2 through hydrogen bonds, van der Waals and alkyl forces with binding energy -9.3 kcal/mol. Additionally, unbinding simulation studies on: ruxolitinib (1), tofacitinib (2), gandotinib (6) and rottlerin (5) in complex with JAK2 revealed that rottlerin (5) took a longer time to unbind from JAK2, compared to ruxolitinib (1), tofacitinib (2) and gandotinib (6). In addition, these data supported our in silico observations for rottlerin (5). The current docking investigations strongly support future research to evaluate the potential of rottlerin (5) as JAK2 inhibitors in the treatment of myeloproliferative neoplasms. In summary, these results suggested that rottlerin (1) might function as better JAK2 inhibitor and should be explored further as a potential solution for the treatment of myelofibrosis.

Rapid Generalized Seizures, Acute Central Nervous System Depression, and Delayed Bradycardia Triggered by Synthetic Cannabinoid “Ganesha” and Methamphetamine - https://biomedres01.blogspot.com/2020/02/rapid-generalized-seizures-acute.html

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Development of Activity of Labour and Occupational Therapies in University Hospital, Pleven, Bulgaria

Development of Activity of Labour and Occupational Therapies in University Hospital, Pleven, Bulgaria

Abstract

Object of current article is to share experience of the Clinic of Physical and Rehabilitation Medicine at the University Hospital - Pleven, in the field of labour therapy and occupational therapy as a part of complete rehabilitation of patients suffering various locomotor and mental disorders. The labour therapy and occupational therapy Service at the University Hospital is established in 1965 by the founder of the physiotherapy in the Pleven hospital, Dr. Rusi Risev, MD. A few large premises are furnished and equipped for carpentry shop, spinning and weaving shop, workshop for paper, leather, yarn and threads. The conducted survey, while applying work therapy within a complete rehabilitation program for patients with various traumas and disorders, received results and accumulated clinical experience give us grounds to recommend equipping such premises in hospitals, in wards for physical and rehabilitation medicine, and to state that the work- and occupational therapy shall take its well-deserved place in improving patients’ quality of life.
Keywords: Labour Therapy; Occupational Therapy; Rehabilitation

Introduction

Patients appropriate for treatment through work activities are patients with locomotor deficit due to limited scope of movements in separate joints or whole limb, or muscle weakness; disorders of cardio-vascular and respiratory systems; metabolism disorders; psychiatric disorders and problems; children with congenital and acquired disorders of central and peripheral nervous system, locomotor system and post-traumatic conditions.
Labour therapy (LT) is a branch of the physical and rehabilitation medicine and due to its specifics has been established as a separate method of treatment. LT means exercise in the form of work activities with treatment purposes. The significance of LT for restoring patient’s independent life and full work capacity is indisputable. The treatment through work activities supports functional, physical and psychic rehabilitation of the patient, improved psychological and emotional state, stimulates patient’s desire to participate actively in the rehabilitation process. The fact that the first described treatments through work activities are connected to treatment of psychiatric disorders expressively points out its psychiatric and therapeutic significance.
The patient’s attention is being kept at the output of the activity which is a basic difference between this therapy and the active kinesiotherapy; it opens chances for emotional expression [1]. Occupational therapy deals mainly with everyday life issues of patients with permanent locomotor and psychiatric disorders. Training and re-training for everyday life activities for people with such disorders is of crucial importance for improving and facilitating their life. For each patient the most important matter is self-service - personal hygiene, dressing, feeding, various home activities [2]. Object of current article is to share experience of the Clinic of Physical and Rehabilitation Medicine at the University Hospital - Pleven, in the field of labour therapy and occupational therapy as a part of complete rehabilitation of patients suffering various locomotor and mental disorders. The labour therapy and occupational therapy Service at the University Hospital is established in 1965 by the founder of the physiotherapy in the Pleven hospital, Dr. Rusi Rusev, MD. A few large premises are furnished and equipped for carpentry shop, spinning and weaving shop, workshop for paper, leather, yarn and threads [3] (Figure 1).
Figure 1: A few large premises are furnished and equipped for carpentry shop, spinning and weaving shop, workshop for paper, leather, yarn and threads.
In 2004 the Medical University of Pleven opened a new academic specialty - Medical Rehabilitation and Ergotherapy, and therefore expanded and rich work in Labour therapy- Sector is required, in order to conduct seminars and clinical practice for the students. Rehabilitative labour therapy or the so-called functional work therapy has the central place in the Service [1]. Its direct purpose is to influence the locomotor deficit in certain joints, limbs or system. Various activities and work with different materials are very useful [4]. The work with paper includes making cards using the quilling technique, folding paper as in origami, papier mache technique, decoupage technique, cutting and applying decorative elements, weaving items from paper rods and other (Figure 2). When working with yarn and textile materials (yarns, threads, pack-threads, fabric) various items are being knitted or crocheted; the patients embroider using embroidery frame, tie macram̩, apply the ajour technique, weave on horizontals or vertical loom or weaving frame (Figure 3). The work with leather includes manufacturing items from leather Рglass cases, purses, book clips, book binds and folder binds, jewelry (Figure 4).
Figure 2: The work with paper includes making cards using the quilling technique, folding paper as in origami, papier mache technique, decoupage technique, cutting and applying decorative elements, weaving items from paper rods and other.
The work with wood includes manufacturing painting frames, fire-writing on souvenirs, processing plywood (Figure 5). When working with plastic materials the easiest to find and use is the bread dough, also fondant dough for making small Figures and decoration of confectionary. Available and easy to work with, especially for children, is the plasticine or potter’s clay (Figure 6). During the years a work therapy for patients in children age has been developed, called game therapy. It is designated mainly to support the general psychological and physical development of children in certain age and to prevent permanent disability. Various toys are appropriate, to support and improve hand grip, moving objects are used to stimulate initial walking skills, games with imitation; for older children are used various activities from school lessons in Domestic Skills and Techniques and Arts (Figures 7 & 8).

Conclusion


The conducted survey, while applying work therapy within a complete rehabilitation program for patients with various traumas and disorders, received results and accumulated clinical experience give us grounds to recommend equipping such premises in hospitals, in wards for physical and rehabilitation medicine, and to state that the work- and occupational therapy shall take its welldeserved place in improving patients’ quality of life. It is our deep belief that we need to popularize work therapy treatment and shall make maximum efforts to restore the activity of abandoned or closed services for work- and occupational therapy or opening new ones, which will contribute to a full-value rehabilitation and independent everyday life of patients.

Effect of Coenzyme Q10 Treatment on Clinical Manifestation in a Young Woman with Mitochondrial Diabetes - https://biomedres01.blogspot.com/2020/02/effect-of-coenzyme-q10-treatment-on.html

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Tuesday, February 25, 2020

Effect of Coenzyme Q10 Treatment on Clinical Manifestations in a Young Woman with Mitochondrial Diabetes

Effect of Coenzyme Q10 Treatment on Clinical Manifestations in a Young Woman with Mitochondrial Diabetes

Abstract

We report the case of a 25-year-old woman with mitochondrial diabetes mellitus (MDM). She was diagnosed with Wolff-Parkinson-White syndrome at 12 years old. She was later diagnosed as diabetes mellitus without autoimmune disorders at 15 years old, and the mitochondrial DNA 3243 mutation was detected by the gene analysis. Neurosensory deafness was identified at 16 years of age, and hypertrophic left ventricular cardiomyopathy was detected at 24 years of age. We started administration of coenzyme Q10 (CQ10), and subsequently her clinical symptoms and glycemic control were improved accompanied by decreasing blood lactate level. We assessed neurological signs of MDM using the Japanese Mitochondrial Disease Rating Scale (JMDRS). The JMDRS was improved from 12/80 points at the start of CQ10 to 5/80 points at 12-month period after starting CQ10. These findings suggest that CQ10 treatment could be effective on clinical symptoms, a lactate level and glycemic control in a patient with MDM.
Keywords: Mitochondrial Diabetes Mellitus; Glycemic Control; Endogenous Insulin Secretion; Neuromuscular Symptom; Coenzyme Q10
Abbrevations: BMI: Body Mass Index, CPR: C-Peptide Immunoreactivity, CQ10: Coenzyme Q10, FPG: Fasting Plasma Glucose, HbA1c: Hemoglobin A1c, JMDRS: Japanese Mitochondrial Disease Rating Scale, MODY: Maturity Onset Diabetes of the Young, MDM: Mitochondrial Diabetes Mellitus, WPW syndrome: Wolff Parkinson White Syndrome

Introduction

Mitochondrial disease shows various clinical manifestations such as neuromuscular disorders, including muscle weakness, encephalopathy, mental disorder and neurosensory deafness, cardiomyopathy, short stature and diabetes mellitus. Of these disorders, diabetes mellitus is known as maternal inherited mitochondrial diabetes mellitus (MDM), which is identified in up to 1% of all patients with diabetes mellitus. The mitochondrial DNA 3243A>G mutation is most common genetic abnormality (80-90%), whereas other mutations, such as 8296A>G and 14577T>G, are less frequent [1]. Diabetes mellitus is the most common endocrine disorder in mitochondrial disease, because mitochondrial dysfunction greatly affects pancreatic β-cells, leading to insulin secretion defect [2]. Coenzyme Q10 (CQ10) is well known to act as an electron carrier of the respiratory chain in mitochondria and has been shown to improve the mutation-associated dysfunction of the respiratory chain in mitochondria. Various reports demonstrated that administration of CQ10 had some clinical benefits toward neuromuscular symptoms [3], elevated lactate levels [4], and neurosensory deafness [5]. On the other hand, there were few reports showing improvement in glycemic control and endogenous insulin secretion when using CQ10 in patients with MDM [5,6]. We encountered a case of MDM with the mitochondrial DNA 3243A>G mutation, and hereby reported changes in glycemic control and other clinical manifestations after administration of CQ10.

Case Report

A 25-year-old woman presented to our hospital with leg numbness, malaise, headache and muscle weakness, which had existed for 1-month period. She was already diagnosed with MDM and treated with insulin. Her hemoglobin A1c (HbA1c) levels continued to be 8-9%, despite multiple daily injections of insulin. She was admitted to our hospital for examination of neuromuscular symptoms and improvement of glycemic control.
In the past history, her growth and psychomotor development were normal. She was diagnosed with Wolff-Parkinson-White (WPW) syndrome at 12 years of age. She was found to have glucosuria through a urine glucose screening at schools at 15 years of age and identified as having diabetes in the detailed examination of the screening program. She was not obese with body mass index (BMI) of 18.8kg/m2, β-cell associated antibodies were all negative, and insulin secretion capacity was maintained at the time of diagnosis. There were no neuromuscular symptoms, including muscle weakness, fatigue and impaired hearing, at that time. Subsequently, maturity-onset diabetes of the young (MODY) genes and mitochondrial DNA genes were analyzed, and the mitochondrial DNA 3243A>G mutation was detected (Figure 1).
Figure 1: Analysis of mitochondrial DNA 3243 mutations.

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Figure 3: Changes in C-peptide (CPR) levels on glucagon loading test before and after using CQ10.
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Discussion

CQ10 is an essential electron carrier in the mitochondrial respiratory chain. It acts as an electron carrier in the electron transport chain from complex I-Ⅱ to complex Ⅱ-Ⅲ, and is present in all tissues and cells in the inner mitochondrial membrane [10]. CQ10 is also a lipid-soluble antioxidant and scavenges reactive oxygen species [11]. The mechanisms connecting mitochondrial DNA 3243 mutations and onset of diabetes are thought to be as follows:
a) Accelerated production of reactive oxygen species and increased oxidative stress,
b) Reduced oxidative phosphorylation and decreased ATP levels in pancreatic β-cells,
c) Damaged signal transduction in pancreatic β-cells and reduction in their cell numbers due to apoptosis,
d) Exhaustion of insulin secretion [12-14].
CQ10 plays a role in stopping step 1), thereby preventing progression to steps 2), 3), and 4). Accordingly, administration of CQ10 might prevent the advance to insulin exhaustion; improving insulin secretion and glycemic control. Richter et al. [15] reported that insulin secretory defects may result from anti-oxidation activities and dysfunction in the mitochondrial respiratory chain. Administration of CQ10 can stop the dysfunction of the mitochondrial respiratory chain and insulin secretion could be improved. The course of the patient described showed important clinical information of possibility of improvement in glycemic control and endogenous insulin secretion as well as clinical symptoms and a blood lactate level with using CQ10 in MDM. There are some reports showing therapeutic effects on neuromuscular symptoms and a blood lactate level [3-6].
On the other hand, there were few reports showing improvement in glycemic control and endogenous insulin secretion when using CQ10 in patients with MDM [5,6]. Okazaki et al. [6] reported a large dose of CQ10 (60 mg/day) was effective to improve HbA1c levels from 8.5% to 7.5% and to increase glucagon loading CPR levels from 1.8 ng/dL to 2.0 ng/mL at the study of 2-year period. There were some other case reports demonstrating the efficacy of CQ10 on glycemic control for a short period less than 1 year [5,16,17]. Reported more increase in CRR response on glucagon loading test and urinary excretion of CPR among 28 patients with MDM compared with 16 patients without receiving CQ10 treatment for 3-year study period. As compared to the studies conducted by Okazaki et al. [5,6] our study period for 1 year is shorter, and it seems too early to judge the effect of CQ10 on glycemic control and endogenous insulin secretion. Longer-term follow-up should be necessary to evaluate the effect of CQ10 on diabetic control in our case. On the other hand, we started some medication, such as prosultiamine, levocarnitine chloride and tocopherol acetate, other than administration of CQ10. These drugs could play a role to improve mitochondrial function with increasing endogenous insulin secretion and reducing plasma glucose levels. In conclusion, we reported the clinical course with CQ10 treatment in the case of MDM presenting with mitochondrial DNA 3243A>G mutation. CQ10 treatment could be effective on clinical symptoms, a lactate level and glycemic control in a patient with MDM.

Tubal Stump Pregnancy in ART Patients Two cases of ectopic stump pregnancy after IVF-ET - https://biomedres01.blogspot.com/2020/02/tubal-stump-pregnancy-in-art-patients.html

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Rapid Generalized Seizures, Acute Central Nervous System Depression, and Delayed Bradycardia Triggered by Synthetic Cannabinoid “Ganesha” and Methamphetamine

Rapid Generalized Seizures, Acute Central Nervous System Depression, and Delayed Bradycardia Triggered by Synthetic Cannabinoid “Ganesha” and Methamphetamine

Abstract

Objective: To report a case of immediate generalized seizure, acute central nervous system (CNS) depression, and delayed bradycardia following low-dose inhalations of synthetic cannabinoid (SCB), Ganesha, a cannabinoid (CB) agonist. Background: Despite the wide use and legalizing movements of SCB, its health risks are under-reported. We report its severe toxic manifestation including rapid-onset seizure, CNS depression, and negative chronotropic effect on the heart triggered by low dose inhalation.
Case Report: A fit 36 years old methamphetamine male user presented with generalized tonic-clonic seizures within three minutes of SCB inhalations. Seizures recurred three times; each episode lasted 3 to 4 minutes. This was followed by acute CNS depression within 30 minutes of SCB use, with fluctuating GCS between 3 and 9. Intubation was performed for airway security. Initial vitals were: T, 37.2; BP, 91/49 mmHg; HR, 78 bpm; RR, 12/min on ventilator. Full blood counts, liver functions and serum chemistry values were unremarkable. Imaging studies including CXR and non-contrast CT of Brain/neck were normal. Bedside ECG were initially normal. Urinary drug screen tested positive for cannabinoid, amphetamine, and benzodiazepines. During ICU admission, recurrent episodes of sinus bradycardia (39 bpm) were observed at approximately 14 hours post-SCB inhalation. Boluses of atropine were required for transient chronotropic support. Patient made unremarkable recovery in the following day and self-discharged.
Discussion: SCB and CB agonist are easily accessible in many parts of the world or via internet. Its neurotoxicity can be potentiated by chronic methamphetamine use. Although some reports suggested CB agonists have anti-epileptic benefits, we believe the risks and benefits of SCB and CB agonists require more cautious evaluation.
Conclusion: Inhalation of SCB or CB agonist can cause rapid generalized seizures and potential coma, especially with concurrent use of methamphetamine. Clinician and general public should be made aware on the severity of its health risks even with low-dose use.
Keywords: Synthetic Cannabinoids, Seizures, Bradycardia, Marijunanas, Methamphetamine
Abbreviations: SCB: Synthetic Cannabinoids; GCS: Glasgow Coma Score; HR: Heart Rate; RASS: Richmond Agitation-Sedation Scale; RR: Respiratory Rate; CT: Computed Tomography; CXR: Chest X-ray; BP: Blood Pressure

Introduction

“Ganesha,” a new form of synthetic cannabinoids (SCB), has becoming a popular alternative to the cannabinoids (CB) [1]. CB-use has been supported by recreational advocates for its potential on pain control, anti-inflammatory, and anti-epileptic effects [2]. However, its adverse effects are growing concerns [3,4]. SCBs act as CB-agonists and should be used with caution. The death rates associated with SCBs have been rising with their popularity [3]. Due to inconsistent means of production and ingredient data, health risks of SCBs are difficult to predict. To date, typical presentations of CB-agonist toxicity ranges from nausea, vomiting, agitation,drowsiness, and tachycardia in mild cases to psychosis, myoclonus, seizures and coma in severe cases [4]. However, these responses are not predictable, especially when mixing with drugs such as methamphetamine, a popular sympathomimetic psychostimulant. Although delayed-onset of seizures have been documented to associate with SCBs [4], rapid onset has not been reported. We report a case of low-dose Ganesha inhalation triggering immediate seizures with acute mental deterioration followed by delayed bradycardia.

Case Report

A 36-years-old healthy male was brought in by ambulance for generalized seizures following two inhalations of SCB, “Ganesha”. Collateral history confirmed the following: 1. profuse vomiting following two puffs of Ganesha; 2. generalized tonic-clonic seizures developed within 3 minutes, with four-limbs thrashing, body twitching, and eyes rolling back; 3. Fluctuating mental status with agitations, Glasgow Coma Score (GCS) range between 3 and 9. Each of the three lasted 3-4 minutes and was not accompanied by postictal incontinence. Intravenous midazolam 2.5mg was given for agitations during transfer, but with little effect. Within 30 minutes of ED arrival, his GCS dropped to 6 (E1 V1 M4) without recovery. An uncomplicated intubation was performed with 100mg Ketamine and 100mg rocuronium. His initial vitals post-intubation were: weight, 95 kg; height, 192 cm; temperature (T), 37.2 ˚C; blood pressure (BP), 91/49 mmHg, heart rate (HR), 78 bpm, respiratory rate (RR), 12/min. BP improved to 112/62 mmHg with 1.5 L of fluid resuscitation. Sedation was maintained at Richmond Agitation- Sedation Scale (RASS) -4 with propofol infusion at 200mg/hr for agitation and airway security.
Full-body examinations were unremarkable. His has right hemicolectomy for bowel cancer at the age of 29. He takes no regular medications other than 2-year history of daily methamphetamineuse. He has 20-pack-year smoking history. Initial ECG was normal, (Figure 1). Chest X-ray (CXR) was clear. Non-contrast computed tomography (CT) of the brain and neck was normal. Full blood count, liver function, serum chemistry and serial arterial blood gas were unremarkable. Urinary drug screens tested positive for amphetamine, cannabinoid, and benzodiazepine, (Figure 2). He developed sinus bradycardia with rates of 39 bpm at 14 hours post-SCB inhalation. Boluses of atropine 600 mcg were required in ICU. The patient made unremarkable recovery on ICU day 2 and was successfully extubated. Unfortunately, he then self-discharged against medical advices and continued to use recreational drugs.
Figure 1: (a) initial ECG during ED presentation. (1b) sinus bradycardia captured 14-hours post-SCB use. No intrinsic cardiac conduction abnormality was detected.
biomedres-openaccess-journal-bjstr

Discussion

Our case supports that SCB’s use can be dangerous. Rapid life-threatening seizures followed by acute mental deterioration can occur with low-dose Ganesha inhalations. Multi-substance cocktail by avid users complicates treatments for toxicity due to a combination of sympathetic and parasympathetic features. Proactive measures for SCB toxicity are sometimes required. SCB has been documented to cause convulsions; however, the onsets are usually delayed and triggered by higher-dose of use [4]. Activation of CB1 receptors by SCB or CB agonist has been postulated to control epilepsy [2,5]; this is contrary to our observation. While the observed seizure activities may be due to patient’s methamphetamine-use, typical features of sympathomimetic toxicity including tachycardia, hypertension, or cerebral ischemia were not observed [6]. On the other hand, chronic methamphetamine-use likely contributed to the low-seizure-threshold through dopamine-store depletion and damages on serotonin and dopamine neuronal transmissions [7]. Conflicting reports on SCB triggering tachycardia or bradycardia are noted [4,8]. We reported a suspected negative chronotropic effect from the use of Ganesha. We acknowledge propofol may suppress HR but only at much higher dose [9].

Conclusion

We demonstrated that Ganesha, a new form of SCB, have multiple serious adverse effects when used with methamphetamine. These risks include immediate seizures, CNS depression and potential respiratory depression, and suspected bradycardia following lowdose inhalation. It is therefore important for clinicians to prepare for these medical emergencies when encountering a patient with SCB toxicity.


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Ventricular Septal Defect in Eight Holstein Calves in a Large Dairy Herd

  Ventricular Septal Defect in Eight Holstein Calves in a Large Dairy Herd Introduction In this clinical case series report, we aimed to pre...