Obesity as a result of overeating as well as a number of well described eating disorders has been accurately considered to be a world-wide epidemic. Recently a number of theories backed by a plethora of scientifically sound neurochemical and genetic studies provide strong evidence that food addiction is similar to psychoactive drug addiction. Our laboratory has published on the concept known as Reward Deficiency Syndrome (RDS) which is a genetic and epigenetic phenomena leading to impairment of the brain reward circuitry resulting in a hypo-dopaminergic function. RDS involves the interactions of powerful neurotransmitters and results in abnormal craving behavior. A number of important facts which could help translate to potential therapeutic targets espoused in this focused review include: (1) consumption of alcohol in large quantities or carbohydrates binging stimulates the brain’s production of and utilization of dopamine; (2) in the meso-limbic system the enkephalinergic neurons are in close proximity, to glucose receptors; (3) highly concentrated glucose activates the calcium channel to stimulate dopamine release from P12 cells; (4) a significant correlation between blood glucose and cerebrospinal fluid concentrations of homovanillic acid the dopamine metabolite; (5) 2-deoxyglucose (2DG), the glucose analog, in pharmacological doses is associated with enhanced dopamine turnover and causes acute glucoprivation. Evidence from animal studies and fMRI in humans support the hypothesis that multiple, but similar brain circuits are disrupted in obesity and drug dependence and for the most part, implicate the involvement of DA-modulated reward circuits in pathologic eating behaviors. Based on a consensus of neuroscience research treatment of both glucose and drug like cocaine, opiates should incorporate dopamine agonist therapy in contrast to current theories and practices that utilizes dopamine antagonistic therapy. Considering that up until now clinical utilization of powerful dopamine D2 agonists have failed due to chronic down regulation of D2 receptors newer targets based on novel less powerful D2 agonists that up-regulate D2 receptors seems prudent. We encourage new strategies targeted at improving DA function in the treatment and prevention of obesity a subtype of reward deficiency. Reward Deficiency Syndrome , lacks enough dopamine receptor sites to release the normal amount of dopamine into the Reward Center of the brain and dopamine function is reduced , tuberoinfundibular neurons, globus pallidus, and other brain regions .It is well known that glucose by the actions of an ATP-sensitive potassium channel modulates GABA terminal transmitter release and SN dopamine neuronal activity. In a study, The RDS hypothesis , embraceIn terms of understanding the brain reward cascade there is evidence that serotonergic activation may also influence dopamine D2 receptor function. This is of interest when we consider the so-called “sweet tooth” which has predominantly been associated with serotonin. The work by It is well known that in preclinical studies 2-deoxyglucose (2DG), the glucose analog, in pharmacological doses is associated with enhanced dopamine turnover and causes acute glucoprivation. In fact, indications from lines of evidence are that dopamine release is associated with a variety of metabolic stressors that include acute glucose deprivation. That dopamine induces hyperglycemia in both animals and man is well known. The direct effects of dopamine on the release of glucose from primary cultured rat hepatocytes were studied in Japan by Certainly, the compulsion and the loss of control observed in the drug taking behaviors of drug-addicted subjects is similar to overeating by obese individuals. Although not well understood the mechanisms of these behaviors were studied by DRD2 AI allele  during pregnancy and lactation. Compared to controls rat offspring demonstrated an increase in weight and BMI, their mothers displayed binge eating and junk food overeating behaviors . These oIn support of hypodopaminergic genetics and sugar addiction In fact, cross-sensitization was observed in rats showing the movement from to sugar to drugs . Surprisbinging, withdrawal, and craving by presenting evidence from animal models of binge eating of sucrose or glucose, in a review that summarized evidence for “food addiction.” In a PANTHER analysis of gene array expression performed on 152 unique genes, resulting in a total of 193 multiple-factor (MF) assignments, sorted into 20 categories  peer reviewed articles on many peripheral and central nervous system (CNS) behaviors and physiological processes. Understandably addiction or even the broader term RDS involves very complex gene × environment interaction and one cannot expect that a single gene like the DRD2 gene would have a powerful effect by itself, however, albeit many negative findings, there is still a plethora of evidence for the role of the DRD2 gene polymorphisms and a number  of addictive and other reward dependent behaviors including: pendence ; drug dependence ; mood diisorders ; rearingehaviors ; obesity compared to normal weight controls favors the surfeit theory rather than the deficit RDS concept. While this might be true we must caution against these findings because the controls in the study may not reflect a phenotype free of all RDS behaviors which could lead to spurious results. The suggestion of blocking Dopamine activity in the reward circuitry may be of interest in the short term but damaging in the long term as discussed in this article (In terms of eating disorders there have been a number of reports indicating the potential link between reward gene polymorphisms and binge eating . The fin article . InteresWhile there is evidence from Stice’s group that polymorphisms in both dopamine D2 and D4 result in a blunted response to palatable foods and subsequent weight gain  a paper We have discussed the potential problems associated with bariatric surgery such as transfer of addiction ,b and thIn addition while we have pointed out that there is evidence for a decreased availability of D2R in obese subjects  there isWhile additional studies are required to determine the link between dopaminergic function and AN as well as other eating disorders, there are a number of neurogenetic reports. It is of interest that the complex KB220Z and variants thereof have overcome brain reward circuitry abnormalities, in protracted abstinent psychostimulant abusers observed using qEEG analysis. In fact, KB220Z following only one oral dose of 24 g resulted in an increase in alpha bands with a concomitant increase in low beta bands after 1 h, an effect which usually requires 10–20 biofeedback sessions. This is further supported by preliminary work in China using fMRI showing direct significant activation of dopaminergic pathways compared to placebo during the resting state . Thus ifIn summary, typically, obesity is associated with abnormal eating behaviors. Brain imaging studies, in both humans and animal models, for the most part, implicate the involvement of DA-modulated reward circuits in pathologic eating behaviors. It is known that food cues increase striatal extracellular DA, providing evidence for the role of DA in the non-hedonic motivational properties of food . In addiThus, we submit that results from these on-going investigations indicate that multiple, but similar brain circuits are disrupted in obesity and drug dependence. We encourage new strategies targeted at improving DA function in the treatment and prevention of obesity a subtype of reward deficiency ,b.The authors contributed equally to this manuscript and all provided approval.Kenneth Blum is the holder of a number of patents in both the US and foreign countries involved with genetic testing and natural D2 agonistic activity to treat RDS including obesity. He is currently the owner of IGENE, LLC., Synaptamine, Inc. and co-owner of Victory Nutrition, LLC., and RD Solutions LLC. He is a paid consultant from Malibu Beach Recovery Center, Path Foundation NY, USA, RDSolutions, Victory Nutrition, and Chief Scientific Advisor Dominion Diagnostics, LLC. Mark S. Gold is a paid consultant of Malibu Beach Recovery Center. There no other conflicts to report.


Despite its long-standing status as the diagnostic “gold standard”, the renal transplant biopsy is limited by a fundamental dependence on descriptive, empirically-derived consensus classification. The recent shift towards personalized medicine has resulted in an increased demand for precise, mechanism-based diagnoses, which is not fully met by the contemporary transplantation pathology standard of care. The expectation is that molecular techniques will provide novel pathogenetic insights that will allow for the identification of more accurate diagnostic, prognostic, and therapeutic targets. Here we review the current state of molecular renal transplantation pathology. Despite significant research activity and progress within the field, routine adoption of clinical molecular testing has not yet been achieved. The recent development of novel molecular platforms suitable for use with formalin-fixed paraffin-embedded tissue will offer potential solution for the major barriers to implementation. The recent incorporation of molecular diagnostic criteria into the 2013 Banff classification is a reflection of progress made and future directions in the area of molecular transplantation pathology. Transcripts related to endothelial injury and NK cell activation have consistently been shown to be associated with antibody-mediated rejection. Prospective multicenter validation and implementation of molecular diagnostics for major entities remains an unmet clinical need in transplantation. It is expected that an integrated system of transplantation pathology diagnosis comprising molecular, morphological, serological, and clinical variables will ultimately provide the greatest diagnostic precision. Despite its limitations, the renal transplant biopsy still represents the diagnostic “gold standard” . Its diaTo date, the majority of the comprehensive data sets that include clinicopathological correlations have been derived from quantitative transcriptomics analysis of renal transplant biopsies and, to a lesser degree, urine and blood –11. DespFor most molecular platforms, extra biopsy material needs to be specifically procured and stabilized, potentially representing additional risk and inconvenience for the patient , 18. HowOrgan donation and especially brain death induces a significant molecular response in donor tissue , 22. Quawnt and notch [At the transcriptional level, the response to tissue injury presents as a reduction in the expression of genes related to cell transport and an up-regulation of cell cycle, repair and tissue remodelling transcripts along with embryonic pathways like nd notch , 24. In nd notch . The mRNnd notch . In micrnd notch . The strnd notch . MoleculNumerous studies have described the molecular phenotype of renal allograft biopsies presenting with the characteristic histological features of TCMR : transcripts expressed by subsets of T lymphocytes (cytotoxic T lymphocytes (CTLs), effector memory T cells, T helper cells, regulatory T cells –31), traHundreds of individual members in the described sets of genes associated with TCMR change their expression in a highly correlated, stereotyped fashion, moving in large groups that reflect the major biological processes operating in renal allografts , 15, 43.Accordingly, the Edmonton group used their comprehensive collection of human renal allograft biopsy mRNA microarray data to build an unsupervised predictive TCMR classifier , 46. ThiIn 2013, the international Banff classification for allograft rejection underwent significant revision and now includes molecular assessment of antibody-mediated injury as a potential diagnostic criterion for ABMR independent of C4d staining . Over thIn the vast majority of ABMR, anti-HLA antibodies find their target in the microcirculation of the allograft. This interaction between antibodies and the endothelial cell causes stress to the microcirculation, mediated through classical complement activation, direct interaction of the antibody with the endothelium, or cell-dependent cytotoxicity via Fc receptors on neutrophils, NK cells, or macrophages . Such inSubsequently, as the correlate of antibody-facilitated cell-dependent cytotoxicity, molecules specific for NK cell infiltration were shown to be associated with microcirculation inflammation  and the presence of DSA , 52. By Several groups have since independently confirmed these mechanistically derived associations between ABMR and endothelial, NK cell, and inflammatory transcripts. The Mayo group studied the intragraft gene expression profiles of positive crossmatch (+XM) kidney transplant recipients who do and do not develop transplant glomerulopathy (TG). Comparison of protocol renal allograft biopsies in + XM/TG+ and control groups revealed significantly altered expression in up to 3200 genes, including inflammatory, NK cell, and endothelial cell transcripts . SimilarThese findings indicate that molecular studies, particularly with endothelial gene sets, can be used to measure ongoing ABMR activity leading to TG, which is associated with eventual progression to graft failure. Therefore, adding quantitative molecular assessments to the Banff classification for DSA-positive cases has the potential to increase diagnostic precision for C4d-negative antibody-mediated rejection.A molecular classifier for the prediction of allograft failure in clinically-indicated biopsies taken more than one year post-transplantation was described as being superior to all known clinical  and morphological risk factors (Banff lesion scores and diagnoses) for allograft failure. Interestingly, the classifier utilized genes included in the acute molecular AKI response as the main source for prediction. This suggests that an ongoing active molecular injury response in the tissue, due to progressive diseases like rejection or glomerular diseases, is the main correlate for functional deterioration in late allograft biopsies . IncreasThe results obtained from genome-wide expression studies in kidney transplant biopsies indicate that the vast majority of differentially expressed molecules represent a stereotyped tissue response to injury caused by and overlapping between different disease processes. However, within this non-specific injury and inflammation response, identification of patterns correlating with disease activity and prognosis can allow for disease-specific information to be elucidated Fig. . FindingIt is therefore likely that an integrated diagnostic system comprising molecular, morphological, serological, and clinical variables, as proposed in the revised 2013 Banff classification, will provide the greatest diagnostic precision . The ado


Cardiac computed tomography angiography (CCTA) has technically matured into a robust imaging modality for various cardiac disorders. Whereas early trials focused on assessment of the efficacy of CCTA in comparison with established recommended methods, current research efforts focus on the effectiveness of the technique in specific clinical scenarios. In this article, we provide an overview of recent technology advances, describe major clinical scenarios in which CCTA has been evaluated, and detail pertinent evidence from completed or ongoing clinical trials, including its use to investigate acute chest pain, its use among patients with stable chest pain syndrome, and its prognostic value for the occurrence of cardiovascular events. Over the last decade cardiac computed tomography angiography (CCTA) has emerged as an established technique for assessment of coronary artery disease (CAD) . As a reWhereas early trials focused on assessment of the efficacy of CCTA in comparison with established reference methods, for example invasive coronary angiography or intravascular ultrasound, more recently, the effectiveness of the technique in specific clinical scenarios has been under investigation. These studies address the true value of the technique in a real-world clinical setting and identify potential downstream effects, for example increased test utilization and costs.In this review, we provide an overview of recent technological advances, with special emphasis on radiation exposure, describe major clinical scenarios in which CCTA has been evaluated, and detail pertinent evidence from completed or ongoing clinical trials, including its use to investigate acute chest pain, use of CCTA for patients with stable chest pain syndrome, and its prognostic value for the occurrence of cardiovascular events.Current implementation and evaluation of CCTA in a variety of clinical scenarios can predominantly be attributed to substantial technical developments in recent years resulting in short examination times, high temporal and spatial resolution, and low-dose acquisition techniques.Initially, CCTA was performed using retrospective ECG gating applying continuous photon emission throughout the cardiac cycle. However, although this approach allows for substantial flexibility with regard to post-processing and assessment of left ventricular function, radiation exposure usually totals 10–20 mSv . More reAt the same time, advanced reconstruction techniques with or without the use of low tube current procedures have been shown to lead to lower radiation exposure acquisitions with maintained high image quality . OverallAfter several small, single-center studies, three major, multicenter trials studied the diagnostic accuracy of CCTA for detection of significant coronary stenosis in comparison with invasive angiography, the established clinical reference standard –14. TheyAcute chest pain is one of the leading symptoms in the emergency department (ED) with more than eight million visits annually in the United States alone . PatientRule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT) study, found excellent sensitivity and negative predictive value (both 100 % for the presence of any atherosclerotic plaque) to rule out ACS in 368 subjects who presented with acute chest pain to the ED and in whom the initial clinical evaluation was inconclusive  [In several observational cohort studies, CCTA has been studied in comparison with invasive coronary angiography for detection of ACS. One of the major studies, the markers) . Hollandmarkers)  examinedmarkers) , 27 haveCoronary Computed Tomography Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment (CT-STAT) study was performed on 699 subjects and enrolled patients with acute chest pain but inconclusive evaluation in the ED [As a result of encouraging efficacy studies, CCTA has been studied in three large multicenter randomized trials to determine whether implementation of the technique results in improved clinical outcome in the acute chest pain setting Table . The Corn the ED . Randomin the ED . As a fon the ED •• found n the ED . Over a n the ED .Table 1RNotably, this effect is associated with an excellent safety profile of CCTA. In two large studies there was no myocardial infarction or cardiac death within the first month after a negative CCTA scan ••, 30. FBetter Evaluation of Acute Chest Pain With Computed Tomography Angiography (BEACON) study is a randomized, controlled trial, currently being conducted in the Netherlands, evaluating the incremental value of CCTA among approximately 500 patients with acute chest pain and suspected ACS . The study is evaluating successful discharge rate of patients undergoing CCTA. Furthermore, in contrast with other studies, the investigators also intend to examine the positive predictive value of severe CAD defined by CCTA for subsequent necessary revascularization. Because this study is the first European trial examining the use of CCTA in the ED setting, the results are relevant, because they provide initial findings on potential benefits in healthcare costs and resource allocation outside the US healthcare system.The Comparing CT Scan and Stress Test in Patients With Known Coronary Artery Disease Hospitalized for Chest Pain (PROSPECT-CAD) focuses on patients hospitalized for acute chest pain, comparing CCTA and radionuclide stress myocardial perfusion imaging . The study objective is to determine whether CCTA or nuclear stress testing is superior in identifying chest pain patients with severe CAD who need to undergo revascularization according to findings of invasive angiography and current guidelines.The Study The CT-STAT trial suggested a potential reduction in costs of care by 38 % when CCTA was compared with myocardial perfusion imaging . HoweverOverall, it seems that further, more cost-oriented analysis is warranted within large randomized trials, to determine whether use of CCTA among patients with acute chest pain eventually results in increased test utilization with limited benefit for the patient. Also, available cost estimates are only true for the United States and have not been evaluated for other countries where reimbursement might be substantially different for imaging, laboratory and other diagnostic testing.The diagnostic work-up of patients with suspected significant CAD depends on the pretest likelihood of disease, which can be assessed by use of a variety of scoring systems, e.g. the Diamond–Forrester Classification , 33. EstAssessment by Coronary Computed Tomography Angiography of Individuals Undergoing Invasive Coronary Angiography (ACCURACY) study, which included 230 patients, was the first prospective multicenter trial to evaluate stable patients without prior known CAD undergoing CCTA and quantitative coronary angiography [Most of the initial studies on the diagnostic accuracy of CCTA were obtained from patients referred for invasive angiography who presented with stable angina. Two recent meta-analyses pooled data from 960 and 1,286 patients, respectively , 38. Botiography . The stuiography .Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography Angiography (CorE-64), an international, multicenter study. Both pretest probability and CAC scoring were important factors for the effectiveness of CCTA to detect significant coronary stenosis, because CCTA was found to be less effective among patients with a CAC score of ≥600 and those with a high pretest probability for obstructive vessel disease [Data from reasonably sized randomized controlled trials of CCTA in the setting of stable angina are not yet available. As such, recommendations by current appropriate use criteria for CCTA among patients with stable angina but low-to-intermediate CAD likelihood, especially in the setting of equivocal prior study results, are based on observational studies . One of  disease .While existing evidence is scarce, there are two large ongoing randomized studies of patients with stable chest pain syndrome.PROspective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) is a randomized controlled trial to determine whether an initial non-invasive anatomic imaging strategy with CCTA is associated with improved clinical outcomes in comparison with a functional testing strategy, including exercise ECG, stress echocardiography, and nuclear myocardial perfusion imaging . Primary and secondary endpoints include time to first event, death, MACE, cumulative radiation exposure, medical costs, and quality of life. The study intends to include 10,000 patients with more than 9,000 subjects enrolled in July 2013.The Randomized Evaluation of Patients With Stable Angina Comparing Diagnostic Examinations (RESCUE) is a randomized, controlled multicenter trial to compare a CCTA-based strategy with a nuclear myocardial perfusion-based diagnostic strategy among patients with stable angina . Results from CCTA and myocardial perfusion imaging are used to direct patients to follow-up visits, optimum medical therapy, and revascularization. Over the follow-up period, incidence of MACE as a primary endpoint is documented. The study is intended to enroll 4,500 patients. The main study hypotheses are that use of CCTA is associated with no increase in MACE or revascularization, reduced cost, reduced risks, additional insights into alternate explanations of chest pain, and increased cost-effectiveness.The International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) is to evaluate the best treatment strategy for patients with stable ischemic heart disease and high risk profile . The study is intended to enroll 8,000 patients who will randomly be assigned to one of two treatment groups: routine invasive coronary angiography followed by revascularization plus optimum medical therapy or optimum medical therapy alone, with revascularization reserved for those who fail medical treatment. The study is powered for a primary endpoint of cardiovascular death or nonfatal myocardial infarction. Before randomization, patients will undergo CCTA to exclude subjects without obstructive CAD or with unprotected left main disease.The excellent diagnostic performance and safety profile of CCTA enables its use as a reference in large-scale clinical trials. The purpose of the Several cost-analyses are available demonstrating that, for patients with a low to intermediate likelihood of obstructive CAD, CCTA is particularly cost-effective compared with other imaging modalities, for example myocardial perfusion imaging , 40. WheBesides the diagnosis of overt cardiovascular disease state, risk stratification remains of critical importance to guide lifestyle modification and therapeutic options. Established imaging modalities that encompass prognostic information are myocardial perfusion imaging and stress echocardiography , which hCoronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry (CONFIRM) as a large multinational prospective, observational registry of patients undergoing CCTA included more than 27,000 patients from twelve cluster sites in six countries in Europe, North America, and Asia [Pooling the evidence from several smaller single-center studies, a recent meta-analysis summarized the prognostic significance of CCTA findings for MACE among patients with stable chest pain syndromes . Data frand Asia , 47. Theand Asia , 47.A major finding of CONFIRM was that the absence of any coronary atherosclerosis is associated with an excellent prognosis, with all-cause mortality as low as 0.65 % after a mean follow-up of 22.5 months. Among patients with CAD, mortality increases from 1.99 % for patients with non-obstructive CAD to 4.95 % for patients with high-risk obstruction . FurtherCCTA has matured into a robust technique with the potential to enhance the work-up of patients in a variety of clinical settings. The volume of evidence is continuously increasing and evaluation of the efficacy of CCTA compared with established recommended methods for detection of significant coronary stenosis has moved beyond scientific evaluation. Instead, current efforts focus on the real-world value and effectiveness of the technique in two major scenarios:patients with acute chest pain; andpatients presenting with symptoms suggestive of stable angina.As the next step in assessment of this novel technology, these large-scale studies are designed as randomized clinical trials in which one group incorporates CCTA as the diagnostic intervention. These trials are critical, because they identify associated side effects, acceptance, and costs. Such studies, alone, will provide the scientific basis for recommendations by international societies and health care providers and affect reimbursement procedures.In the setting of acute chest pain, most of the evidence has been obtained from three large randomized diagnostic trials; these also indicate that use and costs of CCTA require further research. In contrast, such evidence is scarce in the setting of stable angina and current recommendations are based on observational studies and derived cost-effectiveness analysis. However, there are three major ongoing trials that will furnish more comprehensive data and are expected to provide sufficient evidence to enable evaluation of the role of CCTA among patients with stable chest pain . There is rapidly emerging evidence of the prognostic value of the findings of CCTA for the occurrence of cardiovascular events and it can be predicted that the prognostic relevance of CCTA findings will complement the diagnostic value of the technique pending future studies; however, randomized trials are pending. Although stepwise evaluation of novel emerging imaging techniques is a resource-demanding, labor-intensive process, it is the only way costly imaging procedures can prove their superiority not only in respect of excellent image quality but also in respect of relevant outcomes in real-world scenarios. This approach, alone, will ensure that CCTA will be widely adopted clinically and will result in better management of our patients.


Lachesis muta have the highest mortality index. Envenomation by L. muta is characterized by systemic  and local effects . The treatment to reverse the evolution of all the toxic effects is performed by injection of antivenom. However, such therapy does not effectively neutralize tissue damage or any other local effect, since in most cases victims delay seeking appropriate medical care. In this way, alternative therapies are in demand, and molecules from natural sources have been exhaustively tested. In this paper, we analyzed the inhibitory effect of a sulfated galactan obtained from the red seaweed Palisada flagellifera against some toxic activities of L. muta venom. Incubation of sulfated galactan with venom resulted in inhibition of hemolysis, coagulation, proteolysis, edema and hemorrhage. Neutralization of hemorrhage was also observed when the galactan was administered after or before the venom injection; thus mimicking a real in vivo situation. Moreover, the galactan blocked the edema caused by a phospholipase A2 isolated from the same venom. Therefore, the galactan from P. flagellifera may represent a promising tool to treat envenomation by L. muta as a coadjuvant for the conventional antivenom.In Brazil, snakebites are a public health problem and accidents caused by  Accord others , that ind others . Bushmasd others ,8. In thg/snake) . The pros) venom  shows th classes ; serine  classes , plasmin classes , and kal classes  activitiasses [2 ,16, amonSnakebite has received little attention from the pharmaceutical industry, governments or academia to improve antivenom therapy. Administration of antivenom is the only effective and accepted therapy for snakebites. However, it has some disadvantages, especially the poor inhibition of local effects ,4, side Fucus vesiculosus presented a protective effect against the cytotoxic and myotoxic activities of a group of phospholipase A2 myotoxin from crotaline snake venoms [F. vesiculosus, fragments of this sulfated polysaccharide obtained after partial hydrolysis presented lower capacity to prevent muscle necrosis in mouse after injection of purified myotoxin or crude venom [Marine organisms produce molecules with a great chemical diversity derived from primary  and secondary metabolism , making them powerful tools for biotechnological use because of their variety of pharmacological and ecological functions . Moreovee venoms . When code venom . These rde venom .d-galactose and 4-linked α-galactose, named A and B units, respectively [l  characterize a galactan belonging to agaran group, whereas the B units with enantiomeric configuration d  characterize a galactan belonging to carrageenan group. In this work, we have used a purified sulfated galactan from Palisada flagellifera named FHS-3. The structures of the sulfated polysaccharides  produced by this species were previously characterized and described with details [P. flagellifera biosynthesizes a family of highly complex sulfated, methylated and pyruvylated agarans [Several biological activities have been attributed for galactans obtained from seaweeds, including antiviral, anticoagulant, antiangiogenic and antitumor effects ,27,28,29ectively . Frequen details ,31. RegaP. flagellifera to neutralize some toxic activities of L. muta venom. Moreover, its neutralizing ability was also examined against a PLA2 isoform isolated from the same venom (named LM-PLA2-I), suggesting the potential use of these natural polymers in the treatment of snakebite accidents.In this paper, we evaluate the ability of the sulfated galactans isolated from the red seaweed Lachesis venom should be considered a life-threatening disease. Antivenom therapy is effective in neutralizing the systemic toxic effects, if administered in time (within 60 min of the accident), but it is ineffective or less effective against local tissue destruction at the bite site [P. flagellifera against some in vitro and in vivo toxic activities of L. muta venom. FHS-3 reduced hemolytic, proteolytic, coagulation, hemorrhagic and edematogenic activities.Accidents by ite site . So, in ite site ,34, but ite site  and, eveite site ,25. Antiite site ,38,39,40L. muta venom (10 μg/mL) clotted plasma in ca. 60 s and such venom concentration, that represents one MCD, was incubated with FHS-3 at different concentrations . L. muta-induced coagulation with a dose-dependent profile. FHS-3 did not induce coagulation.Abnormal blood clotting and/or bleeding are frequently observed in snake bites and are of clinical relevance . L. mutaL. muta (18 μg/mL). As seen, FHS-3 inhibited more efficiently the proteolytic than the hemolytic activity of L. muta venom, since at 1:20 ratio, FHS-3 inhibited 100% of proteolysis and only 40% of hemolysis, maybe because L. muta venom contains several PLA2 isoenzymes (some are basic and others are acidic) that are responsible for hemolytic activity [As shown in activity ,16,42. AL. muta venom (7 μg/g) induced a hemorrhage halo in mice of 20 mm, which corresponds to two MHD. Then, the effect of FHS-3 on hemorrhagic activity of such L. muta venom concentration was evaluated using the incubation  was given orally before  or after  injection i.d. of L. muta venom, a 30% and 20%-inhibition was achieved, respectively. Moreover, when FHS-3 (70 μg/g) was injected i.v. before L. muta venom, the percentage of inhibition has reached 40% , but when injected after L. muta venom , the inhibitory percentage dropped to half (20%). As another proposal of a treatment for snakebite, L. muta venom was injected i.d. into mice, and 15, 30 or 60 min after, FHS-3 was injected i.d. at the same injection site. As seen in ca. 55%, at any period of time evaluated.Hemorrhage caused by SVMPs are due to the degradation of components of the basement membrane (BM), e.g., collagen type IV and laminin and surrounding extra cellular matrix (ECM) which provide mechanical stability to capillaries . SVMPs aL. muta (5 μg/mL)-induced myotoxic activity was fully inhibited. So, it was interesting to mimic an in vivo situation for such activity as well. In this way, L. muta venom was firstly injected i.m. into mice, and 15 min later, saline was injected i.m.  was co-incubated with venom, ta venom  and myotta venom  of L. mu2 enzymes, which enzymatic activity is Ca2+-dependent are involved as well. After sub plantar injection of L. muta (7 mg/kg) venom or LM-PLA2-I (5 mg/kg) mixed with saline into the paw of mice, an increase of 40% was observed in their volume, and such increase was considered as 100% of edematogenic activity. When such L. muta venom dose was incubated with FHS-3 at 10 mg/kg or 20 mg/kg, edema was reduced by 20% and 50%, respectively (2-I (5 mg/kg)-induced edema by 80% , inhibiting the interaction of the viral glycoprotein C and HS on the cell surface [d-galactosyl units (A units). Additionally, minor quantities of these negative charged groups are present in C-4 and C-6 of the A units. In the B units, sulfate groups occupy principally C-6 of the 4-linked α-l-galactosyl units and C-2 of the 4-linked 3,6-anhydro-α-l-galactosyl units. Minor amounts of sulfate groups are present in C-2 and C-3 of the 4-linked α-l-galactosyl units [d-galactosyl units could be an important factor for the inhibitory effect of the sulfated galactan FHS-3 against L. muta venomand LM-PLA2-I.Edema is another important pathophysiological effect of snake bites, and PLAectively . Moreovea by 80% . So, FHSisolated . Neitherm agents ,25, some effects . The mec surface . For the surface . The galyl units . In thisL. muta that are caused by serine, metalloproteases and/or phospholipases A2. These enzymes of Lachesis and Bothrops genera act in the local tissue damage, being associated with deaths and disabilities in envenomation by snakes. Since antivenom therapy does not block such tissue damage, leading victims to lose their members, alternative treatments for snake bites are relevant. It is worth highlighting that, in the literature there are many articles showing antivenom effect of molecules or crude extracts from natural sources, just when such bioproducts were preincubated with snake venoms. However, in this work, different approaches were tested to analyze the antivenom property of FHS-3, and protocols mimicking real situations of envenomation were employed.FHS-3 inhibited the coagulant , proteolL. muta snake venom was kindly supplied by Fundação Ezequiel Dias (FUNED), Belo Horizonte, Minas Gerais state, Brazil, vacuum dried and stored at −20 °C until use. A phospholipase A2 (LM-PLA2-I) was isolated from L. muta, as previously described [escribed . Balb/c P. flagellifera (J. Agardh) K. W. Nam were collected at the northeast coast of Brazil . An exemplar specimen was deposited at the herbarium of the Department of Botany, Federal University of Paraná  with the identification code UPCB 55549. The algal material was cleaned to remove contaminants, washed with tap water, sun-dried and milled. Whole thalli were used for the polysaccharide extractions. The sulfated galactan FHS-3 was obtained as previously described [P. flagellifera was successively extracted (3×) with water at 25 °C, and the extracts were pooled giving rise to the FC fraction . The algal residue was then extracted (3×) with water at 80 °C, and the extracts were combined yielding the FH fraction . The hot aqueous extract was treated with 2 M KCl, and after centrifugation the supernatant originated the KCl-soluble fraction FHS . FHS was fractionated on a DEAE-Sephacel column that was sequentially eluted with water and NaCl solutions of increasing concentrations (0.1–4.0 M) to give five subfractions (from FHS-1 to FHS-5). The galactan FHS-3  was eluted with 0.6 M NaCl.Specimens of the red seaweed escribed ,31. BrieThe sulfated galactan FHS-3 (10 mg) was resuspended in 1 mL of saline (0.15 M NaCl), aliquoted and kept at −20 °C until assays were carried out. L. muta was determined by the indirect hemolytic test using human erythrocytes and hen’s egg yolk emulsion as substrate [L. muta venom that produced 100% of hemolysis was denoted as Minimum Indirect Hemolytic Concentration (MIHC). The hemolytic inhibitory effect of the sulfated galactan was determined by incubating one MIHC of L. muta venom with FHS-3 at different concentrations (180 and 360 μg/mL) for 30 min 25 °C. Then, the hemolytic activity was evaluated. Control experiments were performed by adding FHS-3 or saline, instead of venom.The degree of hemolysis caused by the venom of ubstrate ,16. The L. muta venom was determined using azocasein as substrate , with minor modification [L. muta venom that was able to produce a variation of about 0.2 at A 420 nm was defined as the Effective Concentration (EC). The proteolytic inhibitory effect of the sulfated galactan was performed by incubating one EC of the L. muta venom with FHS-3 (180 and 360 μg/mL) for 30 min 25 °C, and then proteolytic activity was determined. Control experiments were performed by adding FHS-3 or saline, instead of venom.Proteolytic activity of fication . The conL. muta venom was determined using a digital Amelung coagulometer, model KC4A . Plasma was kindly obtained from healthy volunteers from a local blood bank of the Hospital Universitário Antônio Pedro of the Federal Fluminense University. L. muta venom (50 μL) at different concentrations (2–60 μg/mL) were mixed with 200 μL of a pool of human citrated plasma diluted in saline (1:1), and the concentration of venom that clots plasma in 60 s was called Minimum Coagulant Dose (MCD). To evaluate the effect of the sulfated galactan, one MCD of L. muta venom was incubated with FHS-3 at different concentrations  for 30 min 25 °C, and then the mixture was added to plasma and clotting time recorded. Control experiments were performed by adding FHS-3 or saline, instead of venom.The coagulation activity of L. muta venom was quantified using a procedure described by Kondo [L. muta (100 μL) venom was injected subcutaneously (s.c.) into the abdominal skin of mice, and two hours later, the animals were euthanized by decapitation, abdominal skin removed, stretched, and inspected for visual changes in the internal aspect in order to localize hemorrhagic spots. The amount of L. muta venom (μg/20 g mouse) that was able to produce a hemorrhagic halo of 10 mm was defined as Minimum Hemorrhagic Dose (MHD). The inhibitory effect of FHS-3 sulfated galactan was performed using two MHD through different protocols, called (1) incubation, where FHS-3 (70 and 140 μg/mouse) was incubated with L. muta venom for 30 min at 25 °C, then mixture (100 μL) was injected s.c. into mice; (2) prevention, where (2a) FHS-3 (100 μL) was injected s.c. and 15 min later, L. muta venom (100 μL) was injected s.c. at the same site where FHS-3 has been injected; (2b) FHS-3 (100 μL) was given orally or (2c) intravenously (i.v.), and 15 min later, L. muta venom (100 μL) was injected s.c.; and (3) treatment, in which L. muta venom (100 μL) was injected s.c.; and (3a) 15 min, (3b) 30 min or (3c) 60 min later, FHS-3 (100 μL) was injected s.c. at the same site of venom injection. Hemorrhagic activity was expressed as the mean diameter (in millimeter) of the hemorrhagic halo induced by L. muta venom in the absence and presence of the FHS-3. Negative control was performed by injecting saline or FHS-3, instead of venom.Hemorrhagic lesion produced by by Kondo , with moL. muta venom or LM-PLA2-I was determined in accordance to [L. muta venom (7 μg/g) or LM-PLA2-I (5 μg/g) in the right paw, while the left paw received 50 μL of saline. One hour after injection, edema was evaluated and expressed as the percentage of increase in the weight of the right foot pad compared to the left one. The effect of the sulfated galactan on edema was investigated by incubating FHS-3 (10 and 20 μg/g) with L. muta venom for 30 min 25 °C, and then the mixture was injected s.c. into mice (right foot pad) and edema was measured.Edema-inducing activity of dance to , with moL. muta venom or saline was injected (50 μL) intramuscularly (i.m.) into mice under the right tibial anterior muscles, so that the injected site was positioned just over the Extensor Digitorius Longus (EDL) muscle [−1), as previously reported [L. muta venom (5 μg/mL) was incubated with FHS-3 (200 μg/mL) or saline for 30 min at 25 °C, then mixture (50 μL) was injected i.m. into mice, and treatment (2), in which L. muta venom (50 μL) was injected i.m., and 15 min later, FHS-3 (50 μL) was injected i.m. at the same site of venom injection (2a), orally (2b) or intravenously (2c). In parallel, negative control was performed by injecting saline, instead of FHS. Two hours later, myotoxicity was determined, as described.) muscle . Blood sinjected  μL intrat-test. Significance was taken as p < 0.05.Results are expressed as means ± SEM obtained with the indicated number of animals or experiments performed. The statistical significance of differences among experimental groups was evaluated using the Student’s P. flagellifera had antivenom potential against the toxic effects of L. muta venom. It is worth highlighting that the protocols tested were similar to real snake bite situations. However, additional data would be necessary to understand the inhibitory mechanism of FHS-3. For a more efficient treatment of local venom toxicity, a combination of antivenom molecules would be a logical progression from this work, since snake venoms are composed of several toxins with multiple activities. A sulfated galactan isolated from the red marine alga


Glucagon-like peptide-1 (GLP-1) receptor agonists improve glycemic control and cardiometabolic risk factors in adults with type 2 diabetes mellitus, but pediatric data is sparse.2) and type 2 diabetes in the first 6 months after treatment initiation. Two patients with morbid obesity who failed conventional therapy with insulin glargine and Metformin were treated with the addition of Exenatide. Metabolic parameters were obtained at 3 and 6 months post intervention.This is the first report to describe the effects of GLP-1 receptor agonist Exenatide on metabolic risk and weight in adolescents with morbid obesity (BMI>35kg/mImprovements in cardiometabolic risk factors, such as fasting glucose and triglyceride levels, as well as HbA1c, were reached at 6 months compared to baseline.Our cases highlight the therapeutic potential of exenatide for adolescent patients with morbid obesity and type 2 diabetes. Glucagon-like peptide-1 (GLP-1) receptor agonist Exenatide is an incretin mimetic approved by the US Food and Drug Administration in 2005 as an adjunct to diet and exercise for glycemic control in adults with type 2 diabetes. Improvements in cardiometabolic risk factors and weight in type 2 diabetes patients using Exenatide are well described in adults; however, reports in adolescents are limited to non-diabetic youth with obesity [Anthropometric measures , body mass index (BMI)) and blood pressure (BP) were measured as previously reported  at basel2  and underwent LAGB at age 14 years 3 months. Weight problems were present from early infancy. She had Blount’s disease requiring 5 surgical procedures to correct leg bowing and remained with limited mobility. Family history was notable for type 2 diabetes, hypertension, and stroke.A 16 year old Hispanic female was diagnosed with type 2 diabetes 24 months after laparoscopic adjustable gastric banding (LAGB). She presented to the Center for Adolescent Bariatric Surgery (CABS) for evaluation of severe morbid obesity with BMI 86.2kg/mAt initial preoperative visit, laboratory evaluation revealed metabolic syndrome with hypertriglyceridemia (170mg/dl), low high-density lipoprotein (HDL) 35mg/dl, impaired fasting glucose (IFG) 106mg/dl, and increased WC 188cm in addition to impaired glucose tolerance (140mg/dl) with HbA1c 6.5% and c-reactive protein (CRP) 46.2mg/dl. Following surgery, she lost 13.2kg over 6 weeks, but by 24 months post-operatively, her weight had increased to 17.4kg above her preoperative weight. A 2-hour OGTT demonstrated fasting glucose (FG) 188mg/dl, 2 hour glucose 293mg/dl and HbA1c 8.8% resulting in the diagnosis of type 2 diabetes. Metformin 850mg BID and Lantus 10 units were started, but she self discontinued Metformin due to gastrointestinal side effects.2. After 6 months, she had a weight loss of 4.4kg, with improvements in BMI (−1.6kg/m2), FG (−56mg/dl), triglycerides (TG) (−68mg/dl), low-density lipoprotein (LDL) (−16mg/dl), total cholesterol (TC) (−31mg/dl), and CRP (−20%). She tolerated Exenatide and Lantus 15 units without complaint. She was lost to follow-up and returned one year later on Lantus and Metformin 1000mg twice daily with Exenatide self-discontinued.Exenatide 5ug SQ twice daily (BID) was started as adjunctive therapy to Lantus 15 units at weight 209.0kg, and BMI 87.0kg/mWith her weight 207.2kgs, HbA1c 11.2% and FG 297mg/dl, Exenatide 2mg once weekly (QW) was added to her Lantus and metformin regimen. At 3 months, her weight decreased to 198.9kgs (−8.3kgs) and FG decreased to 160mg/dl (−137). By 6 months, HbA1c substantially decreased to 8.4% with FG 103mg/dl and reached 7.6% by 9 months post therapy with stabilization of weight at 199.3kgs.A 14 year old Hispanic female with a 3 year history of type 2 diabetes on once-daily DPP-4 inhibitor Sitagliptin presented for evaluation of morbid obesity with asthma, obstructive sleep apnea, reflux, and irregular menses. She was overweight since preschool age. Family history was notable for type 2 diabetes, obesity, hypertension, hyperlipidemia, and cholelithiasis.2. Laboratory values were consistent with type 2 diabetes with HbA1c 10.7%, FG 210mg/dL, and 2 hour glucose 378mg/dL, and metabolic syndrome with TG 138mg/dL, HDL 39mg/dL, WC 142cm and elevated BP 120/83 (96th percentile diastolic). Despite Sitagliptin100mg daily, Lantus 28 units daily and Metformin XR 1000mg, HbA1c remained between 9.9% and 10.3% for 6 months. She refused further increase in Metformin dose given gastrointestinal complaints. Sitagliptin was stopped and Exenatide 2mg QW was initiated as adjuvant treatment to Lantus 28 units and Metformin 1000mg daily at weight 131.1kg, BMI 54.4kg/m2, HbA1c 10.2%, and FG 163mg/dl. Within two months of treatment, HbA1c improved to 7.9%. After 6 months, she had sustained glycemic control with HbA1c 8.3% and notable improvements in cardiometabolic parameters including FG (−17mg/dl), insulin (−26uIU/ml), and TG (−12mg/dl). Patient’s weight was 131.5kg on day of gastric sleeve resection surgery with Exenatide QW discontinued following surgery due to normalization of blood glucose levels (HbA1c 5.8%) and weight 118.9kg noted at 2 months postoperatively.At initial preoperative evaluation for bariatric surgery, weight was 129.3kg, height was 154.5cm, and BMI was 54.2kg/mThese are the first two cases in adolescents with morbid obesity and type 2 diabetes mellitus to document 6 month effects on cardiometabolic risk factors, weight, and glycemic control with GLP-1 receptor agonist Exenatide therapy. Improvements in metabolic parameters, HbA1c and weight have previously been documented in adult populations with type 2 diabetes. However, there is scarce longitudinal data pertaining to the pediatric population limited to two studies in non diabetic youth with obesity.Exenatide is an incretin mimetic that shares approximately 50% sequence identity with human GLP-1, a gut derived factor rapidly secreted from the L-cells of the lower gut following meal ingestion and one of the most potent insulin secreting substances known –7. GLP-12 analyzed the effects of Exenatide BID on BMI and cardiometabolic risk factors in nondiabetic youth. Compared to controls, Exenatide significantly improved BMI , weight , fasting insulin  and OGTT-derived insulin sensitivity (p=0.02) [Two pediatric studies have evaluated Exenatide as a weight-loss therapy in extreme pediatric obesity. A 6 month pilot study of 12 children and adolescents ages 9–16 years old with BMI ≥ 35kg/m2, p=0.02), weight  and final BMI of −4% after the 3 month open label extension with trend towards reduction in HbA1c  [In a randomized, clinical trial by the same group, 26 adolescents 12–19 years old with severe obesity without diabetes were randomized to either three months of Exenatide or placebo then three months of open-label extension with Exenatide for all. Compliance was excellent and medication was well tolerated with mild to moderate events such as nausea (62% in Exenatide group vs. 31% in placebo group), abdominal pain (15% vs 23%), diarrhea (8% vs 31%), headache (23% vs 46%), and vomiting (31% vs 8%) with no episodes of hypoglycemia or pancreatitis. Compared to placebo, the Exenatide group had greater reduction in BMI (−1.13kg/mOur findings with Exenatide highlight the therapeutic potential of Exenatide and extend to the morbidly obese adolescent type 2 diabetes patient population previously described data regarding improvement in cardiometabolic risk factors in adults and in non-diabetic, obese adolescent patients. These findings suggest that Exenatide therapy may offer an additional treatment option that should be evaluated in larger, well-controlled trials of adolescent type 2 diabetes patients with morbid obesity.


Kaposi's sarcoma (KS) is an uncommon borderline vascular tumor involving mostly the cutaneous and mucosal sites of the body. Among the four distinctly clinicopathological presentations of KS, the iatrogenic form principally occurs in kidney transplant recipients receiving immunosuppressive therapy. It rarely occurs in the head and neck region as primary site or in other groups of patients under immunosuppressive therapy.We present of the case of a patient with right nose KS. The patient had history of systemic lupus erythematosus (SLE) and was under immunosuppressive therapy.Once we keep KS in mind, the definite diagnosis can be made using routine histological examination and immunohistochemical study despite the rarity of the disease in this site. Kaposi's sarcoma (KS) was named after an Austrian dermatologist, Moritz Kaposi, who first described five cases of this unusual tumor in 1872 [A 31-year-old woman presented with a 1-month history of swelling on the right side of her nose. She also had a history of SLE with lupus nephritis and was under immunosuppressive therapy, mainly with prednisolone ranging from 10 to 20 mg per day for 9 years. A physical examination revealed no other specific findings. A sinoscopic examination showed a bulging nodule on her right anterior nasal floor near the nostril. Folliculitis with secondary infection was initially diagnosed, and amoxicillin with clavulanic acid was prescribed, but the lesion remained despite 1-week of the medication. A biopsy was undertaken for the suspicion of neoplasm.The specimen received consisted of five fragments of tissue measuring up to 0.5 × 0.4 × 0.1 cm with a soft consistency and focal hemorrhage. Histological analyses under hematoxylin and eosin (H & E) staining revealed a submucosal nodular tumor effacing normal structures (Figure Iatrogenic KS principally occurs in kidney transplant recipients receiving immunosuppressive therapy. The incidence varies among different patient groups, but there is a 500- to 1000-fold difference compared to the general population . The diset al. had found that only 24 documented rheumatologic patients from 1966 to 2002 developed KS [However, most patients receiving corticosteroids or other immunosuppressive regimens do not develop KS, especially in non-transplant settings. Although it has been stated that Kaposi's sarcoma also has a higher incidence in patients who have received immunosuppression therapy for various medical diseases, Louthrenoo loped KS . This fiAlthough KS is well known to occur at almost any cutaneous and mucosal site of the body, the head and neck region is usually secondarily involved and rarely the site of initial presentation . KS primThe behavior and thus the treatment of KS depend on a number of factors such as the form of the disease, symptoms, location and extent of the lesion, the immunocompetence of the patient, and the general medical condition of the patient . Local eKS is an uncommon borderline vascular tumor, which occurs under various clinicopathological settings. KS is rare in the head and neck region and primary development in the nasal cavity is exceptional. Although iatrogenic KS is not uncommonly encountered in renal transplantation patients, it is rare in patients under immunosuppressive therapy for other medical reasons. The diagnosis of KS requires a high level of suspicion during histological examination and a panel of IHC studies would generally produce a firm conclusion. The treatment and prognosis depend on multiple factors and require consideration on a case-by-case basis.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.AIDS: acquired immunodeficiency syndrome; H & E: hematoxylin- and eosin; HHV8: human herpesvirus 8; IHC: immunohistochemical; KS: Kaposi's sarcoma; LANA-1: latency-associated nuclear antigen; SLE: systemic lupus erythematosus.The authors declare that they have no competing interests.CKH and CTD conceived the idea for the manuscript, conducted a literature search, and drafted the manuscript. CCW performed surgery and obtained images. LLY provided and reviewed pathological images, and critically revised the manuscript. All authors read and approved the final manuscript.


To compare delayed enhancement DECT with CCTA and LGE MRI for detection of scars after myocardial infarction and to analyze the possible additive value of delayed DECT as part of CCTA protocol.19 patients  with history of myocardial infarction ( >1 year) were prospectively enrolled in the study. The CCTA protocol consisted of prospectively gated CTA and DECT. DECT was performed with single-tube 64-row CT in gemstone spectral imaging (GSI) mode with 8 min delay after contrast media injection. Using a 4-point transmurality scale CCTA images were visually assessed for first-pass arterial enhancement deficit and late enhancement in DECT images using iodine distribution maps. Per-segment analysis was performed by 2 observers independently. LGE MRI was performed after CT (range: 1-3 days) as a reference standard. Test characteristics  between normal myocardium and scar tissue) for detection of myocardial scar were calculated both for CCTA and DECT. Per segment agreement between modalities was investigated with Spearman rank correlation coefficient.141/323  of LV segments showed LGE on MRI. At segmental level delayed DECT had good accuracy (90%) for scar evaluation with excellent specificity (99%) and satisfactory sensitivity (78%). CCTA protocol without integration of delayed DECT had accuracy, sensitivity and specificity 92%, 88%, 95%, respectively. Addition of delayed DECT results did not improve CCTA performance . CR of scar tissue was higher for CTA 274%±29% vs. 123±6% for DECT, p=0.008). Scores of transmurality were significant lower for CCTA and delayed DECT than for MRI .Detection of ischemic scars with delayed DECT and CCTA showed a good correlation with MRI. Delayed DECT detects myocardial scars with good accuracy but integration of delayed DECT into CCTA protocol did not improved performance of CCTA for detection of chronic scars and could be omitted from cardiac CT protocols in order to reduce radiation exposure to patient.N/A.


Kabuki syndrome (KS) is a multiple congenital anomalies/intellectual disability syndrome characterized by developmental delay, specific facial features, skeletal and visceral abnormalities. This syndrome is caused by mutations in MLL2 and KDM6A gene. Autoimmune abnormalities such as idiopathic thrombocytopenic purpura, hemolytic anemia, thyroiditis, and vitiligo have been described very rarely in patients with KS ,2,3. HerCase report: A female patient aged 7 7/12 years presented with short stature. There was no consanguinity between her parents. She was born as a term neonate weighing 2100 g as the product of a twin pregnancy and had no perinatal complications. On physical examination, the patient was noted to have large and low-set ears, broad and arched eyebrows, elongated palpebral fissures with eversion of the lateral third of the lower eyelid, as well as high and narrow palate. She also had other phenotypic malformations such as numerous vitiligo lesions of different sizes in the neck, brachydactyly, prominent fetal finger pads, and hyperlaxity in her joints. Her height was 116.3 cm (-1.85 standard deviation score [SDS]) and weight was 21.7 kg (-0.78 SDS). She had sensorineural hearing loss  and moderate mental retardation . She had a normal female karyotype . A clinical diagnosis of KS was considered.4) was 0.42 ng/dL (reference range: 0.91-1.92), Anti-microsomal antibody: 450.6 U/mL (reference range: 0-9), anti-thyroglobulin antibody: 2766 U/mL (reference range: 0-4)]. Thyroid ultrasonography demonstrated a rough pattern, consistent with thyroiditis. Levothyroxine (50 µg/day) replacement therapy induced a euthyroid state (TSH: 3.65 mIU/L and fT4: 1.15 ng/dL).Additionally, laboratory findings revealed autoimmune thyroiditis [thyroid-stimulating hormone (TSH): 242 mIU/L (reference range: 0.55-6.7) and free thyroxine (fTThe main causes of KS are point mutations with large intragenic deletions and duplications of the histone methyl transferase MLL2 gene ,4,5. We In several patients, KS was reported to be associated with autoimmune abnormalities such as idiopathic thrombocytopenic purpura, hemolytic anemia, thyroiditis, and vitiligo ,5. The aPeer-review: Internal peer-reviewed.


Classic Kaposi Sarcoma (KS) is vascular sarcoma, known to be more common in Mediterranean elderly men and characterized by an indolent clinical behavior. To our knowledge, this is the first evidence in literature, describing a spontaneous partial regression in a non-HIV, non-iatrogenic KS.A 68-years old woman, presenting with weight loss and respiratory symptoms, was diagnosed with a classic KS involving lungs and mediastinal lymph nodes. No skin or mucosal lesions were identified, HIV positivity was ruled out. Due to patient’s choice, she was kept under surveillance with 3-monthly thorax-abdomen-pelvis computed tomography scan (TAP CT). A first reassessment proved progressive disease (PD) associated with symptoms worsening. A new TAP CT, performed at 5 months from the diagnosis, showed stable disease (SD), with a minor reduction in size of mediastinal lymphadenopathies. A further reassessment, performed 5 months later, resulted in a partial response (PR) despite the absence of any medical treatment. Up to date, the disease is in remission, patient is asymptomatic and still on surveillance.Given the possible indolent behaviour of KS, we believe that close surveillance can represent a valuable approach in selected cases. KS is a locally aggressive endothelial tumour belonging to the family of vascular sarcoma. According to aetiology and epidemiology, four variants have been described: classic KS, usually affecting Mediterranean elderly men; endemic African KS, common in middle-aged adults and children in Equatorial Africa; iatrogenic KS, usually occurring in solid organ transplant recipients but also in patients receiving immunosuppressive treatment (i.e. corticosteroid) for a long time; acquired immunodeficiency syndrome associated KS, the most aggressive variant, affecting human immunodeficiency virus (HIV) positive patients. KS is invariably associated with human herpes virus type 8 (HHV-8), which seems to play a key role in KS pathogenesis . KS typiPulmonary involvement is common in critically immunodeficient patients, occurring approximately in 45% of those with cutaneous AIDS-related KS with previous or concomitant mucocutaneous lesions. Lung metastases from sporadic KS are rare, especially in female and pediatric series with a distinct male predominance . TreatmeA 68-years old woman, with no previous medical history, presented with severe weight loss, shortness of breath and cough ECOG PS: 2). A chest x-ray followed by a thorax-abdomen-pelvis computed tomography (TAP CT) showed the presence of a 53 mm large mass in the left lower lobe (LLL) with pericardial involvment and a 30 × 18 mm large lesion with similar morphological features in the upper lobe of the left lung. Multiple bilateral lung nodules and a 26 mm large carinal lymphadenopathy were also reported , an increase in size of the known lesion in the LLL (60 mm) and a stability of the carinal lymphnodes Figure . DespiteSpontaneous regression of KS has been previously described in the iatrogenic type. Interruption of corticosteroids , systemiWritten informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Mesolimbic dopamine encodes the benefits of a course of action. However, the value of an appetitive reward depends strongly on an animal’s current state. To investigate the relationship between dopamine, value, and physiological state, we monitored sub-second dopamine release in the nucleus accumbens core while rats made choices between food and sucrose solution following selective satiation on one of these reinforcers. Dopamine signals reflected preference for the reinforcers in the new state, decreasing to the devalued reward and, after satiation on food, increasing for the valued sucrose solution. These changes were rapid and selective, with dopamine release returning to pre-satiation patterns when the animals were re-tested in a standard food-restricted state. Such rapid and selective adaptation of dopamine-associated value signals could provide an important signal to promote efficient foraging for a varied diet.  •Dopamine reward prediction errors are shaped by physiological state•Both choices and dopamine signals rapidly update after selective satiation•In a new state, dopamine signals mainly only update with experience•When returning to a familiar state, dopamine immediately signals stored values Dopamine signals information about reward value used for learning and decision making. Papageorgiou et al. show that mesolimbic dopamine coding of reward prediction errors rapidly updates to reflect current state-dependent values. The phasic activity of midbrain dopamine neurons and dopamine release in regions such as the nucleus accumbens (NAc) signal predictions of future reward and discrepancies between such predictions and received reward . These sFood-restricted rats were trained to perform a two-option operant decision-making task where the selection of each option was associated with a particular type of reward (food pellet or sucrose solution) A. SessioIn the first pre-devaluation baseline session (baseline A), the group of rats overall displayed no overall preference in general for either reward type on choice trials (t test against 50% for food choices: t(7) = 0.168, p = 0.87), no difference in response latencies to the two options on forced trials (t(6) = 0.94, p = 0.38; the data from one animal was lost because of a computer error), and no differences in the numbers of wrong-lever choices or missed trials  < 1.60, p > 0.15).Prior to the devaluation sessions, the rats consumed, on average, either 11.5 g  of pellets or 24.75 ml  of sucrose solution. This manipulation reliably altered the animals’ preference for the reward types  = −2.84, p = 0.01; devalue sucrose solution, t(7) = 4.13, p < 0.01) B. There These changes in subjective valuation were temporary and specific to the devaluation session. Preference returned to indifference in the baseline B session run in between the counterbalanced devaluation sessions (t(7) = 1.08, p = 0.32), and there was no change in choices from the pre-devaluation baseline session (t(7) = 1.18, p = 0.28).We monitored dopamine release in the NAc core  using faTo examine the effect of selective satiety and, consequently, a selective change in the subjective value of one of the options, on value-related dopamine signals at the time of reward delivery, we ran a linear regression on the two devaluation sessions A and 2B.devalued reward when compared to receiving that same reward in the baseline session (p > 0.05). Instead, there was a small but significant increase in dopamine when receiving the valued option for both reinforcers when compared to the same situation during baseline testing  C. TherefThese results demonstrate that mesolimbic dopamine flexibly encodes reward prediction error signals shaped by the specific properties of a reward to satisfy a current need. Midbrain dopamine neurons in primates tested for multiple days in a similar state have been shown to encode reward prediction errors that reflect the animals’ subjective preference for different reward types . Here, wSeveral of our results, therefore, appear consistent with key predictions of model-free temporal difference learning models. Dopamine release on SWITCH trials in the devaluation sessions principally encoded surprising changes in reward identity based on discrepancies between expected and received value rather than the sensory surprise of receiving the alternative reinforcer. This does not rule out that coding of reward identity prediction errors may exist in other contexts, where the value difference between the options is less prominent or when a change in identity is more relevant for behavior. For instance, the SWITCH trials here occurred as rare fluctuations in an otherwise stable task, but in other paradigms, such as unblocking or reversal learning, a change in reward identity can be more long lasting and of more significance for behavior . EquallyWe observed a strong modulation of both food- and sucrose-solution-elicited dopamine by the amount of reinforcer consumed within and prior to the session. Such selective modulation of stored value signals by specific satiety may be important to promote efficient and varied foraging behaviors. Cue-elicited dopamine release rapidly updated, with significant differences between the valued and devalued signals being evident within the first block of trials following selective satiation. However, this appeared to be predominantly shaped by direct incentive learning in the new state. While there was a general reduction in dopamine on the first trials of the devaluation sessions, compared to the preceding baseline sessions, this was not selective for the devalued option. This is in line with studies showing a general activating role for the NAc core, and dopamine transmission in this region, in the presence of reward-associated cues to motivate and invigorate available actions .However, it is notable that there were already selective differences in dopamine levels in the period after lever extension while the rat was making a response and waiting for either the valued or devalued reward. Therefore, some aspects of dopamine signaling can partially update without direct experience of the outcome . MoreoveTogether, our data add to the evidence indicating a close link between mesolimbic dopamine and physiological state . Ventral17 male Sprague-Dawley rats were used for this experiment, of which 8 contributed data reported here see the . During We used fast-scan cyclic voltammetry to record dopamine release from chronically implanted carbon fiber electrodes in the NAc, as described previously , as animAs in previous studies, dopamine signals were extracted using principal-component analysis . To quanG.K.P. and M.E.W. conceived the study; G.K.P. and M.B. performed surgeries; G.K.P. collected the data with the assistance of F.C.; M.E.W. and G.K.P. analyzed the data; and M.E.W. and G.K.P. wrote the manuscript.


In addition, we also showed that dopamine (1 mM) treatment in vitro, does not affect sperm viability but decreases total and progressive sperm motility. This effect is reversed by blocking the dopamine transporter with the selective inhibitor vanoxerine (GBR12909) and non-selective inhibitors of dopamine reuptake such as nomifensine and bupropion. The effect of dopamine in sperm physiology was evaluated and we demonstrated that acrosome integrity and thyrosine phosphorylation in equine sperm is significantly reduced at high concentrations of this catecholamine. In summary, our results revealed the presence of monoamine transporter DAT, NET and SERT in equine sperm, and that the dopamine uptake by DAT can regulate sperm function, specifically acrosomal integrity and sperm motility.Dopamine is a catecholamine with multiple physiological functions, playing a key role in nervous system; however its participation in reproductive processes and sperm physiology is controversial. High dopamine concentrations have been reported in different portions of the feminine and masculine reproductive tract, although the role fulfilled by this catecholamine in reproductive physiology is as yet unknown. We have previously shown that dopamine type 2 receptor is functional in boar sperm, suggesting that dopamine acts as a physiological modulator of sperm viability, capacitation and motility. In the present study, using immunodetection methods, we revealed the presence of several proteins important for the dopamine uptake and signalling in mammalian sperm, specifically monoamine transporters as dopamine (DAT), serotonin (SERT) and norepinephrine (NET) transporters in equine sperm. We also demonstrated for the first time in equine sperm a functional dopamine transporter using  Dopamine is a catecholamine that participates in many biological processes in mammals, acting on functions related to cognition, emotions and control of motor activity, among others in vitro, in hamster sperm Evidence shows that catecholamines exert their actions on different parameters of sperm physiology. They have been shown to induce capacitation in mouse Presence of different catecholaminergic receptors in sperm has been reported, including the presence of α2- and β-adrenergic receptors in mouse and human sperm In the present study we show the presence of DAT transporter in equine sperm and we investigate this transporter function and its participation in equine sperm function. We also demonstrate the presence of the SERT and NET transporters in equine sperm. These results suggest a high degree of conservation of the mammalian catecholaminergic system and the participation of dopamine in the control of the overall mammalian sperm function.in vitro sperm capacitation assays. Using immunofluorescence and Western blot assays, we have demonstrated the presence of the dopamine transporter in equine sperm  transport by 24±6% and 42±6% respectively, values that are significantly lower with respect to the control without inhibitor treatment  on sperm cell viability, acrosomal integrity and sperm motility were evaluated at three incubation times. The results obtained at 1, 3 and 6 hours did not reveal significant changes in sperm viability at the different concentrations of dopamine used . The effTotal sperm motility in the presence of 0.01, 0.1 and 1 mM dopamine was also determined. We observed a strong inhibition in total sperm motility only at dopamine concentration of 1 mM after incubating for 1, 3 and 6 hours , similarFinally, to evaluate possible signalling pathways involved in the negative regulation of sperm motility by high doses of dopamine, we assessed the overall pattern of tyrosine phosphorylation. Major changes were observed on tyrosine phosphorylation during different incubation times, with a biphasic and dose dependent behavior, increassing their level at 10 µM dopamine and decreassing their level with dopamine at 100 µM and 1 mM .Using Western blot and fluorescent immucytochemical analyses, we evaluated the presence of other monoamine transporters that may be involved, albeit with lower selectivity in the incorporation of dopamine in equine sperm. The presence of NET and SERT transporters in equine sperm was verified by immunodetection in whole protein extract . NET andBy immunofluorescence assay, NET distribution was specific in acrosome region in the head sperm . A similOur results clearly indicate that equine sperm  express a wide range of proteins from the dopaminergic system, specifically monoamine transporters, such as dopamine, norepinephrine and serotonin transporters. These findings, together with existing knowledge from other research literature in vitro sperm function, particularly in the control of sperm motility, maintenance of acrosomal integrity and tyrosine phosphorylation in a wide range of target proteins, it might be suggested that these higher catecholamine concentrations could participate in the modulation of in vivo sperm function. This hypothesis is reinforced by previous results from our laboratory in which both total and progressive motility and also phosphotyrosines of boar sperm in in vitro capacitation assays were inhibited by dopamine without affecting sperm cell viability Mammalian sperm are exposed to variable concentrations of catecholamines during their passage through the reproductive tracts, both male and female. Catecholamines, especially norepinephine, have been reported to participate in testicular function We have hypothesized that catecholamine could be concentrated in micro-domains from mammalian oviduct (ampulla and isthmus region) and promote a sperm selection during ovulation. Many authors have reported higher concentration of catecholamine in oviductal fluid at different stages of ovarian activity. During rabbit’s oestrus it has been found that dopamine and norepinephrine concentrations are close to 8 and 27 µM, respectively in the isthmus region, and oscillating dopamine concentrations between 1–10 µM during ovulation and coitus + transport assays demonstrate the presence of a functional dopamine transporter in equine sperm, suggesting that this transporter would be capable of receiving and generating the modulatory effects of this catecholamine. The Km obtained for this transporter was of approximately 11 µM. There seem to be no previous measurements of equine DAT transport activity in the literature, but the Km of DAT for ASP+ in human, using cultured HEK293 cells transfected with human DAT, reveal a Km of 3.2 µM The ASP++ uptake , on the other hand, 10 µM bupropion would be sufficient to completely inactivate DAT and NET, but not SERT . We have not disregarded the presence of non-classical monoamine transporters or non-neuronal transporters that are not affected by classical inhibitors of monoamine transporters An unexpected event is that 50 µM nomifensine completely fails to inhibit the incorporation of ASPIn summary, we have demonstrated that equine sperm express dopamine receptors and transporters. Moreover, our results indicate that this dopaminergic system is functional in the studied sperm. Considering that catecholamines are present throughout the entire passage of sperm along the male and female reproductive tracts, it is logical to think that they may fulfill some function in sperm and reproductive physiology. We have also shown that high dopamine concentrations dramatically affect sperm motility without altering viability; however these sperm could experiment a decrease in its hability to capacitation. In light of the results obtained in this study, greater concentrations of dopamine could help immobilize sperm in the oviductal reservoirs promoting a possible positive selection of the best sperm until the ovulation, just at the moment in which catecholamine levels fall. Subsequently, other factors present in oviduct and follicular fluid could stimulate sperm motility and capacitation, thus enhancing the oocyte penetration in the appropriate segment. Finally, the gradient in the concentration of dopamine in the oviduct  would be a simple and effective system to modulate the sperm physiology in the oviduct and optimizing the fertility in equine.+ (D289), anti-goat Alexa 488 (A11055) were obtained from Invitrogen and vanoxerine (GBR12909–[0421]) was obtained from Tocris Bioscience. Other reagents used were acquired from Sigma Aldrich or Merck.Antibodies anti DAT (sc-7515), NET (sc-51157), SERT (sc-1458), DAT peptide (sc-7515 P), nomifensine (sc-253197) and bupropion (sc-217802) were obtained from Santa Cruz Biotechnology, Inc. Anti PY20 (P4110) and anti β-tubulin (T5201), dopamine (H8502), tetrazolium blue (N5514) and PSA-FITC (L0770) were obtained from Sigma Aldrich. ASPHuman semen samples were obtained by masturbation and collected in sterile plastic containers from volunteer’s healthy young men and with previous written consent, the protocols used in this study were approved by the Committee Bioethic of Medical Science of Universidad Austral de Chile (CI#213-2014).The stallions samples used were obtained from animals following the regulations of the Committee on the Bioethics of Animals for Research of Universidad Austral de Chile, instance that reviewed and approved the protocols used in this study (C#151-2014). The only manipulation of animals was semen collection using standard procedures established by Haras Militar Pupunahue (Ejército de Chile). Bovine sperm samples used correspond to frozen commercial doses obtained from Centro de Inseminación Artificial . Boar sperm samples used correspond to refrigerated commercial doses obtained from Servicios Genéticos Porcinos, S. L. .Ejaculates were obtained from six stallions (Heavy Draft breeds): Ardennés (2), Percherón (2) and Bretón de Montaña (2), aged between 7 and 15 years, property of Haras Militar Pupunahue, XIV Región de los Ríos, Máfil, Valdivia, Chile. The Haras Militar Pupunahue, as a partner member of the Fondef D08I1076 proyect, explicitly approved the use of the samples for scientific research purposes. All stallions were proven to be fertile. Ejaculated sperm obtained and used for the study had viability and motility parameters of greater than 70 and 65% respectively.2, 5.5 mM glucose, 22 mM Hepes, 4.8 mM lactic acid hemicalcium salt, 1 mM pyruvate, pH 7.25) in the absence of albumin (BSA), sodium bicarbonate and progesterone. Samples were maintained at 4°C until required for different assays. Previous to each experimental procedure, sperm viability and motility was measured, rejecting those ejaculated sperm with a viability of less than 70% and a motility of less than 65%. Whitten’s medium modified (enrichment with BSA and bicarbonate) was used during each assay performance, and all experiments were done at different times of incubation (in presence or absence of dopamine) by 1, 3 or 6 hours. In each case, as control, was evaluated the basal status of viability, acrosomal reaction or motility, previous to the start experiment and when the experiment was finished.Semen was collected with the aid of an artificial vagina, was filtered to eliminate the gel fraction and was diluted to a ratio of 1∶1 with UHT skimmed milk at 37°C and refrigerated at 4°C for transport to Laboratory of Cryobiology and Sperm Function Analysis, Universidad Austral de Chile, Valdivia. Once in the laboratory, semen was centrifuged at 600×g for 20 minutes and the pellet re-suspended in incubation medium or Whitten’s medium . Human semen was obtained by masturbation and collected with posterior liquefaction in sterile plastic containers from volunteer’s healthy young men. Samples were processed for protein extraction as has been previously reported With the aim of detecting the presence of the dopamine transporter in sperm, as well as the norepinefrine and serotonin transporters, indirect immunofluorescence and Western blot techniques were used.For immunodetection by indirect fluorescence, bovine, equine and human sperm were utilized according to the protocol described by Ramírez et al., (2009) Samples were processed for protein extract preparation as has been previously reported + incorporation experiments, equine sperm were incubated with 8 µM ASP+ for 10 min at 37°C. A total of 240 readings were made, every 5 seconds. Saturation curves were tested at different concentrations of ASP+ (0 to 30 µM) at a fixed reading time of 20 min. All ASP+ dilutions were performed in PBS with 30 µM Trypan blue to eliminate extracellular fluorescence. Changes in intracellular ASP+ concentration were quantified by the increase in fluorescence emitted at 609 nm, readings performed with a microplate reader.Dopamine transport was performed as described by Mason et al., (2005) We have previously shown that high dopamine doses inhibit capacitation and motility This parameter was analyzed with the viability module of the computer-assisted sperm analysis (CASA) system (SCA Microptics), using a biochromatic fluorescent stain based on the use of acridine orange (10 µM) and ethidium bromide (2.5 µM) fluorophores in a protocol modified from Cortés-Gutiérrez et al., (2008) The acrosomal status analysis or acrosomal reaction in sperm after dopamine incubation was performed exactly as described Ramírez et al., (2009) This parameter was analyzed with the motility module of the CASA system (SCA Microptics). To perform this analysis, 5 µl samples of each one of the treatments were used, mounted onto a slide pre-warmed to 37°C and covered with a coverslip. Samples were analyzed in a microscope coupled to a high-speed camera (takes 25 images per second of various fields), at a magnification of 200X. Images were processed and analyzed with the software, Sperm Class Analyzer 4.2.0.1. Progressive sperm were defined as those with values of straightness coefficient (STR)>75% and with linearity coefficient (LIN)>50%. Spermatozoa were also classified as slow, medium and fast following their curvilinear velocity (VCL) values. In this classification, slow sperm were those with VCL between 10 µm/sec and 45 µm/sec, medium sperm had a VCL between 46 µm/sec and 90 µm/sec and fast sperm were those with VCL>90 µm/sec. Spermatozoa with VCL values below 10 µm/sec were considered non motile.+ incorporation assays, saturation curves, inhibition of ASP+ transport, the effect of dopamine on viability, acrosomal reaction, total and progressive motility and DAT inhibition, the mean ± the standard error (SEM) of the medium was displayed graphically. The different assays were analyzed statistically with a Student’s t-test with Bonferroni correction for viability and variance analysis (ANOVA), using GraphPad v5.0 for Windows software. A difference was considered to be statistically significant and highly significant when p<0.05 and p<0.01 respectively.For time-dependent ASPFigure S1Presence of Dopamine Transporter (DAT) in mammalian sperm. Eigthteen micrograms of total protein extract from boar (line 1), human (line 2), stallion (line 3), and bull (line 4) sperm were analyzed by SDS-PAGE and Western blot using a specific human anti-DAT antibody. Positions of relevant molecular weight standards are indicated on the left. Images are representative of three independent experiments.(TIF)Click here for additional data file.