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Abdulsalam AJ, Aksakal MF, Kara M, Kaymak B, Özçakar L. Ultrasonographic follow-up in Bell's Palsy: Part (of the facial Nerve) to look at? Clin Neurophysiol 2024; 162:271-272. [PMID: 38472039 DOI: 10.1016/j.clinph.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/10/2024] [Indexed: 03/14/2024]
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Ciki K, Alavanda C, Kara M. Novel Mutation in the HSD17B10 Gene Accompanied by Dysmorphic Findings in Female Patients. Mol Syndromol 2024; 15:211-216. [PMID: 38841322 PMCID: PMC11149976 DOI: 10.1159/000535589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 11/26/2023] [Indexed: 06/07/2024] Open
Abstract
Introduction Hydroxysteroid 17-beta dehydrogenase type 10 (HSD10) protein is a mitochondrial enzyme. Multisystemic involvement occurs in HSD10 deficiency as in other mitochondrial diseases. HSD10 deficiency (disease) is rare. Less than 40 index cases have been reported so far. A female patient is even rarer because of X-linked transmission. Five index female cases have been reported. Case Presentation We report a three-year-old female patient who was investigated due to microcephaly and global developmental delay. She had significant dysmorphic findings. The tiglylglycine peak was detected in urinary organic acid analysis. Other metabolic investigations and laboratory tests were unremarkable. Mild cerebral atrophy, mild ventricular dilation, thin corpus callosum, and an increase in T2 signal in the globus pallidus were revealed at brain magnetic resonance imaging. Heterozygous novel mutation in the HSD17B10 gene was found by whole-exome sequencing (WES) analysis. We started isoleucine-restricted diet and a "cocktail" of the mitochondrial vitamin. Discussion/Conclusion We will see HSD10 disease patients more frequently with the increasing use of WES and genetic panels. Thus, different findings and phenotypes of the HSD10 disease will be revealed.
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Abdulsalam AJ, Analay P, Kaymak B, Kara M, Özçakar L. Ultrasonography in Bell's Palsy: seeing the nerve rather than trialing on the muscles. Eur Arch Otorhinolaryngol 2024; 281:3299-3300. [PMID: 38393355 DOI: 10.1007/s00405-024-08526-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024]
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Abdulsalam AJ, Merza AH, Kara M. Letter to the editor - 'Labelling sarcopenia in cardiovascular patients with SARC-F? A definite faux pas'. Eur J Cardiovasc Nurs 2024:zvae068. [PMID: 38813939 DOI: 10.1093/eurjcn/zvae068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 05/01/2024] [Indexed: 05/31/2024]
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Abdulsalam AJ, Aksakal MF, Kara M, Özçakar L. Upscaling Facial Nerve Injections: Ultrasound Guidance to Avoid "Minimal Complications". J Craniofac Surg 2024:00001665-990000000-01611. [PMID: 38771190 DOI: 10.1097/scs.0000000000010190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/05/2024] [Indexed: 05/22/2024] Open
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Abdulsalam AJ, Merza AH, Kara M. Evaluating sarcopenia in cancer patients: focus on the rectus femoris muscle. Support Care Cancer 2024; 32:350. [PMID: 38744746 DOI: 10.1007/s00520-024-08566-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/10/2024] [Indexed: 05/16/2024]
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Abdulsalam AJ, Aksakal MF, Kara M, Özçakar L. Osteosarcopenia: Adjust for the BMI or Bare the Bias. Calcif Tissue Int 2024; 114:554-555. [PMID: 38413429 DOI: 10.1007/s00223-024-01203-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 02/29/2024]
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Kara M, Sekizkardeş M, Abdulsalam AJ, Kaymak B, Aydın G, Özçakar L. Two-step Ultrasound Guidance for Needle Electromyography and Botulinum Toxin Injections in Cervical Dystonia. Neurol India 2024; 72:665-666. [PMID: 39042001 DOI: 10.4103/neurol-india.neurol-india-d-24-00174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/05/2024] [Indexed: 07/24/2024]
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Abdulsalam AJ, Kara M, Özçakar L. Ultrasound is mightier than bioimpedance spectrometry but not ad lib. J Nephrol 2024; 37:1005-1006. [PMID: 38653926 DOI: 10.1007/s40620-024-01943-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/24/2024] [Indexed: 04/25/2024]
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Abdulsalam AJ, Kara M, Özçakar L. Elevating the findings by substituting in "ISarcoPRM". J Neurooncol 2024; 168:185-186. [PMID: 38563853 DOI: 10.1007/s11060-024-04653-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024]
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Abdulsalam AJ, Demirel K, Aksakal MF, Kara M, Kaymak B, Özçakar L. Ultrasound imaging and guidance in Bell's palsy. PM R 2024. [PMID: 38661294 DOI: 10.1002/pmrj.13181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 04/26/2024]
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Abdulsalam AJ, Kara M, Kaymak B. Botulinum Toxin Injection of the Flexor Digitorum Profundus: Are We Forgetting Something? Can J Neurol Sci 2024:1-2. [PMID: 38654670 DOI: 10.1017/cjn.2024.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
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Abdulsalam AJ, Kara M, Özçakar L. The ISarcoPRM Algorithm: A Thoroughfare for the 'Geriatric Pandemic'. Calcif Tissue Int 2024; 114:450. [PMID: 38141135 DOI: 10.1007/s00223-023-01174-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
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Yalçınkaya B, Sağ BT, Aksakal MF, Analay P, Ocak H, Kara M, Kaymak B, Özçakar L. Optimal examination for traumatic nerve/muscle injuries in earthquake survivors: a retrospective observational study. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2024; 41:120-127. [PMID: 38576339 DOI: 10.12701/jyms.2024.00087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/14/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Physiatrists are facing with survivors from disasters in both the acute and chronic phases of muscle and nerve injuries. Similar to many other clinical conditions, neuromusculoskeletal ultrasound can play a key role in the management of such cases (with various muscle/nerve injuries) as well. Accordingly, in this article, a recent single-center experience after the Turkey-Syria earthquake will be rendered. METHODS Ultrasound examinations were performed for various nerve/muscle lesions in 52 earthquake victims referred from different cities. Demographic features, type of injuries, and applied treatment procedures as well as detailed ultrasonographic findings are illustrated. RESULTS Of the 52 patients, 19 had incomplete peripheral nerve lesions of the brachial plexus (n=4), lumbosacral plexus (n=1), and upper and lower limbs (n=14). CONCLUSION The ultrasonographic approach during disaster relief is paramount as regards subacute and chronic phases of rehabilitation. Considering technological advances (e.g., portable machines), the use of on-site ultrasound examination in the (very) early phases of disaster response also needs to be on the agenda of medical personnel.
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Kara M, Kara Ö, Durmuş ME, Analay P, Şener FE, Çıtır BN, Korkmaz GO, Ünlü Z, Tiftik T, Gürçay E, Mülkoğlu C, Yalçınkaya B, Bağcıer F, Aksakal MF, Erdoğan K, Sertçelik A, Çakır B, Kaymak B, Özçakar L. The Relationship Among Probable SARCopenia, Osteoporosis and SuprasPinatus Tendon Tears in Postmenopausal Women: The SARCOSP Study. Calcif Tissue Int 2024; 114:340-347. [PMID: 38342790 PMCID: PMC10957602 DOI: 10.1007/s00223-024-01183-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/05/2024] [Indexed: 02/13/2024]
Abstract
We aimed to investigate the relationship among probable sarcopenia, osteoporosis (OP) and supraspinatus tendon (SSP) tears in postmenopausal women. Postmenopausal women screened/followed for OP were recruited. Demographic data, comorbidities, exercise/smoking status, and handgrip strength values were recorded. Probable sarcopenia was diagnosed as handgrip strength values < 20 kg. Achilles and SSP thicknesses were measured using ultrasound. Among 1443 postmenopausal women, 268 (18.6%) subjects had SSP tears. Unilateral tears were on the dominant side in 146 (10.1%) and on the non-dominant side in 55 women (3.8%). In contrast to those without, women with SSP tears had older age, lower level of education, thinner SSP and lower grip strength (all p < 0.05). In addition, they had higher frequencies of hypertension, hyperlipidemia, DM, OP and probable sarcopenia, but lower exercise frequency (all p < 0.05). Binary logistic regression modeling revealed that age [odds ratio (OR): 1.046 (1.024-1.067 95% CI)], hypertension [OR: 1.560 (1.145-2.124 95% CI)], OP [OR: 1.371 (1.022-1.839 95% CI)] and probable sarcopenia [OR: 1.386 (1.031-1.861 95% CI)] were significant predictors for SSP tears (all p < 0.05). This study showed that age, presence of hypertension, probable sarcopenia and OP were related with SSP tears in postmenopausal women. To this end, although OP appeared to be related to SSP tears, SSP tear/thickness evaluation can be recommended for OP patients, especially those who have other risk factors such as older age, higher BMI, hypertension, and probable sarcopenia.
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Analay P, Kara M, Özçakar L. Temporal Muscle Thickness: A Far-Fetched Measurement in Sarcopenia. J Am Med Dir Assoc 2024; 25:671. [PMID: 38432643 DOI: 10.1016/j.jamda.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
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Abdulsalam AJ, Abdulsalam MA, Kara M. Sarcopenia/Osteoporosis in Obstructive Sleep Apnea Syndrome: Beauty Lies in the Details. J Clin Densitom 2024; 27:101482. [PMID: 38507866 DOI: 10.1016/j.jocd.2024.101482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/22/2024]
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Güner G, Özçakar L, Baytar Y, Onur MR, Demir M, Aktaş BY, Aktepe OH, Güven DC, Taban H, Yıldırım HÇ, Akın S, Aksoy S, Kara M, Dizdar Ö. Sonographic Measurements of Rectus Femoris Muscle Thickness Strongly Predict Neutropenia in Cancer Patients Receiving Chemotherapy. Cancers (Basel) 2024; 16:1061. [PMID: 38473418 DOI: 10.3390/cancers16051061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 02/22/2024] [Accepted: 03/03/2024] [Indexed: 03/14/2024] Open
Abstract
The objective of this study was to explore the possible association between low skeletal muscle mass (SMM)-assessed by computed tomography (CT) and ultrasound (US)-and hematologic toxicity in cancer patients. A prospective cohort study was conducted in cancer patients who received anthracycline-based chemotherapy between 2018 and 2020 and who had baseline abdominal CT including L3 level for measuring SMM. Regional muscle measurements were carried out using US. A total of 65 patients (14 males, 51 females) were included. ROC (receiver operating characteristic) analysis identified threshold values of 18.0 mm [AUC (area under the curve) = 0.765] for females and 20.0 mm (AUC = 0.813) for males, predicting severe neutropenia. Using these cut-offs, females with low rectus femoris (RF) thickness (<18.0 mm) had a significantly higher incidence of grade ≥3 neutropenia (50.0% vs. 10.8%, p = 0.005), and males with low RF values (<20.0 mm) had a higher incidence (80.0% vs. 22.2%, p = 0.063). A regression analysis, irrespective of age, gender, and body mass index, revealed that only low RF muscle thickness increased the risk of grade 3-4 neutropenia by 9.210 times (95% CI = 2.401-35.326, p = 0.001). Utilizing US to measure RF muscle thickness aids in identifying cancer patients at an elevated risk of developing neutropenia. Needless to say, US can serve as a convenient and easily accessible tool for assessing low SMM, providing repeat point-of-care evaluations in clinical practice.
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Pirri C, Stecco C, Güvener O, Mezian K, Ricci V, Jačisko J, Fojtik P, Kara M, Chang KV, Dughbaj M, Özçakar L. EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Ankle/Foot. Am J Phys Med Rehabil 2024; 103:e29-e34. [PMID: 37903600 DOI: 10.1097/phm.0000000000002349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
ABSTRACT In this dynamic scanning protocol, ultrasound examination of the ankle is described using various maneuvers to assess different conditions. Real-time patient examination and scanning videos are used for better simulation of daily clinical practice. The protocol is prepared by several/international experts in the field of musculoskeletal ultrasound and within the umbrella of European Musculoskeletal Ultrasound Study Group in Physical and Rehabilitation Medicine/Ultrasound Study Group of the International Society of Physical and Rehabilitation Medicine.
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Ricci V, Mezian K, Chang KV, Onishi K, Kara M, Naňka O, Özçakar L. Ultrasound-guided injection of the ankle joint: cadaveric investigation of the anterolateral approach. Surg Radiol Anat 2024; 46:241-248. [PMID: 38261020 DOI: 10.1007/s00276-023-03282-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Injection of the tibiotalar (TT) joint is commonly performed in clinical practice under ultrasound (US) guidance using an anteromedial approach. However, in some patients, this approach may be technically challenging due to post-traumatic and/or degenerative bony changes. Therefore, the aim of this cadaveric investigation was to demonstrate the feasibility of the ultrasound-guided (USG) injection of the ankle joint via the anterolateral sulcus (ALS) by confirming the dye placement/distribution inside the articular space. Likewise, the safety of the procedure has also been evaluated by measuring the distance between the needle and the intermediate dorsal cutaneous nerve of the foot. DESIGN A descriptive laboratory study with eight embalmed cadaveric ankles using the Fix for Life (F4L) method was performed at the setting of an academic institution. The interventional technique and the related anatomical findings were illustrated. During the injection, the needle was advanced into the TT joint through the ALS under US guidance, i.e., in-plane anterior-to-posterior approach. With the objective to confirm its correct placement, the needle was kept in situ and-to demonstrate the location of the dye inside the articular space-all eight ankles were injected with 3 mL of green color dye. Thereafter, a layer-by-layer anatomical dissection was performed on all four cadavers. RESULTS The position of the needle's tip within the ALS was confirmed in all specimens. Accurate placement of the dye inside the articular space of the ankle was confirmed in seven of the eight cadaveric ankles, with 87.5% of accuracy. Herewith, unintentional spilling of the dye within the superficial soft tissues was reported in two of the eight ankles (25.0%). The mean distance between the needle and the intermediate dorsal cutaneous nerve of the foot, measured in all eight procedures, was 3 cm. CONCLUSION USG injection of the ALS using the in-plane, anterior-to-posterior approach can accurately place the injectate inside the articular space. CLINICAL RELEVANCE This cadaveric investigation described the accuracy and potential pitfalls of USG injection of the ankle via the anterolateral approach which represents an alternative technique in patients with reduced accessibility of the anteromedial recess due to degenerative and/or post-traumatic bony changes.
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Erdoğan K, Durmuş ME, Kara Ö, Kara M, Özçakar L. Prompt Sonographic Assessment of Body Composition After Bariatric Surgery. Obes Surg 2024; 34:666-667. [PMID: 37964163 DOI: 10.1007/s11695-023-06775-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 11/16/2023]
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Aksakal MF, Abdulsalam AJ, Kaymak B, Kara M, Özçakar L. Dental treatment can be a 'headache'. Br Dent J 2024; 236:186. [PMID: 38332078 DOI: 10.1038/s41415-024-7059-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
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Analay P, Kara M, Özçakar L. Gauging the Diagnosis of Sarcopenia: A Side Note for Nephrologists. J Ren Nutr 2024:S1051-2276(24)00005-0. [PMID: 38281652 DOI: 10.1053/j.jrn.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/08/2024] [Indexed: 01/30/2024] Open
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Kara M. [Latent Macrophage and Immature B Cell Lines Generated with Hygromycin-Resistant Murine Gammaherpesvirus 68 Genome Expresses Modest Levels of Viral miRNAs]. Mol Biol (Mosk) 2024; 58:154-156. [PMID: 38943586 DOI: : 10.31857/s0026898424010148, edn: nvdcry] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/26/2023] [Indexed: 07/01/2024]
Abstract
Murine gammaherpesvirus 68 (MHV68) establishes latency mainly in B cells and causes lymphomas reminiscent of human gammaherpesvirus diseases in laboratory mice. To study the molecular mechanism of virus infection and how the viral determinants control cell and eventually cause tumorigenesis, readily available latently infected cell lines are essential. For in vitro MHV68 latency studies, only two cell culture systems have been available. Gammaherpesviruses are known to infect developing B cells and macrophages, therefore we aimed to expand the MHV68 latently infected cell line repertoire. Here, several latently infected immature B cell and macrophage-like cell line clones were generated. Hygromycin-resistant recombinant MHV68 was isolated from a laboratory-made latent cell line, HE2.1, and propagated to develop stable cell lines that carry the viral genome under hygromycin selection. Subclones of these cells lines were analyzed for viral miRNA expression by TaqMan qPCR and assessed for expression of a lytic viral transcript M3. The cell lines maintain the viral genome as an episome shown by the digestion-circularization PCR assay. Latently infected cell lines generated here do not express viral miRNAs higher than the parental cell line. However, these cell lines may provide an alternative tool to study latency mechanisms and miRNA target identification studies.
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Kara M, Erdal YS, Doğan Y, Erdal ÖD, D'Amico V, Özçakar L. The chronicle of headache treatment throughout human history from trepanation to perisutural botulinum toxin injections. Int J Neurosci 2023; 133:1399-1402. [PMID: 35603776 DOI: 10.1080/00207454.2022.2081166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022]
Abstract
To provide a historic snapshot as regards the evolution of headache treatment throughout the human history, i.e. starting from trepanation to perisutural botulinum toxin (BoNT) injections. Ancient surgeons had aimed to reach the cranium with trepanation (a surgical operation) for headache. As BoNT inhibits the release of nociceptive and pro-inflammatory neuropeptides, it has been recently suggested as an effective alternative in the prophylactic treatment of chronic migraine headache. Chronic migraine is a complex neurological disorder for which the underlying pathophysiology is yet not totally explained. According to the generally accepted hypotheses, peripheral neurogenic activation and central trigeminal sensitization are the two main mechanisms through which its pain develops. Since the headache most commonly occurs around the perisutural areas, and as the primary pathogenesis stem from the meningeal nerve fibers; collateral sensorial branches of the meningeal nerves can be optimal paths to transport BoNT inside the cranium. Concerning the therapeutic efficacy, we anticipate that perisutural injections would be technically challenging with blind techniques and actually possible only if performed under an imaging guidance, e.g. very conveniently with high frequency ultrasound.
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