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Rei N, Valente CA, Vaz SH, Farinha-Ferreira M, Ribeiro JA, Sebastião AM. Changes in adenosine receptors and neurotrophic factors in the SOD1G93A mouse model of amyotrophic lateral sclerosis: Modulation by chronic caffeine. PLoS One 2022; 17:e0272104. [PMID: 36516126 PMCID: PMC9749988 DOI: 10.1371/journal.pone.0272104] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/13/2022] [Indexed: 12/15/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is characterized by the progressive degeneration of corticospinal tract motor neurons. Previous studies showed that adenosine-mediated neuromodulation is disturbed in ALS and that vascular endothelial growth factor (VEGF) has a neuroprotective function in ALS mouse models. We evaluated how adenosine (A1R and A2AR) and VEGF (VEGFA, VEGFB, VEGFR-1 and VEGFR-2) system markers are altered in the cortex and spinal cord of pre-symptomatic and symptomatic SOD1G93A mice. We then assessed if/how chronic treatment of SOD1G93A mice with a widely consumed adenosine receptor antagonist, caffeine, modulates VEGF system and/or the levels of Brain-derived Neurotrophic Factor (BDNF), known to be under control of A2AR. We found out decreases in A1R and increases in A2AR levels even before disease onset. Concerning the VEGF system, we detected increases of VEGFB and VEGFR-2 levels in the spinal cord at pre-symptomatic stage, which reverses at the symptomatic stage, and decreases of VEGFA levels in the cortex, in very late disease states. Chronic treatment with caffeine rescued cortical A1R levels in SOD1G93A mice, bringing them to control levels, while rendering VEGF signaling nearly unaffected. In contrast, BDNF levels were significantly affected in SOD1G93A mice treated with caffeine, being decreased in the cortex and increased in spinal the cord. Altogether, these findings suggest an early dysfunction of the adenosinergic system in ALS and highlights the possibility that the negative influence of caffeine previously reported in ALS animal models results from interference with BDNF rather than with the VEGF signaling molecules.
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Affiliation(s)
- Nádia Rei
- Faculdade de Medicina, Instituto de Farmacologia e Neurociências, Universidade de Lisboa, Lisboa, Portugal
- Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisboa, Portugal
| | - Cláudia A. Valente
- Faculdade de Medicina, Instituto de Farmacologia e Neurociências, Universidade de Lisboa, Lisboa, Portugal
- Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisboa, Portugal
| | - Sandra H. Vaz
- Faculdade de Medicina, Instituto de Farmacologia e Neurociências, Universidade de Lisboa, Lisboa, Portugal
- Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisboa, Portugal
| | - Miguel Farinha-Ferreira
- Faculdade de Medicina, Instituto de Farmacologia e Neurociências, Universidade de Lisboa, Lisboa, Portugal
- Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisboa, Portugal
| | - Joaquim A. Ribeiro
- Faculdade de Medicina, Instituto de Farmacologia e Neurociências, Universidade de Lisboa, Lisboa, Portugal
- Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisboa, Portugal
| | - Ana M. Sebastião
- Faculdade de Medicina, Instituto de Farmacologia e Neurociências, Universidade de Lisboa, Lisboa, Portugal
- Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisboa, Portugal
- * E-mail:
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Palmer BR, Paterson MA, Frampton CM, Pilbrow AP, Skelton L, Pemberton CJ, Doughty RN, Ellis CJ, Troughton RW, Richards AM, Cameron VA. Vascular endothelial growth factor-A promoter polymorphisms, circulating VEGF-A and survival in acute coronary syndromes. PLoS One 2021; 16:e0254206. [PMID: 34260629 PMCID: PMC8279389 DOI: 10.1371/journal.pone.0254206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 06/22/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Development of a competent collateral circulation in established coronary artery disease is cardio-protective. The vascular endothelial growth factor (VEGF) system plays a key role in this process. We investigated the prognostic performance of circulating VEGF-A and three genetic variants in the VEGFA gene in a clinical coronary cohort. METHODS AND RESULTS The Coronary Disease Cohort Study (CDCS) recruited 2,140 patients, with a diagnosis of acute coronary syndrome (ACS), after admission to Christchurch or Auckland City Hospitals between July 2002 and January 2009. We present data for 1927 patients from the cohort genotyped for three SNPs in the VEGF-A gene, rs699947 (C-2578A), rs2010963 (C405G) and rs3025039 (C936T). Plasma VEGF-A concentrations were assayed in a subgroup (n = 550) of CDCS patients (geometric mean 36.6 [34.7-38.5] pg/ml). VEGF-A levels correlated with patient heart rate at baseline (p = 0.034). None of rs699947, rs3025039, nor rs2010963 genotypes were significantly associated with VEGF-A levels, but rs3025039 genotype was positively associated with collateral vessels perfusion according to the Rentrop classification (p = 0.01) and baseline natriuretic peptide levels (p<0.05). Survival in the CDCS cohort was independently associated with baseline VEGF-A levels and (in males) with rs699947 genotype. CONCLUSIONS This study is strongly suggestive that VEGF-A levels have value as a prognostic biomarker in coronary heart disease patients and SNPs in VEGF-A deserve further investigation as prognostic markers and indicators of angiogenic potential influencing the formation of collateral circulation.
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Affiliation(s)
- Barry R. Palmer
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
- School of Health Sciences, College of Health, Massey University, Wellington, New Zealand
| | - Melinda A. Paterson
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Chris. M. Frampton
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Anna P. Pilbrow
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Lorraine Skelton
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Chris J. Pemberton
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Robert N. Doughty
- Faculty of Medicine and Health Sciences, Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Chris J. Ellis
- Faculty of Medicine and Health Sciences, Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Richard W. Troughton
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - A. Mark Richards
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
- Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore
| | - Vicky A. Cameron
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
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The Role of Moderate Aerobic Exercise as Determined by Cardiopulmonary Exercise Testing in ALS. Neurol Res Int 2018; 2018:8218697. [PMID: 29666705 PMCID: PMC5832023 DOI: 10.1155/2018/8218697] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/05/2017] [Indexed: 12/11/2022] Open
Abstract
Introduction The efficacy of cardiopulmonary exercise testing (CPET) to determining exercise intensity has not been established in Amyotrophic Lateral Sclerosis (ALS). We studied this intervention. Methods We included 48 ALS patients randomized in 2 groups: G1 (n = 24), exercise intensity leveled by CPET; G2 (n = 24), standard care limited by fatigue, during 6 months. ALS functional scale (ALSFRS-R) and forced vital capacity (FVC) were performed every 3 months; CPET was done at admission (T1) and 6 months later (T2). We registered oxygen uptake, carbon dioxide output, and ventilation at anaerobic threshold and at peak effort. Primary outcome was functional change. We used parametric statistics for comparisons and multiple regression analyses to identify independent predictors of functional decline. Results At T1 both groups were identical, except for higher FVC in G1 (p = 0.02). At T2, ALSFRS-R was higher (p = 0.035) in G1. Gas exchange variables at T2 did not change in G1 but had significant differences in G2 (p < 0.05). Multiregression analyses showed the Spinal ALSFRS-R slope and Intervention group (p < 0.001) as significant predictors of ALSFRS-R at T2. Conclusion Aerobic exercise defined by CPET is feasible and can improve functional outcome in ALS. This trial is registered with Clinical trials.gov ID: NCT03326622.
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Influence of Resistance Training on Neuromuscular Function and Physical Capacity in ALS Patients. JOURNAL OF NEURODEGENERATIVE DISEASES 2017; 2017:1436519. [PMID: 28596929 PMCID: PMC5449732 DOI: 10.1155/2017/1436519] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 04/24/2017] [Indexed: 12/14/2022]
Abstract
Objectives The present study aimed to explore the effect of resistance training in patients with amyotrophic lateral sclerosis (ALS), a disease characterized by progressive motor neuron loss and muscle weakness. Materials and Methods Following a 12-week “lead-in” control period, a population of ALS patients from Funen, Denmark, completed a 12-week resistance training program consisting of 2-3 sessions/week. Neuromuscular function (strength and power) and voluntary muscle activation (superimposed twitch technique) were evaluated before and after both control and training periods. Physical capacity tests (chair rise and timed up and go), the revised ALS functional rating scale (ALSFRS-R) scores, and muscle cross sectional area (histology) were also assessed. Results Of twelve ALS patients assessed for eligibility, six were included and five completed the study. Training did not significantly affect the ALSFRS-R score, and loss of neuromuscular function (strength and power) increased following the training period. However, an improved functionality (chair rise) and an increase in greatly hypertrophied type II fibres combined with an increase in atrophied fibres following the training period compared to the control period were observed. Conclusion In this small study, the present form of resistance training was unable to attenuate progressive loss of neuromuscular function in ALS, despite some changes in physical capacity and morphology.
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Gonçalves M, De Carvalho M, Peixoto C, Alves P, Barreto C, Oliva A, Pinto S, Laborinho-Pronto A, Gromicho M, Costa J. Phosphoneurofilament heavy chain and vascular endothelial growth factor as cerebrospinal fluid biomarkers for ALS. Amyotroph Lateral Scler Frontotemporal Degener 2016; 18:134-136. [PMID: 27538346 DOI: 10.1080/21678421.2016.1212894] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Margarida Gonçalves
- a Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa , Oeiras , Portugal
| | - Mamede De Carvalho
- b Hospital de Santa Maria, Centro Hospitalar Lisboa-Norte , Lisbon , Portugal.,c Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon , Portugal , and
| | - Cristina Peixoto
- a Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa , Oeiras , Portugal.,d Instituto de Biologia Experimental e Tecnológica , Oeiras , Portugal
| | - Paula Alves
- a Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa , Oeiras , Portugal.,b Hospital de Santa Maria, Centro Hospitalar Lisboa-Norte , Lisbon , Portugal.,c Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon , Portugal , and.,d Instituto de Biologia Experimental e Tecnológica , Oeiras , Portugal
| | - Carmo Barreto
- a Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa , Oeiras , Portugal.,d Instituto de Biologia Experimental e Tecnológica , Oeiras , Portugal
| | - Abel Oliva
- a Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa , Oeiras , Portugal.,d Instituto de Biologia Experimental e Tecnológica , Oeiras , Portugal
| | - Susana Pinto
- c Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon , Portugal , and
| | - Ana Laborinho-Pronto
- c Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon , Portugal , and
| | - Marta Gromicho
- c Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon , Portugal , and
| | - Júlia Costa
- a Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa , Oeiras , Portugal
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Costa J, de Carvalho M. Emerging molecular biomarker targets for amyotrophic lateral sclerosis. Clin Chim Acta 2016; 455:7-14. [PMID: 26774696 DOI: 10.1016/j.cca.2016.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 01/05/2016] [Accepted: 01/12/2016] [Indexed: 12/12/2022]
Abstract
Amyotrophic lateral sclerosis is a rapidly progressive neurodegenerative disease that affects upper (UMN) and lower motor (LMN) neurons. It is associated with a short survival and there is no effective treatment, in spite of a large number of clinical trials. Strong efforts have been made to identify novel disease biomarkers to support diagnosis, provide information on prognosis, to measure disease progression in trials and increase our knowledge on disease pathogenesis. Electromyography by testing the function of the LMN can be used as a biomarker of its dysfunction. A number of electrophysiological and neuroimaging methods have been explored to identify a reliable marker of UMN degeneration. Recently, strong evidence from independent groups, large cohorts of patients and multicenter studies indicate that neurofilaments are very promising diagnostic biomarkers, in particular cerebrospinal fluid and blood levels of phosphoneurofilament heavy chain and neurofilament light chain. Furthermore, their increased levels are associated with poor prognosis. Additional studies have been performed aiming to identify other biomarkers, which alone or in combination with neurofilaments could increase the sensitivity and the specificity of the assays. Emerging molecular marker targets are being discovered, but more studies with standardized methods are required in larger cohorts of ALS patients.
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Affiliation(s)
- Júlia Costa
- Laboratory of Glycobiology, Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa, Avenida da República, 2780-157 Oeiras, Portugal.
| | - Mamede de Carvalho
- Institute of Physiology-Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Portugal; Department Neurosciences, Hospital de Santa Maria-CHLN, Lisbon, Portugal
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Lunetta C, Lizio A, Sansone VA, Cellotto NM, Maestri E, Bettinelli M, Gatti V, Melazzini MG, Meola G, Corbo M. Strictly monitored exercise programs reduce motor deterioration in ALS: preliminary results of a randomized controlled trial. J Neurol 2015; 263:52-60. [DOI: 10.1007/s00415-015-7924-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 09/29/2015] [Accepted: 09/30/2015] [Indexed: 12/11/2022]
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Dadon-Nachum M, Ben-Yaacov K, Ben-Zur T, Barhum Y, Yaffe D, Perlson E, Offen D. Transplanted modified muscle progenitor cells expressing a mixture of neurotrophic factors delay disease onset and enhance survival in the SOD1 mouse model of ALS. J Mol Neurosci 2014; 55:788-97. [PMID: 25330859 DOI: 10.1007/s12031-014-0426-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 09/16/2014] [Indexed: 12/14/2022]
Abstract
Neurotrophic factors (NTFs) are essential growth factor proteins that support the development, survival, and proper function of neurons. We have developed muscle progenitor cell (MPC) populations expressing brain-derived neurotrophic factor (BDNF), glial-derived neurotrophic factor (GDNF), vascular endothelial growth factor (VEGF), or insulin-like growth factor-1 (IGF-1). Transplantation of a mixture of such MPC populations (MPC-MIX) into the hind legs of SOD1 G93A transgenic mice (SOD1 mice), the commonly used model of ALS, delayed the onset of disease symptoms by 30 days and prolonged the average lifespan by 13 days. Treated mice also showed a decrease in the degeneration of neuromuscular junction and an increase in axonal survival. Cellular mechanism assays suggest a synergistic rescue effect of NTFs that involves the AKT and BAD signaling pathways. The results suggest that long-term delivery of a mixture of several NTFs by the transplantation of engineered MPC has a beneficial effect in the ALS mouse model.
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Affiliation(s)
- M Dadon-Nachum
- Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Gonçalves M, Tillack L, de Carvalho M, Pinto S, Conradt HS, Costa J. Phosphoneurofilament heavy chain and N-glycomics from the cerebrospinal fluid in amyotrophic lateral sclerosis. Clin Chim Acta 2014; 438:342-9. [PMID: 25261856 DOI: 10.1016/j.cca.2014.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 08/26/2014] [Accepted: 09/10/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND Amyotrophic Lateral Sclerosis (ALS) is a fatal neurodegenerative disease of the motor neuron for which no clinically validated biomarkers have been identified. METHODS We have quantified by ELISA the biomarker phosphoneurofilament heavy chain (pNFH) in the cerebrospinal fluid (CSF) of ALS patients (n=29) and age-matched control patients with other diseases (n=19) by ELISA. Furthermore, we compared protein N-glycosylation of the CSF in ALS patients and controls, by applying a glycomics approach based on liquid chromatography and mass spectrometry. RESULTS pNFH levels were significantly higher in ALS patients in comparison with controls (P<0.0001) in particular in fast progressors. The N-glycans found in the CSF were predominantly complex diantennary with sialic acid in α2,3- and α2,6-linkage, and bisecting N-acetylglucosamine-containing structures as well as peripherally fucosylated structures were found. As compared with controls the ALS group had a significant increase of a peak composed of the monosialylated diantennary glycans A2G2S(6)1 and FA2G2S(3)1 (P=0.0348). CONCLUSIONS Our results underscore the value of pNFH as a biomarker in ALS. In addition, we identified a variation of the N-glycosylation pattern in ALS, suggesting that this change should be explored in future studies as potential biomarker.
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Affiliation(s)
- Margarida Gonçalves
- Laboratory of Glycobiology, Instituto de Tecnologia Química e Biológica, Universidade Nova de Lisboa, Avenida da República, 2780-157 Oeiras, Portugal
| | - Linda Tillack
- GlycoThera GmbH, Feodor-Lynen Strasse 35, 30625 Hannover, Germany
| | - Mamede de Carvalho
- Department Neurosciences, Hospital de Santa Maria, Lisbon, Portugal; Translational Clinical Physiology Unit, Instituto de Medicina Molecular, Institute of Physiology, Faculty of Medicine - University of Lisbon, Portugal
| | - Susana Pinto
- Department Neurosciences, Hospital de Santa Maria, Lisbon, Portugal; Translational Clinical Physiology Unit, Instituto de Medicina Molecular, Institute of Physiology, Faculty of Medicine - University of Lisbon, Portugal
| | - Harald S Conradt
- GlycoThera GmbH, Feodor-Lynen Strasse 35, 30625 Hannover, Germany
| | - Júlia Costa
- Laboratory of Glycobiology, Instituto de Tecnologia Química e Biológica, Universidade Nova de Lisboa, Avenida da República, 2780-157 Oeiras, Portugal.
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Pronto-Laborinho AC, Pinto S, de Carvalho M. Roles of vascular endothelial growth factor in amyotrophic lateral sclerosis. BIOMED RESEARCH INTERNATIONAL 2014; 2014:947513. [PMID: 24987705 PMCID: PMC4022172 DOI: 10.1155/2014/947513] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 03/24/2014] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal devastating neurodegenerative disorder, involving progressive degeneration of motor neurons in spinal cord, brainstem, and motor cortex. Riluzole is the only drug approved in ALS but it only confers a modest improvement in survival. In spite of a high number of clinical trials no other drug has proved effectiveness. Recent studies support that vascular endothelial growth factor (VEGF), originally described as a key angiogenic factor, also plays a key role in the nervous system, including neurogenesis, neuronal survival, neuronal migration, and axon guidance. VEGF has been used in exploratory clinical studies with promising results in ALS and other neurological disorders. Although VEGF is a very promising compound, translating the basic science breakthroughs into clinical practice is the major challenge ahead. VEGF-B, presenting a single safety profile, protects motor neurons from degeneration in ALS animal models and, therefore, it will be particularly interesting to test its effects in ALS patients. In the present paper the authors make a brief description of the molecular properties of VEGF and its receptors and review its different features and therapeutic potential in the nervous system/neurodegenerative disease, particularly in ALS.
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Affiliation(s)
- Ana Catarina Pronto-Laborinho
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal
- Instituto de Medicina Molecular (IMM), Translational Clinical Physiology Unit, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal
| | - Susana Pinto
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal
- Instituto de Medicina Molecular (IMM), Translational Clinical Physiology Unit, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal
| | - Mamede de Carvalho
- Institute of Physiology, Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal
- Instituto de Medicina Molecular (IMM), Translational Clinical Physiology Unit, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal
- Department of Neurosciences, Hospital Santa Maria, Centro Hospitalar Lisboa Norte, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal
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