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Riaz K, Suneel S, Hamza Bin Abdul Malik M, Kashif T, Ullah I, Waris A, Di Nicola M, Mazza M, Sani G, Martinotti G, De Berardis D. MDMA-Based Psychotherapy in Treatment-Resistant Post-Traumatic Stress Disorder (PTSD): A Brief Narrative Overview of Current Evidence. Diseases 2023; 11:159. [PMID: 37987270 PMCID: PMC10660711 DOI: 10.3390/diseases11040159] [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: 09/06/2023] [Revised: 10/24/2023] [Accepted: 10/31/2023] [Indexed: 11/22/2023] Open
Abstract
Post-traumatic stress disorder (PTSD) is a debilitating mental health disorder that causes significant dysfunction in individuals. Currently, there are many approved pharmacotherapy and psychotherapy treatment options for PTSD, but unfortunately, half of the patients do not respond to traditional therapies. In this article, we review clinical trials and research on 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy in PTSD patients, its pharmacokinetics, and current treatment guidelines for PTSD. Our findings are based on the results of the efficacy of MDMA-assisted psychotherapy from six phase II randomized controlled trials. MDMA-assisted psychotherapy for PTSD has received the "breakthrough therapy" designation from the FDA. MDMA can reduce PTSD symptoms even in treatment-resistant cases by increasing certain neurohormones, i.e., dopamine, serotonin, norepinephrine, and oxytocin. It also modulates activities in the brain regions involved in fear and anxiety. Future research is needed to show whether the advantages outweigh the disadvantages and whether its use can be integrated into available treatment options for PTSD.
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Affiliation(s)
- Kainat Riaz
- Dow Medical College, Dow University of Health Sciences, Karachi 75700, Pakistan; (K.R.); (S.S.)
| | - Sejal Suneel
- Dow Medical College, Dow University of Health Sciences, Karachi 75700, Pakistan; (K.R.); (S.S.)
| | | | - Tooba Kashif
- Jinnah Sindh Medical University, Karachi 75510, Pakistan;
| | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar 25120, Pakistan; (I.U.); (A.W.)
| | - Abdul Waris
- Kabir Medical College, Gandhara University, Peshawar 25120, Pakistan; (I.U.); (A.W.)
| | - Marco Di Nicola
- Department of Geriatrics, Neuroscience and Orthopedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.D.N.); (M.M.); (G.S.)
| | - Marianna Mazza
- Department of Geriatrics, Neuroscience and Orthopedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.D.N.); (M.M.); (G.S.)
| | - Gabriele Sani
- Department of Geriatrics, Neuroscience and Orthopedics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.D.N.); (M.M.); (G.S.)
| | - Giovanni Martinotti
- Department of Neurosciences, Imaging, and Clinical Sciences, University G. D’Annunzio, 66100 Chieti-Pescara, Italy;
| | - Domenico De Berardis
- Department of Psychiatry, Azienda Sanitaria Locale 4, 64100 Teramo, Italy
- School of Nursing, University of L’Aquila, 67100 L’Aquila, Italy
- International Centre for Education and Research in Neuropsychiatry, Samara State Medical University, 443100 Samara, Russia
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Modi JP, Shen W, Menzie-Suderam J, Xu H, Lin CH, Tao R, Prentice HM, Schloss J, Wu JY. The Role of NMDA Receptor Partial Antagonist, Carbamathione, as a Therapeutic Agent for Transient Global Ischemia. Biomedicines 2023; 11:1885. [PMID: 37509524 PMCID: PMC10377037 DOI: 10.3390/biomedicines11071885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
Carbamathione (Carb), an NMDA glutamate receptor partial antagonist, has potent neuroprotective functions against hypoxia- or ischemia-induced neuronal injury in cell- or animal-based stroke models. We used PC-12 cell cultures as a cell-based model and bilateral carotid artery occlusion (BCAO) for stroke. Whole-cell patch clamp recording in the mouse retinal ganglion cells was performed. Key proteins involved in apoptosis, endoplasmic reticulum (ER) stress, and heat shock proteins were analyzed using immunoblotting. Carb is effective in protecting PC12 cells against glutamate- or hypoxia-induced cell injury. Electrophysiological results show that Carb attenuates NMDA-mediated glutamate currents in the retinal ganglion cells, which results in activation of the AKT signaling pathway and increased expression of pro-cell survival biomarkers, e.g., Hsp 27, P-AKT, and Bcl2 and decreased expression of pro-cell death markers, e.g., Beclin 1, Bax, and Cleaved caspase 3, and ER stress markers, e.g., CHOP, IRE1, XBP1, ATF 4, and eIF2α. Using the BCAO animal stroke model, we found that Carb reduced the brain infarct volume and decreased levels of ER stress markers, GRP 78, CHOP, and at the behavioral level, e.g., a decrease in asymmetric turns and an increase in locomotor activity. These findings for Carb provide promising and rational strategies for stroke therapy.
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Affiliation(s)
- Jigar Pravinchandra Modi
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
- Center of Complex Systems and Brain Sciences, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Wen Shen
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
- Program in Integrative Biology, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Janet Menzie-Suderam
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
- Program in Integrative Biology, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Hongyuan Xu
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Chun-Hua Lin
- Department of Nursing, Kang-Ning University, Taipei 11485, Taiwan
| | - Rui Tao
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
- Program in Integrative Biology, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Howard M Prentice
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
- Center of Complex Systems and Brain Sciences, Florida Atlantic University, Boca Raton, FL 33431, USA
- Program in Integrative Biology, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - John Schloss
- Department of Pharmaceutical Science, American University of Health Sciences, Signal Hill, CA 90755, USA
| | - Jang-Yen Wu
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
- Center of Complex Systems and Brain Sciences, Florida Atlantic University, Boca Raton, FL 33431, USA
- Program in Integrative Biology, Florida Atlantic University, Boca Raton, FL 33431, USA
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Zarcone TJ. Neuroscience and Actometry: an example of the benefits of the precise measurement of behavior. Brain Res Bull 2022; 185:86-90. [PMID: 35472566 DOI: 10.1016/j.brainresbull.2022.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 12/20/2022]
Abstract
PURPOSE Assess the impact the force-plate actometer, invented by Stephen C. Fowler, has had on behavioral neuroscience so far and what may be possible for future progress. METHODS The web service Scopus was queried on April 28, 2021 for articles that cited the Journal of Neuroscience Methods paper titled "A force-plate actometer for quantitating rodent behaviors: illustrative data on locomotion, rotation, spatial patterning, stereotypies, and tremor" resulting in 134 articles. Articles were coded by the author for type (e.g., research, review, book chapter), phenomenon (e.g., stress, addiction), intervention (e.g., pharmacological), and measure (e.g., distance traveled, tremor). CONCLUSIONS Of the 134 citations, 116 were research articles, 10 were review articles, 7 were book chapters and one was an advertisement. The force-plate actometer has been used to study a variety of phenomena and its measurement capabilities were expanded. While primarily used for rats and mice, other species have been used.
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Affiliation(s)
- Troy J Zarcone
- National Institute on Drug Abuse, 301 North Stonestreet Ave, Bethesda, MD 20892.
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van Amsterdam J, Brunt TM, Pierce M, van den Brink W. Hard Boiled: Alcohol Use as a Risk Factor for MDMA-Induced Hyperthermia: a Systematic Review. Neurotox Res 2021; 39:2120-2133. [PMID: 34554408 PMCID: PMC8639540 DOI: 10.1007/s12640-021-00416-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/07/2021] [Accepted: 09/11/2021] [Indexed: 11/10/2022]
Abstract
Although MDMA (ecstasy) is a relatively safe recreational drug and is currently considered for therapeutic use for the treatment of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD), recreational MDMA use occasionally elicits hyperthermia and hyponatremia, sometimes with a fatal outcome. Specific risk factors for both adverse effects are profuse sweating while vigorously dancing under unfavorable conditions such as high ambient temperatures and insufficient fluid suppletion which result in dehydration. Concomitant use of MDMA and alcohol is highly prevalent, but adds to the existing risk, because alcohol facilitates the emergence of MDMA-induced adverse events, like hyperthermia, dehydration, and hyponatremia. Because of potential health-related consequences of concomitant use of MDMA and alcohol, it is important to identify the mechanisms of the interactions between alcohol and MDMA. This review summarizes the main drivers of MDMA-induced hyperthermia, dehydration, and hyponatremia and the role of concomitant alcohol use. It is shown that alcohol use has a profound negative impact by its interaction with most of these drivers, including poikilothermia, exposure to high ambient temperatures, heavy exercise (vigorous dancing), vasoconstriction, dehydration, and delayed initiation of sweating and diuresis. It is concluded that recreational and clinical MDMA-users should refrain from concomitant drinking of alcoholic beverages to reduce the risk for adverse health incidents when using MDMA.
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Affiliation(s)
- Jan van Amsterdam
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Tibor M Brunt
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Mimi Pierce
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Wim van den Brink
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
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Mustafa NS, Bakar NHA, Mohamad N, Adnan LHM, Fauzi NFAM, Thoarlim A, Omar SHS, Hamzah MS, Yusoff Z, Jufri M, Ahmad R. MDMA and the Brain: A Short Review on the Role of Neurotransmitters in Neurotoxicity. Basic Clin Neurosci 2021; 11:381-388. [PMID: 33613876 PMCID: PMC7878040 DOI: 10.32598/bcn.9.10.485] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/10/2018] [Accepted: 02/19/2019] [Indexed: 11/24/2022] Open
Abstract
N-Methyl-3, 4-methylenedioxyamphetamine (MDMA), or ecstasy is a recreational drug of abuse. It is a synthetic substance that affects the body’s systems, which its mechanism of action and treatment should be more investigated. MDMA provides an immediate enjoyable feeling by stimulating the release of neurotransmitters, such as dopamine and serotonin in the brain. Unfortunately, abnormal regulation of the brain neurotransmitters, as well as the increased oxidative stress causes damage to the brain neurons after the MDMA exposure. Only a few studies have been done regarding its treatment. Thus, the treatment of MDMA complications should be further explored mainly by targeting its mechanism of action in the neurotransmitter systems. Hence, this study presents a short review regarding the recent findings on the role of neurotransmitters to cause MDMA neurotoxicity. The results will be useful for future research in elucidating the potential treatment based on the targeted mechanisms to treat the neurotoxic effects of MDMA.
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Affiliation(s)
- Nor Suliana Mustafa
- Centre for Research in Addiction (CentRenA), University of Sultan Zainal Abidin, Terengganu, Malaysia.,Faculty of Medicine, City Campus, University of Sultan Zainal Abidin, Terengganu, Malaysia
| | - Nor Hidayah Abu Bakar
- Centre for Research in Addiction (CentRenA), University of Sultan Zainal Abidin, Terengganu, Malaysia.,Faculty of Medicine, City Campus, University of Sultan Zainal Abidin, Terengganu, Malaysia
| | - Nasir Mohamad
- Centre for Research in Addiction (CentRenA), University of Sultan Zainal Abidin, Terengganu, Malaysia.,Faculty of Medicine, City Campus, University of Sultan Zainal Abidin, Terengganu, Malaysia
| | - Liyana Hazwani Mohd Adnan
- Centre for Research in Addiction (CentRenA), University of Sultan Zainal Abidin, Terengganu, Malaysia.,Faculty of Medicine, City Campus, University of Sultan Zainal Abidin, Terengganu, Malaysia
| | - Nurul Farah Aina Md Fauzi
- Centre for Research in Addiction (CentRenA), University of Sultan Zainal Abidin, Terengganu, Malaysia.,Faculty of Medicine, City Campus, University of Sultan Zainal Abidin, Terengganu, Malaysia
| | - Abdulsoma Thoarlim
- Centre for Research in Addiction (CentRenA), University of Sultan Zainal Abidin, Terengganu, Malaysia.,Faculty of Islamic Contemporary Studies, University of Sultan Zainal Abidin, Terengganu, Malaysia
| | - Syed Hadzrullathfi Syed Omar
- Centre for Research in Addiction (CentRenA), University of Sultan Zainal Abidin, Terengganu, Malaysia.,Research Institute for Islamic Products, Malay Civilization University of Sultan Zainal Abidin, Terengganu, Malaysia
| | - Mohd Shafiee Hamzah
- Faculty of Medicine, City Campus, University of Sultan Zainal Abidin, Terengganu, Malaysia.,Faculty of Islamic Contemporary Studies, University of Sultan Zainal Abidin, Terengganu, Malaysia
| | - Zawawi Yusoff
- Faculty of Medicine, City Campus, University of Sultan Zainal Abidin, Terengganu, Malaysia.,Faculty of Islamic Contemporary Studies, University of Sultan Zainal Abidin, Terengganu, Malaysia
| | - Mahdi Jufri
- Faculty of Pharmacy, University of Indonesia, Indonesia
| | - Rashidi Ahmad
- Academic Unit of Emergency Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Mégarbane B, Oberlin M, Alvarez JC, Balen F, Beaune S, Bédry R, Chauvin A, Claudet I, Danel V, Debaty G, Delahaye A, Deye N, Gaulier JM, Grossenbacher F, Hantson P, Jacobs F, Jaffal K, Labadie M, Labat L, Langrand J, Lapostolle F, Le Conte P, Maignan M, Nisse P, Sauder P, Tournoud C, Vodovar D, Voicu S, Claret PG, Cerf C. Management of pharmaceutical and recreational drug poisoning. Ann Intensive Care 2020; 10:157. [PMID: 33226502 PMCID: PMC7683636 DOI: 10.1186/s13613-020-00762-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/09/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis. METHODS A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d'Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology. RESULTS The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature. CONCLUSIONS The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N-acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.
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Affiliation(s)
- Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Mathieu Oberlin
- Emergency Department, HuManiS Laboratory (EA7308), University Hospital, Strasbourg, France
| | - Jean-Claude Alvarez
- Department of Pharmacology and Toxicology, Inserm U-1173, FHU Sepsis, Raymond Poincaré Hospital, AP-HP, Paris-Saclay University, Garches, France
| | - Frederic Balen
- Emergency Department, Toulouse University Hospital, Toulouse, France
| | - Sébastien Beaune
- Department of Emergency Medicine, Ambroise Paré Hospital, AP-HP, INSERM UMRS-1144, Paris-Saclay University, Boulogne-Billancourt, France
| | - Régis Bédry
- Hospital Secure Unit, Pellegrin University Hospital, Bordeaux, France
| | - Anthony Chauvin
- Emergency Department, Hôpital Lariboisière, AP-HP, Paris, France
| | - Isabelle Claudet
- Pediatric Emergency Department Children’s Hospital CHU Toulouse, Toulouse, France
| | - Vincent Danel
- Department of Emergency Medicine, University Hospital of Grenoble, Grenoble, France
| | - Guillaume Debaty
- 5525, University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-IMAG UMR, Grenoble, France
| | | | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM U942, University of Paris, Paris, France
| | - Jean-Michel Gaulier
- Laboratory of Toxicology, EA 4483 - IMPECS - IMPact de L’Environnement Chimique Sur La Santé Humaine, University of Lille, Lille, France
| | | | - Philippe Hantson
- Intensive Care Department, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Frédéric Jacobs
- Polyvalent Intensive Care Unit, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, Clamart, France
| | - Karim Jaffal
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Magali Labadie
- Poison Control Centre of Bordeaux, University Hospital of Bordeaux, Bordeaux, France
| | - Laurence Labat
- Laboratory of Toxicology, Federation of Toxicology APHP, Lariboisière Hospital, INSERM UMRS-1144, University of Paris, Paris, France
| | - Jérôme Langrand
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Frédéric Lapostolle
- SAMU 93-UF Recherche-Enseignement-Qualité, Inserm, U942, Avicenne Hospital, AP-HP, Paris-13 University, Bobigny, France
| | - Philippe Le Conte
- Department of Emergency Medicine, University Hospital of Nantes, Nantes, France
| | - Maxime Maignan
- Emergency Department, Grenoble University Hospital, INSERM U1042, Grenoble Alpes University, Grenoble, France
| | - Patrick Nisse
- Poison Control Centre, University Hospital of Lille, Lille, France
| | - Philippe Sauder
- Intensive Care Unit, University Hospital of Strasbourg, Strasbourg, France
| | | | - Dominique Vodovar
- Poison Control Center of Paris, Federation of Toxicology, Fernand-Widal-Lariboisière Hospital, AP-HP, INSERM UMRS-1144, University of Paris, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, Federation of Toxicology, Lariboisière Hospital, AP-HP, INSERM MURS-1144, University of Paris, 2 Rue Ambroise Paré, Paris, 75010 France
| | - Pierre-Géraud Claret
- Department of Anesthesia Resuscitation Pain Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Charles Cerf
- Intensive Care Unit, Foch Hospital, Suresnes, France
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Multivisceral Failure in a Context of Serotonin Syndrome Induced by MDMA: The Investigation of a Unique and Nationwide Network. J Addict Med 2020; 14:175-177. [DOI: 10.1097/adm.0000000000000544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Modi J, Menzie-Suderam J, Xu H, Trujillo P, Medley K, Marshall ML, Tao R, Prentice H, Wu JY. Mode of action of granulocyte-colony stimulating factor (G-CSF) as a novel therapy for stroke in a mouse model. J Biomed Sci 2020; 27:19. [PMID: 31907023 PMCID: PMC6943893 DOI: 10.1186/s12929-019-0597-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 11/27/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The FDA approved drug granulocyte-colony stimulating factor (G-CSF) displays anti-apoptotic and immunomodulatory properties with neurogenesis and angiogenic functions. It is known to demonstrate neuroprotective mechanisms against ischemic global stroke. Autophagy is a method for the degradation of intracellular components and in particular, unrestrained autophagy may lead to uncontrolled digestion of affected neurons as well as neuronal death in cerebral ischemia. Mitochondrial dynamics is vital for the regulation of cell survival and death after cerebral ischemia and an early upstream event in neuronal death is mitochondrial fission. We examined the pro-survival mechanisms of G-CSF against apoptosis resulting from autophagy, mitochondrial stress and endoplasmic reticulum (ER) stress. METHODS Male Swiss Webster mice (20 weeks of age) were subjected to bilateral common carotid artery occlusion (BCAO) for 30 min. After occlusion, mice were injected with G-CSF (50 μg/kg) subcutaneously for 4 days. Behavioral analysis was carried out using the corner test and locomotor activity test before animals were sacrificed on day 4 or day 7. Key proteins in ER stress, autophagy and mitochondrial stress induced apoptosis were analyzed by immunoblotting. RESULTS G-CSF improved neurological deficits and improved behavioral performance on corner and locomotor test. G-CSF binds to G-CSF receptors and its activation leads to upregulation of Akt phosphorylation (P-Akt) which in turn decreases levels of the ER stress sensor, GRP 78 and expression of proteins involved in ER stress apoptosis pathway; ATF6, ATF4, eIF2α, XBP1, Caspase 12 and CHOP. G-CSF treatment significantly decreased Beclin-1, an autophagy marker, and decreased mitochondrial stress biomarkers DRP1 and P53. G-CSF also up-regulated the mitochondrial fusion protein, OPA1 and anti-apoptotic protein Bcl-2 while down-regulating the pro-apoptotic proteins Bax, Bak and PUMA. CONCLUSIONS G-CSF is an endogenous ligand in the CNS that has a dual activity that is beneficial both in reducing acute neuronal degeneration and adding to long-term plasticity after cerebral ischemia. G-CSF treatment exerts neuroprotective effects on damaged neurons through the suppression of the ER stress and mitochondrial stress and maintains cellular homeostasis by decreasing pro-apoptotic proteins and increasing of anti-apoptotic proteins.
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Affiliation(s)
- Jigar Modi
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, 33431, USA
- Center of Complex Systems and Brain Sciences, Florida Atlantic University, Boca Raton, FL, USA
| | - Janet Menzie-Suderam
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, 33431, USA
- Program in Integrative Biology, Florida Atlantic University, Boca Raton, FL, 33431, USA
| | - Hongyuan Xu
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, 33431, USA
| | - Paola Trujillo
- Program in Integrative Biology, Florida Atlantic University, Boca Raton, FL, 33431, USA
| | - Kristen Medley
- Program in Integrative Biology, Florida Atlantic University, Boca Raton, FL, 33431, USA
| | | | - Rui Tao
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, 33431, USA
- Program in Integrative Biology, Florida Atlantic University, Boca Raton, FL, 33431, USA
| | - Howard Prentice
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, 33431, USA.
- Center of Complex Systems and Brain Sciences, Florida Atlantic University, Boca Raton, FL, USA.
- Program in Integrative Biology, Florida Atlantic University, Boca Raton, FL, 33431, USA.
| | - Jang-Yen Wu
- Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, 33431, USA.
- Center of Complex Systems and Brain Sciences, Florida Atlantic University, Boca Raton, FL, USA.
- Program in Integrative Biology, Florida Atlantic University, Boca Raton, FL, 33431, USA.
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9
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Musolino ST, Schartner EP, Hutchinson MR, Salem A. Minocycline attenuates 3,4-methylenedioxymethamphetamine-induced hyperthermia in the rat brain. Eur J Pharmacol 2019; 858:172495. [PMID: 31238065 DOI: 10.1016/j.ejphar.2019.172495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/21/2019] [Accepted: 06/21/2019] [Indexed: 10/26/2022]
Abstract
Hyperthermia is most dangerous clinical symptom of acute MDMA administration, and a key factor related to potentially life-threatening MDMA-induced complications. MDMA induces a consistently faster onset of brain hyperthermia when compared to a delayed and moderate hyperthermia in the body, and the most harmful effects of MDMA are related to its modulation of neural functions. The primary focus of this study was to investigate the effects of minocycline, a centrally acting tetracycline derivative on MDMA-induced brain hyperthermia at high ambient temperature. However, we also simultaneously recorded body temperature, heart rate, and locomotor activity changes, allowing us to gain a better understanding of the mechanisms underlying the MDMA-induced hyperthermic response. We also investigated the effects of MDMA at normal ambient temperature to provide further evidence as to the importance of environmental factors on the intensity of MDMA's temperature effects. At normal ambient temperature, MDMA (10 mg/kg, i.p.) induced a significant brain and body hypothermia for the first 90 min following drug administration, and significantly increased heart rate and locomotor activity compared to saline controls. At high ambient temperature however, MDMA (10 mg/kg, i.p.) induced a robust and extended brain and body hyperthermia, as well as significantly increased heart rate and locomotor activity. A 3-day minocycline (50 mg/kg, i.p.) pre-treatment significantly attenuated MDMA-induced increases in brain temperature, body temperature, heart rate, and locomotor activity. Our findings indicate that minocycline is more effective in attenuating the exacerbated MDMA-induced hyperthermic response in the brain compared to the body at high ambient temperature.
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Affiliation(s)
- Stefan T Musolino
- ARC Centre of Excellence for Nanoscale BioPhotonics and Institute for Photonics and Advanced Sensing, Adelaide, SA, 5005, Australia; Discipline of Pharmacology, Adelaide Medical School, The University of Adelaide, Adelaide, SA, 5005, Australia.
| | - Erik P Schartner
- ARC Centre of Excellence for Nanoscale BioPhotonics and Institute for Photonics and Advanced Sensing, Adelaide, SA, 5005, Australia; School of Physical Sciences, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Mark R Hutchinson
- ARC Centre of Excellence for Nanoscale BioPhotonics and Institute for Photonics and Advanced Sensing, Adelaide, SA, 5005, Australia; Discipline of Pharmacology, Adelaide Medical School, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Abdallah Salem
- Discipline of Pharmacology, Adelaide Medical School, The University of Adelaide, Adelaide, SA, 5005, Australia
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10
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Shokry IM, Shields CJ, Callanan JJ, Ma Z, Tao R. Differential role of dose and environment in initiating and intensifying neurotoxicity caused by MDMA in rats. BMC Pharmacol Toxicol 2019; 20:47. [PMID: 31383036 PMCID: PMC6683525 DOI: 10.1186/s40360-019-0326-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 07/18/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND MDMA causes serotonin (5-HT) syndrome immediately after administration and serotonergic injury in a few days or weeks. However, a serotonin syndrome is not always followed by serotonergic injury, indicating different mechanisms responsible for two adverse effects. The goal of present study was to determine causes for two adverse events and further test that dose and environment have a differential role in initiating and intensifying MDMA neurotoxicity. METHODS Initiation and intensification were examined by comparing neurotoxic effects of a high-dose (10 mg/kg × 3 at 2 h intervals) with a low-dose (2 mg/kg × 3) under controlled-environmental conditions. Initiation of a serotonin syndrome was estimated by measuring extracellular 5-HT, body-core temperature, electroencephalogram and MDMA concentrations in the cerebrospinal fluid, while intensification determined in rats examined under modified environment. Initiation and intensification of the serotonergic injury were assessed in rats by measuring tissue 5-HT content, SERT density and functional integrity of serotonergic retrograde transportation. RESULTS Both low- and high-dose could cause increases in extracellular 5-HT to elicit a serotonin syndrome at the same intensity. Modification of environmental conditions, which had no impact on MDMA-elicited increases in 5-HT levels, markedly intensified the syndrome intensity. Although either dose would cause the severe syndrome under modified environments, only the high-dose that resulted in high MDMA concentrations in the brain could cause serotonergic injury. CONCLUSION Our results reveal that extracellular 5-HT is the cause of a syndrome and activity of postsynaptic receptors critical for the course of syndrome intensification. Although the high-dose has the potential to initiate serotonergic injury due to high MDMA concentrations present in the brain, whether an injury is observed depends upon the drug environment via the levels of reactive oxygen species generated. This suggests that brain MDMA concentration is the determinant in the injury initiation while reactive oxygen species generation associated with the injury intensification. It is concluded that the two adverse events utilize distinctly different mediating molecules during the toxic initiation and intensification.
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Affiliation(s)
- Ibrahim M. Shokry
- Department of Biomedical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road, Boca Raton, FL 33431 USA
- Ross University School of Veterinary Medicine, Basseterre, Saint Kitts and Nevis
| | - Connor J. Shields
- Department of Biomedical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road, Boca Raton, FL 33431 USA
| | - John J. Callanan
- Ross University School of Veterinary Medicine, Basseterre, Saint Kitts and Nevis
| | - Zhiyuan Ma
- Department of Biomedical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road, Boca Raton, FL 33431 USA
| | - Rui Tao
- Department of Biomedical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road, Boca Raton, FL 33431 USA
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11
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Shokry IM, DeSuza K, Callanan JJ, Shim G, Ma Z, Tao R. Individuals with Hyperthyroidism are More Susceptible to having a Serious Serotonin Syndrome Following MDMA (Ecstasy) Administration in Rats. ANNALS OF FORENSIC RESEARCH AND ANALYSIS 2018; 5:1052. [PMID: 31172032 PMCID: PMC6548465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
In a recreational use of 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy"), some but not all users are stricken with a serious serotonin (5-hydroxytryptamine; 5-HT) syndrome. This raises a question as to whether there exist subpopulations that are more susceptible to MDMA intoxication. The hypothesis was tested with hyperthyroid versus euthyroid rats by measuring changes in body-core temperature (T cor) and 5-HT in the hypothalamus. In the euthyroid rats, injection of MDMA at a recreationally relevant dose had no serious effect on T cor. In contrast, the same dose was sufficient to evoke life-threatening hyperthermia in hyperthyroid rats. Neurochemical studies revealed that there was greater 5-HT efflux in the hyperthyroid than the euthyroid rats. These effects were blocked by pretreatment with M100907, a 5-HT2A receptor antagonist. In summary, our data support the hypothesis that individuals with hyperthyroidism are more susceptible to having a serious serotonin syndrome following MDMA administration.
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Affiliation(s)
- Ibrahim M. Shokry
- Charles E. Schmidt College of Medicine, Florida Atlantic University, USA
- Ross University School of Veterinary Medicine, West Indies
| | - Kayla DeSuza
- Charles E. Schmidt College of Medicine, Florida Atlantic University, USA
| | | | - Giselle Shim
- Charles E. Schmidt College of Medicine, Florida Atlantic University, USA
| | - Zhiyuan Ma
- Charles E. Schmidt College of Medicine, Florida Atlantic University, USA
| | - Rui Tao
- Charles E. Schmidt College of Medicine, Florida Atlantic University, USA
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12
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Zaitsu K, Noda S, Iguchi A, Hayashi Y, Ohara T, Kimura Y, Koketsu Y, Kosaki T, Kusano M, Sato T, Ishikawa T, Tsuchihashi H, Suzuki K, Ishii A. Metabolome analysis of the serotonin syndrome rat model: Abnormal muscular contraction is related to metabolic alterations and hyper-thermogenesis. Life Sci 2018; 207:550-561. [DOI: 10.1016/j.lfs.2018.06.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/26/2018] [Accepted: 06/28/2018] [Indexed: 02/02/2023]
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13
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Tao R, Shokry IM, Callanan JJ. Environment Influencing Serotonin Syndrome Induced by Ecstasy Abuse. ANNALS OF FORENSIC RESEARCH AND ANALYSIS 2017; 4:1039. [PMID: 29732414 PMCID: PMC5931730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Ecstasy is a recreational drug containing 3,4-methylenedioxymethamphetamine (MDMA). In the U.S., there are several millions of lifetime users, and millions each year added to the list as new users. Only several thousand every year show signs of severe toxicity and require emergency intervention. The illness is known as serotonin (5-HT) syndrome, which can be mild, moderate or severe. The relationship between mild, moderate and severe syndromes appears to be interchangeable, but the severe syndrome is life-threatening. The serotonergic mechanisms of how the mild or moderate syndrome becomes severe and life-threatening have attracted considerable attention in the last few years as an effort to explore new treatments potentially to manage illness and prevent death of patients. High levels of extracellular 5-HT in the brain produced by large doses of MDMA are not always necessary to cause a severe serotonin syndrome. Additional mechanisms may be more important. Recent research has demonstrated that environmental conditions (i.e., non-drug factors) are more critical in determining the severity of MDMA-induced serotonin syndrome than the drug dose. The purpose of the current article was to review available evidence regarding the effect of non-drug factors on serotonergic extrasynaptic receptor responsivity and the severity of MDMA-induced serotonin syndrome.
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Affiliation(s)
- Rui Tao
- Charles E. Schmidt College of Medicine, Florida Atlantic University, USA
| | - Ibrahim M. Shokry
- Charles E. Schmidt College of Medicine, Florida Atlantic University, USA
- Ross University School of Veterinary Medicine, West Indies
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14
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Hrometz SL, Ebert JA, Grice KE, Nowinski SM, Mills EM, Myers BJ, Sprague JE. Potentiation of Ecstasy-induced hyperthermia and FAT/CD36 expression in chronically exercised animals. Temperature (Austin) 2017; 3:557-566. [PMID: 28090559 PMCID: PMC5198810 DOI: 10.1080/23328940.2016.1166310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 03/10/2016] [Accepted: 03/10/2016] [Indexed: 11/16/2022] Open
Abstract
Fatal hyperthermia as a result of 3,4-methylenedioxymethamphetamine (MDMA) use involves non-esterified free fatty acids (NEFA) and the activation of mitochondrial uncoupling proteins (UCP). NEFA gain access into skeletal muscle via specific transport proteins, including fatty acid translocase (FAT/CD36). FAT/CD36 expression is known to increase following chronic exercise. Previous studies have demonstrated the essential role of NEFA and UCP3 in MDMA-induced hyperthermia. The aims of the present study were to use a chronic exercise model (swimming for two consecutive hours per day, five days per wk for six wk) to increase FAT/CD36 expression in order to: 1) determine the contribution of FAT/CD36 in MDMA (20 mg/kg, s.c.)-mediated hyperthermia; and 2) examine the effects of the FAT/CD36 inhibitor, SSO (sulfo-N-succinimidyl oleate), on MDMA-induced hyperthermia in chronic exercise and sedentary control rats. MDMA administration resulted in hyperthermia in both sedentary and chronic exercise animals. However, MDMA-induced hyperthermia was significantly potentiated in the chronic exercise animals compared to sedentary animals. Additionally, chronic exercise significantly reduced body weight, increased FAT/CD36 protein expression levels and reduced plasma NEFA levels. The FAT/CD36 inhibitor, SSO (40 mg/kg, ip), significantly attenuated the hyperthermia mediated by MDMA in chronic exercised but not sedentary animals. Plasma NEFA levels were elevated in sedentary and exercised animals treated with SSO prior to MDMA suggesting attenuation of NEFA uptake into skeletal muscle. Chronic exercise did not alter skeletal muscle UCP3 protein expression levels. In conclusion, chronic exercise potentiates MDMA-mediated hyperthermia in a FAT/CD36 dependent fashion.
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Affiliation(s)
- Sandra L Hrometz
- Department of Pharmaceutical Sciences, College of Pharmacy, Natural and Health Sciences, Manchester University , Fort Wayne, IN, USA
| | - Jeremy A Ebert
- Department of Pharmaceutical and Biomedical Sciences, The Raabe College of Pharmacy, Ohio Northern University , Ada, OH, USA
| | - Karen E Grice
- Department of Pharmaceutical and Biomedical Sciences, The Raabe College of Pharmacy, Ohio Northern University , Ada, OH, USA
| | - Sara M Nowinski
- Division of Pharmacology and Toxicology, College of Pharmacy, University of Texas at Austin , Austin, TX, USA
| | - Edward M Mills
- Division of Pharmacology and Toxicology, College of Pharmacy, University of Texas at Austin , Austin, TX, USA
| | - Brian J Myers
- Department of Chemistry and Biochemistry, The Getty College of Arts & Sciences, Ohio Northern University ; Ada, OH, USA
| | - Jon E Sprague
- The Ohio Attorney General's Center for the Future of Forensic Science, Bowling Green State University , Bowling Green, OH, USA
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15
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Shokry IM, Callanan JJ, Sousa J, Tao R. New Insights on Different Response of MDMA-Elicited Serotonin Syndrome to Systemic and Intracranial Administrations in the Rat Brain. PLoS One 2016; 11:e0155551. [PMID: 27192423 PMCID: PMC4871448 DOI: 10.1371/journal.pone.0155551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 04/29/2016] [Indexed: 11/19/2022] Open
Abstract
In spite of the fact that systemic administration of MDMA elicits serotonin syndrome, direct intracranial administration fails to reproduce the effect. To reconcile these findings, it has been suggested that the cause of serotonin syndrome is attributed mainly to MDMA hepatic metabolites, and less likely to MDMA itself. Recently, however, this explanation has been challenged, and alternative hypotheses need to be explored. Here, we tested the hypothesis that serotonin syndrome is the result of excessive 5HT simultaneously in many brain areas, while MDMA administered intracranially fails to cause serotonin syndrome because it produces only a localized effect at the delivery site and not to other parts of the brain. This hypothesis was examined using adult male Sprague Dawley rats by comparing 5HT responses in the right and left hemispheric frontal cortices, right and left hemispheric diencephalons, and medullar raphe nucleus. Occurrence of serotonin syndrome was confirmed by measuring change in body temperature. Administration routes included intraperitoneal (IP), intracerebroventricular (ICV) and reverse microdialysis. First, we found that IP administration caused excessive 5HT in all five sites investigated and induced hypothermia, suggesting the development of the serotonin syndrome. In contrast, ICV and reverse microdialysis caused excessive 5HT only in regions of delivery sites without changes in body-core temperature, suggesting the absence of the syndrome. Next, chemical dyes were used to trace differences in distribution and diffusion patterns between administration routes. After systemic administration, the dyes were found to be evenly distributed in the brain. However, the dyes administered through ICV or reverse microdialysis injection still remained in the delivery sites, poorly diffusing to the brain. In conclusion, intracranial MDMA administration in one area has no or little effect on other areas, which must be considered a plausible reason for the difference in MDMA-elicited serotonin syndrome between systemic and intracranial administrations.
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Affiliation(s)
- Ibrahim M Shokry
- Ross University School of Veterinary Medicine, St. Kitts, West Indies
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States of America
| | - John J Callanan
- Ross University School of Veterinary Medicine, St. Kitts, West Indies
| | - John Sousa
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States of America
| | - Rui Tao
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, United States of America
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Zaretsky DV, Zaretskaia MV, Durant PJ, Rusyniak DE. Treadmill running restores MDMA-mediated hyperthermia prevented by inhibition of the dorsomedial hypothalamus. Brain Res 2015; 1608:75-81. [PMID: 25725382 DOI: 10.1016/j.brainres.2015.02.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 02/16/2015] [Accepted: 02/17/2015] [Indexed: 02/08/2023]
Abstract
The contribution of exercise to hyperthermia mediated by MDMA is not known. We recently showed that inhibiting the dorsomedial hypothalamus (DMH) attenuated spontaneous locomotion and hyperthermia and prevented deaths in rats given MDMA in a warm environment. The goal of this study was to confirm that restoring locomotion through a treadmill would reverse these effects thereby confirming that locomotion mediated by the DMH contributes to MDMA-mediated hyperthermia. Rats were randomized to receive bilateral microinjections, into the region of the DMH, of muscimol (80pmol/100nl) or artificial CSF followed by a systemic dose of either MDMA (7.5mg/kg, i.v.) or saline. Immediately after the systemic injection, rats were placed on a motorized treadmill maintained at 32°C. Rats were exercised at a fixed speed (10m/min) until their core temperature reached 41°C. Our results showed that a fixed exercise load abolished the decreases in temperature and mortality, seen previously with inhibition of the DMH in freely moving rats. Therefore, locomotion mediated by neurons in the DMH is critical to the development of hyperthermia from MDMA.
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Affiliation(s)
- Dmitry V Zaretsky
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Maria V Zaretskaia
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Pamela J Durant
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Daniel E Rusyniak
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, USA.
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