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Mikolka P, Kosutova P, Kolomaznik M, Nemcova N, Hanusrichterova J, Curstedt T, Johansson J, Calkovska A. The Synthetic Surfactant CHF5633 Restores Lung Function and Lung Architecture in Severe Acute Respiratory Distress Syndrome in Adult Rabbits. Lung 2024; 202:299-315. [PMID: 38684519 PMCID: PMC11143048 DOI: 10.1007/s00408-024-00689-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 03/23/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Acute respiratory distress syndrome (ARDS) is a major cause of hypoxemic respiratory failure in adults. In ARDS extensive inflammation and leakage of fluid into the alveoli lead to dysregulation of pulmonary surfactant metabolism and function. Altered surfactant synthesis, secretion, and breakdown contribute to the clinical features of decreased lung compliance and alveolar collapse. Lung function in ARDS could potentially be restored with surfactant replacement therapy, and synthetic surfactants with modified peptide analogues may better withstand inactivation in ARDS alveoli than natural surfactants. METHODS This study aimed to investigate the activity in vitro and the bolus effect (200 mg phospholipids/kg) of synthetic surfactant CHF5633 with analogues of SP-B and SP-C, or natural surfactant Poractant alfa (Curosurf®, both preparations Chiesi Farmaceutici S.p.A.) in a severe ARDS model (the ratio of partial pressure arterial oxygen and fraction of inspired oxygen, P/F ratio ≤ 13.3 kPa) induced by hydrochloric acid instillation followed by injurious ventilation in adult New Zealand rabbits. The animals were ventilated for 4 h after surfactant treatment and the respiratory parameters, histological appearance of lung parenchyma and levels of inflammation, oxidative stress, surfactant dysfunction, and endothelial damage were evaluated. RESULTS Both surfactant preparations yielded comparable improvements in lung function parameters, reductions in lung injury score, pro-inflammatory cytokines levels, and lung edema formation compared to untreated controls. CONCLUSIONS This study indicates that surfactant replacement therapy with CHF5633 improves lung function and lung architecture, and attenuates inflammation in severe ARDS in adult rabbits similarly to Poractant alfa. Clinical trials have so far not yielded conclusive results, but exogenous surfactant may be a valid supportive treatment for patients with ARDS given its anti-inflammatory and lung-protective effects.
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Affiliation(s)
- Pavol Mikolka
- Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia.
| | - Petra Kosutova
- Biomedical Centre Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Maros Kolomaznik
- Biomedical Centre Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Nikolett Nemcova
- Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Juliana Hanusrichterova
- Biomedical Centre Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Tore Curstedt
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Jan Johansson
- Department of Biosciences and Nutrition, Karolinska Institutet, Neo, Huddinge, Sweden
| | - Andrea Calkovska
- Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
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Dargaville PA, Herting E, Soll RF. Neonatal surfactant therapy beyond respiratory distress syndrome. Semin Fetal Neonatal Med 2023; 28:101501. [PMID: 38040584 DOI: 10.1016/j.siny.2023.101501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Whilst exogenous surfactant therapy is central to the management of newborn infants with respiratory distress syndrome, its use in other neonatal lung diseases remains inconsistent and controversial. Here we discuss the evidence and experience in relation to surfactant therapy in newborns with other lung conditions in which surfactant may be deficient or dysfunctional, including meconium aspiration syndrome, pneumonia, congenital diaphragmatic hernia and pulmonary haemorrhage. We find that, for all of these diseases, administration of exogenous surfactant as bolus therapy is frequently associated with transient improvement in oxygenation, likely related to temporary mitigation of surfactant inhibition in the airspaces. However, for none of them is there a lasting clinical benefit of surfactant therapy. By virtue of interrupting disease pathogenesis, lavage therapy with dilute surfactant in MAS offers the greatest possibility of a more pronounced therapeutic effect, but this has yet to be definitively proven. Lavage therapy also involves a greater degree of procedural risk.
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Affiliation(s)
- Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
| | - Egbert Herting
- Department of Paediatrics, University of Luebeck, Luebeck, Germany
| | - Roger F Soll
- Division of Neonatal-Perinatal Medicine, Larner College of Medicine, The University of Vermont, Burlington, USA
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De Luca D, Arroyo R, Foligno S, Autilio C, Touqui L, Kingma PS. Early life surfactant protein-D levels in bronchoalveolar lavage fluids of extremely preterm neonates. Am J Physiol Lung Cell Mol Physiol 2023; 325:L411-L418. [PMID: 37489844 DOI: 10.1152/ajplung.00079.2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/06/2023] [Accepted: 07/18/2023] [Indexed: 07/26/2023] Open
Abstract
Surfactant protein-D (SP-D) is a hydrophilic protein with multiple crucial anti-inflammatory and immunological functions. It might play a role in the development and course of pulmonary infections, acute respiratory distress syndrome, and other respiratory disorders. Only few small neonatal studies have investigated SP-D: we aimed to investigate the links between this protein, measured in the first hours of life in extremely preterm neonates, and clinical outcomes, as well its relationship with pulmonary secretory phospholipase A2 (sPLA2). Bronchoalveolar lavage fluids were obtained within the first 3 h of life. SP-D and sPLA2 were measured with ELISA and radioactive method, respectively; epithelial lining fluid concentrations were estimated with urea ratio. Clinical data were prospectively collected. One hundred extremely preterm neonates were nonconsecutively studied. SP-D was significantly raised with increasing gestational age (24-26 wk: 68 [0-1,694], 27 or 28 wk: 286 [0-1,328], 29 or 30 wk: 1,401 [405-2,429] ng/mL, overall P = 0.03). SP-D was significantly higher in cases with clinical chorioamnionitis with fetal involvement (1,138 [68-3,336]) than in those without clinical chorioamnionitis with fetal involvement (0 [0-900] ng/mL, P < 0.001). SP-D was lower in infants with bronchopulmonary dysplasia (BPD) (251 [0-1,550 ng/mL]) compared with those without bronchopulmonary dysplasia (BPD) or who died before its diagnosis (977 [124-5,534 ng/mL], P = 0.05) and this was also significant upon multivariate analysis [odds ration (OR): 0.997 (0.994-0.999), P = 0.024], particularly in neonates between 27- and 28-wk gestation. SP-D significantly correlated with the duration of hospital stay (ρ = -0.283, P = 0.002), invasive ventilation (ρ = -0.544, P = 0.001), and total sPLA2 activity (ρ = 0.528, P = 0.008). These findings help understanding the role of SP-D early in life and support further investigation about the role of SP-D in developing BPD.NEW & NOTEWORTHY Surfactant protein-D increases with gestational age and is inversely associated with BPD development. These results have been obtained in the first hours of life of extremely preterm neonates with optimal perinatal care.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Raquel Arroyo
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
| | - Silvia Foligno
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Paris, France
| | - Chiara Autilio
- Department of Biochemistry and Molecular Biology, Faculty of Biology, Research Institut-Hospital "12 de Octubre," Complutense University, Madrid, Spain
| | - Lhousseine Touqui
- Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, Paris, France
- Mucoviscidose et Bronchopathies chroniques, Institut Pasteur, Université Paris-Cité, Paris, France
| | - Paul S Kingma
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Cincinnati Bronchopulmonary Dysplasia Center, The Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
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Dushianthan A, Grocott MPW, Murugan GS, Wilkinson TMA, Postle AD. Pulmonary Surfactant in Adult ARDS: Current Perspectives and Future Directions. Diagnostics (Basel) 2023; 13:2964. [PMID: 37761330 PMCID: PMC10528901 DOI: 10.3390/diagnostics13182964] [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: 08/10/2023] [Revised: 09/10/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major cause of hypoxemic respiratory failure in adults, leading to the requirement for mechanical ventilation and poorer outcomes. Dysregulated surfactant metabolism and function are characteristic of ARDS. A combination of alveolar epithelial damage leading to altered surfactant synthesis, secretion, and breakdown with increased functional inhibition from overt alveolar inflammation contributes to the clinical features of poor alveolar compliance and alveolar collapse. Quantitative and qualitative alterations in the bronchoalveolar lavage and tracheal aspirate surfactant composition contribute to ARDS pathogenesis. Compared to neonatal respiratory distress syndrome (nRDS), replacement studies of exogenous surfactants in adult ARDS suggest no survival benefit. However, these studies are limited by disease heterogeneity, variations in surfactant preparations, doses, and delivery methods. More importantly, the lack of mechanistic understanding of the exact reasons for dysregulated surfactant remains a significant issue. Moreover, studies suggest an extremely short half-life of replaced surfactant, implying increased catabolism. Refining surfactant preparations and delivery methods with additional co-interventions to counteract surfactant inhibition and degradation has the potential to enhance the biophysical characteristics of surfactant in vivo.
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Affiliation(s)
- Ahilanandan Dushianthan
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Michael P. W. Grocott
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | | | - Tom M. A. Wilkinson
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Anthony D. Postle
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health System Foundation Trust, Southampton SO16 6YD, UK; (M.P.W.G.); (T.M.A.W.); (A.D.P.)
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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Ito M, Kato S, Saito M, Miyahara N, Arai H, Namba F, Ota E, Nakanishi H. Bronchopulmonary Dysplasia in Extremely Premature Infants: A Scoping Review for Identifying Risk Factors. Biomedicines 2023; 11:biomedicines11020553. [PMID: 36831089 PMCID: PMC9953397 DOI: 10.3390/biomedicines11020553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 01/28/2023] [Accepted: 01/31/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Over the years, bronchopulmonary dysplasia (BPD) affects the pulmonary function of infants, resulting in chronic health burdens for infants and their families. The aim of this scoping review was to screen available evidence regarding perinatal risk factors associated with the development and severity of BPD. METHODS The eligibility criteria of the studies were year of publication between 2016 and 2021; setting of a developed country; English or Japanese as the study language; and randomized controlled, cohort, or case-control design. The titles and abstracts of the studies were screened by independent reviewers. RESULTS Of 8189 eligible studies, 3 were included for severe BPD and 26 were included for moderate BPD. The risk factors for severe BPD were male sex, iatrogenic preterm birth, maternal hypertensive disorders of pregnancy (HDP), low gestational age, small-for-gestational-age (SGA) birth weight, mechanical ventilation on day 1, and need for patent ductus arteriosus (PDA) management. The risk factors for moderate or severe BPD included male sex, premature rupture of membranes, clinical chorioamnionitis, maternal HDP, SGA birth weight, bubbly/cystic appearance on X-ray, and PDA management. CONCLUSIONS We identified several risk factors for BPD. We plan to confirm the validity of the new classification using the existing dataset.
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Affiliation(s)
- Masato Ito
- Department of Pediatrics, Akita University Graduate School of Medicine, Akita 010-8543, Japan
- Correspondence:
| | - Shin Kato
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8602, Japan
| | - Makoto Saito
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8546, Japan
| | - Naoyuki Miyahara
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe 350-8550, Japan
| | - Hirokazu Arai
- Department of Neonatology, Akita Red Cross Hospital, Akita 010-1495, Japan
| | - Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe 350-8550, Japan
| | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Sciences, St. Luke’s International University, Chuo 104-0044, Japan
- Tokyo Foundation for Policy Research, Tokyo 106-6234, Japan
| | - Hidehiko Nakanishi
- Research and Development Center for New Medical Frontiers, Department of Advanced Medicine, Division of Neonatal Intensive Care Medicine, Kitasato University School of Medicine, Sagamihara 252-0375, Japan
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MIKOLKA P, KOSUTOVA P, KOLOMAZNIK M, MATEFFY S, NEMCOVA N, MOKRA D, CALKOVSKA A. Efficacy of surfactant therapy of ARDS induced by hydrochloric acid aspiration followed by ventilator-induced lung injury - an animal study. Physiol Res 2022; 71:S237-S249. [PMID: 36647912 PMCID: PMC9906666 DOI: 10.33549/physiolres.935003] [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] [Indexed: 02/02/2023] Open
Abstract
The development of acute respiratory distress syndrome (ARDS) is known to be independently attributable to aspiration-induced lung injury. Mechanical ventilation as a high pressure/volume support to maintain sufficient oxygenation of a patient could initiate ventilator-induced lung injury (VILI) and thus contribute to lung damage. Although these phenomena are rare in the clinic, they could serve as the severe experimental model of alveolar-capillary membrane deterioration. Lung collapse, diffuse inflammation, alveolar epithelial and endothelial damage, leakage of fluid into the alveoli, and subsequent inactivation of pulmonary surfactant, leading to respiratory failure. Therefore, exogenous surfactant could be considered as a therapy to restore lung function in experimental ARDS. This study aimed to investigate the effect of modified porcine surfactant in animal model of severe ARDS (P/F ratio </=13.3 kPa) induced by intratracheal instillation of hydrochloric acid (HCl, 3 ml/kg, pH 1.25) followed by VILI (V(T) 20 ml/kg). Adult rabbits were divided into three groups: untreated ARDS, model treated with a bolus of poractant alfa (Curosurf®, 2.5 ml/kg, 80 mg phospholipids/ml), and healthy ventilated animals (saline), which were oxygen-ventilated for an additional 4 h. The lung function parameters, histological appearance, degree of lung edema and levels of inflammatory and oxidative markers in plasma were evaluated. Whereas surfactant therapy with poractant alfa improved lung function, attenuated inflammation and lung edema, and partially regenerated significant changes in lung architecture compared to untreated controls. This study indicates a potential of exogenous surfactant preparation in the treatment of experimental ARDS.
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Affiliation(s)
- Pavol MIKOLKA
- Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Petra KOSUTOVA
- Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Maros KOLOMAZNIK
- Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Stanislav MATEFFY
- Diagnostic Center of Pathology in Prešov, Unilabs Slovakia, Martin, Slovak Republic
| | - Nikolett NEMCOVA
- Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Daniela MOKRA
- Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Andrea CALKOVSKA
- Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
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De Luca D, Foligno S, Autilio C, Vivanti A, Vanderkerckhove M, Martinovic J, Raschetti R, Guillot L, Touqui L. Secretory phospholipase A2 expression and activity in preterm clinical chorioamnionitis with fetal involvement. Am J Physiol Lung Cell Mol Physiol 2022; 323:L121-L128. [PMID: 35762614 DOI: 10.1152/ajplung.00516.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Secretory phospholipase A2 (sPLA2) regulates the first step of inflammatory cascade and is involved in several pathological processes. sPLA2 also plays a role in preterm labor and parturition, since they are triggered by inflammatory mediators such as prostaglandins. Interestingly, chorioamnionitis (i.e.: the presence of intrauterine inflammation) is also often associated with preterm birth. We aimed to verify if chorioamnionitis with fetal involvement modifies sPLA2 activity and expression profile in mothers and neonates delivered prematurely. We collected maternal plasma and amniotic fluid, as well as bronchoalveolar lavage fluid from preterm neonates born to mothers with or without clinical chorioamnionitis with fetal involvement. We measured concentrations of sPLA2 subtype-IIA and -IB, total enzyme activity and proteins. Urea ratio was used to obtain epithelial lining fluid concentrations. Enzyme activity measured in maternal plasma (p<0.001) and amniotic fluid (p<0.001) was higher in chorioamnionitis cases than in controls. This was mainly due to the increased production of sPLA2-IIA as the subtype -IB was present in a smaller amount and was similar between the two groups; sPLA2-IIA was increased in epithelial lining fluid (p=0.045) or increased, although without statistical significance, in maternal plasma (p=0.06) and amniotic fluid (p=0.08) of chorioamnionitis cases. Cytokines known to increase sPLA2-IIA expression (TNF-a, IL-1b) or whose expression was increased by sPLA2-IIA (IL-8) were higher in histologically confirmed chorioamnionitis (TNF-a (p=0.028), IL-1b (p<0.001) and IL-8 (p=0.038)). These data represent the basis for future studies on sPLA2-IIA inhibition to prevent deleterious consequences of chorioamnionitis and preterm birth.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Medical Centre, Paris Saclay University Hospitals, APHP (Clamart), Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University (Le Plessis Robinson), Paris, France
| | - Silvia Foligno
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Medical Centre, Paris Saclay University Hospitals, APHP (Clamart), Paris, France
| | - Chiara Autilio
- Department of Biochemistry and Molecular Biology, Faculty of Biology, and Research Institut-Hospital "12 de Octubre," Complutense University, Madrid, Spain
| | - Alexandre Vivanti
- Division of Obstetrics and Gynecology, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP (Clamart), Paris, France
| | - Melanie Vanderkerckhove
- Division of Obstetrics and Gynecology, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP (Clamart), Paris, France
| | - Jelena Martinovic
- Unit of Fetopathology, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP (Clamart), Paris, France
| | - Roberto Raschetti
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Medical Centre, Paris Saclay University Hospitals, APHP (Clamart), Paris, France
| | - Loïc Guillot
- Sorbonne Université, INSERM UMR-S938, Centre de Recherche Saint-Antoine (CRSA), Paris, France
| | - Lhousseine Touqui
- Sorbonne Université, INSERM UMR-S938, Centre de Recherche Saint-Antoine (CRSA), Paris, France
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Kattner AA. After me, the deluge: The intricacies of pulmonary surfactant. Biomed J 2021; 44:645-650. [PMID: 34942391 PMCID: PMC8847826 DOI: 10.1016/j.bj.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 11/18/2022] Open
Abstract
This issue of the Biomedical Journal provides a comprehensive insight into the role of pulmonary surfactant and influencing its components as well as involved molecules to treat a variety of respiratory distress disorders. We also discover how epithelial mesenchymal transition (EMT) could be targeted as part of a therapeutic strategy against lung cancer. Furthermore, a method is described to eliminate chemoresistance against gemcitabine, a drug administered to treat pancreatic cancer. We gain an insight into the composition of salivary calcium particles in periodontitis, a technique to circumvent complications in hip surgery, and a potential treatment to accelerate diabetic wound healing. Moreover, we get to know an essential oil that exerts a similar effect as diazepam on the central nervous system. A trial in patients with myofascial pain syndrome demonstrates how laser assisted trigger point therapy leads to immediate relief. Finally, a case study outlines the discovery of a genetic mutation that plays a role in intellectual disability.
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