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Wu Z, Wang Y, Gao R, Chen J, Chen Y, Li M, Gao Y. Potential therapeutic effects of traditional Chinese medicine in acute mountain sickness: pathogenesis, mechanisms and future directions. Front Pharmacol 2024; 15:1393209. [PMID: 38895636 PMCID: PMC11183292 DOI: 10.3389/fphar.2024.1393209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/06/2024] [Indexed: 06/21/2024] Open
Abstract
Background and objectives Acute mountain sickness (AMS) is a pathology with different symptoms in which the organism is not adapted to the environment that occurs under the special environment of high altitude. Its main mechanism is the organism's tissue damage caused by acute hypobaric hypoxia. Traditional Chinese medicine (TCM) theory focuses on the holistic concept. TCM has made remarkable achievements in the treatment of many mountain sicknesses. This review outlines the pathogenesis of AMS in modern and traditional medicine, the progress of animal models of AMS, and summarizes the therapeutic effects of TCM on AMS. Methods Using the keywords "traditional Chinese medicine," "herbal medicine," "acute mountain sickness," "high-altitude pulmonary edema," "high-altitude cerebral edema," "acute hypobaric hypoxia," and "high-altitude," all relevant TCM literature published up to November 2023 were collected from Scopus, Web of Science, PubMed, and China National Knowledge Infrastructure databases, and the key information was analyzed. Results We systematically summarised the effects of acute hypobaric hypoxia on the tissues of the organism, the study of the methodology for the establishment of an animal model of AMS, and retrieved 18 proprietary Chinese medicines for the clinical treatment of AMS. The therapeutic principle of medicines is mainly invigorating qi, activating blood and removing stasis. The components of botanical drugs mainly include salidroside, ginsenoside Rg1, and tetrahydrocurcumin. The mechanism of action of TCM in the treatment of AMS is mainly through the regulation of HIF-1α/NF-κB signaling pathway, inhibition of inflammatory response and oxidative stress, and enhancement of energy metabolism. Conclusion The main pathogenesis of AMS is unclear. Still, TCM formulas and components have been used to treat AMS through multifaceted interventions, such as compound danshen drip pills, Huangqi Baihe granules, salidroside, and ginsenoside Rg1. These components generally exert anti-AMS pharmacological effects by inhibiting the expression of VEGF, concentration of MDA and pro-inflammatory factors, down-regulating NF-κB/NLRP3 pathway, and promoting SOD and Na + -K + -ATPase activities, which attenuates acute hypobaric hypoxia-induced tissue injury. This review comprehensively analyses the application of TCM in AMS and makes suggestions for more in-depth studies in the future, aiming to provide some ideas and insights for subsequent studies.
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Affiliation(s)
- Zhenhui Wu
- School of Pharmacy, Jiangxi University of Chinese Medicine, Nanchang, China
- Department of Hematology, Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang, China
| | - Yihao Wang
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Rong Gao
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Junru Chen
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Yingfan Chen
- Department of Traditional Chinese Medicine, The Sixth Medical Center of Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Maoxing Li
- Beijing Institute of Radiation Medicine, Beijing, China
| | - Yue Gao
- School of Pharmacy, Jiangxi University of Chinese Medicine, Nanchang, China
- Beijing Institute of Radiation Medicine, Beijing, China
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Ma B, Li Q, Li M, Wang J, Fan N, Yang S, Shi W, Wang R, Yin D. Effect of butylphthalide on prevention and treatment of high altitude cerebral edema in rats. Heliyon 2024; 10:e27833. [PMID: 38560678 PMCID: PMC10979156 DOI: 10.1016/j.heliyon.2024.e27833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 04/04/2024] Open
Abstract
3-n-butylphthalide (NBP) contains one of the main active ingredients of celery seed. It has a series of pharmacological mechanisms, including reconstitution of microcirculation, protection of mitochondrial function, inhibition of oxidative stress, and inhibition of neuronal apoptosis. Based on the complex multi-targeting of NBP pharmacological mechanisms, the clinical applications of NBP are increasing, and more and more clinical studies and animal experiments have focused on NBP. In this study, we used male Sprague Dawley rats as an animal model to elucidate the intervention effect of butylphthalide on high altitude cerebral edema (HACE), and also compared the effect of butylphthalide and rhodiola rosea on HACE. Firstly, we measured the changes of body weight and brain water content and observed the pathological changes of brain tissues. In addition, the contents of inflammatory factors, oxidative stress and brain neurotransmitters were assessed by enzyme-linked immunoassay kits, and finally, the expression of apoptotic proteins in brain tissues was determined by western blotting. The results showed that NBP reduced brain water content, attenuated brain tissue damage, altered inflammatory factors, oxidative stress indicators, and brain neurotransmitter levels, and in addition NBP inhibited the expression of Caspase-related apoptotic proteins. Therefore, NBP has the potential to treat and prevent HACE.
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Affiliation(s)
- Bohua Ma
- Department of Pharmacy, Qingyang People's Hospital, Qingyang City, Gansu Province, China
- Department of Pharmacy, General Hospital of Xin- jiang Military Region, Urumqi, Xinjiang, China
| | - Qian Li
- Department of Pharmacy, General Hospital of Xin- jiang Military Region, Urumqi, Xinjiang, China
| | - Meng Li
- Department of Pharmacy, General Hospital of Xin- jiang Military Region, Urumqi, Xinjiang, China
| | - Jiangtao Wang
- Department of Pharmacy, General Hospital of Xin- jiang Military Region, Urumqi, Xinjiang, China
| | - Ning Fan
- Department of Pharmacy, General Hospital of Xin- jiang Military Region, Urumqi, Xinjiang, China
| | - Shanpeng Yang
- Department of Pharmacy, General Hospital of Xin- jiang Military Region, Urumqi, Xinjiang, China
| | - Wenhui Shi
- Department of Pharmacy, General Hospital of Xin- jiang Military Region, Urumqi, Xinjiang, China
| | - Rui Wang
- Department of Pharmacy, General Hospital of Xin- jiang Military Region, Urumqi, Xinjiang, China
| | - Dongfeng Yin
- Department of Pharmacy, General Hospital of Xin- jiang Military Region, Urumqi, Xinjiang, China
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春花, 白玛康卓. [Establishment and Evaluation of a Mice Model of High-Altitude Cerebral Edema]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2023; 54:1269-1275. [PMID: 38162056 PMCID: PMC10752796 DOI: 10.12182/20231160604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Indexed: 01/03/2024]
Abstract
Objective To establish an animal model of high-altitude cerebral edema (HACE), to explore the altitude and oxygen partial pressure conditions that can lead to obvious clinical manifestations of HACE, and to lay the foundation for further research of the pathogenic mechanisms and intervention strategies of HACE. Methods Male BALB/c mice of 8 weeks old were randomly assigned to Control and HACE groups. The Control group (n=10) was treated with normobaric and normoxic conditions, while the HACE groups were placed in hypobaric hypoxic (HH) chambers for the durations of 6 h, 12 h, 24 h, 48 h and 72 h, respectively, receiving treatments of simulated HH conditions at the altitudes of 4000 m (n=10 for each group receiving different durations of HH treatment), 5000 m (n=10 for each group receiving different durations of HH treatment), and 6000 m (n=10 for each group receiving different durations of HH treatment). HE staining was performed to observe the morphological changes of the brain tissue and the appropriate simulated altitude conditions were selected accordingly for the construction and evaluation of the best HACE model. The HACE model was evaluated in the following ways, the mouse brain was weighed and the cerebral edema was measured accordingly, Evans blue (EB) was injected to determine the permeability of the blood-brain barrier (BBB), and the cell apoptosis was determined by immunofluorescence staining. Results There were no deaths in the groups treated with the HH conditions of the altitudes of 4000 m and 5000 m, while the mortality in the 6000 m altitude treatment groups was 12.2%. HE staining showed no significant changes in brain morphology or structure in the group receiving HH treatment for the altitude of 4000 m. A small amount of brain cell edema was observed in the groups receiving 48 h and 72 h of HH treatment for the altitude of 5000 m. The groups receiving HH treatment for the altitude of 6000 m demonstrated the most prominent modeling effect. HE staining showed increased volume and swelling of brain cells in all the 6000 m groups, especially in the 24 h, 48 h and 72 h treatment groups. In all the 6000 m groups, cell arrangement disorder, gap enlargement, and nuclear contraction were observed. Evaluation of the modeling effect demonstrated that, in the HACE mice model constructed with the HH conditions for the altitude of 6000 m, cerebral edema and EB permeability increased after 12 h HH treatment and there was no obvious apoptosis in the modeling groups receiving different durations of treatment. Conclusion The HACE model can be established effectively by simulating conditions at the altitude of 6000 m (the atmospheric pressure being 47.19 kPa and the oxygen partial pressure being 9.73 kPa) with a HH chamber.
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Affiliation(s)
- 春花
- 西藏大学医学院 (拉萨 850000)Medical College of Tibet University, Lhasa 850000, China
| | - 白玛康卓
- 西藏大学医学院 (拉萨 850000)Medical College of Tibet University, Lhasa 850000, China
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Li Y, Li C, Luo T, Yue T, Xiao W, Yang L, Zhang Z, Han F, Long P, Hu Y. Progress in the Treatment of High Altitude Cerebral Edema: Targeting REDOX Homeostasis. J Inflamm Res 2023; 16:2645-2660. [PMID: 37383357 PMCID: PMC10296571 DOI: 10.2147/jir.s415695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023] Open
Abstract
With the increasing of altitude activities from low-altitude people, the study of high altitude cerebral edema (HACE) has been revived. HACE is a severe acute mountain sickness associated with exposure to hypobaric hypoxia at high altitude, often characterized by disturbance of consciousness and ataxia. As for the pathogenesis of HACE, previous studies suggested that it might be related to the disorder of cerebral blood flow, the destruction of blood-brain barrier and the injury of brain parenchyma cells caused by inflammatory factors. In recent years, studies have confirmed that the imbalance of REDOX homeostasis is also involved in the pathogenesis of HACE, which mainly leads to abnormal activation of microglia and destruction of tight junction of vascular endothelial cells through the excessive production of mitochondrial-related reactive oxygen species. Therefore, this review summarizes the role of REDOX homeostasis and the potential of the treatment of REDOX homeostasis in HACE, which is of great significance to expand the understanding of the pathogenesis of HACE. Moreover, it will also be helpful to further study the possible therapy of HACE related to the key link of REDOX homeostasis.
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Affiliation(s)
- Yubo Li
- School of Clinical Medicine, Chengdu University of TCM, Chengdu, People’s Republic of China
- Basic Medical Laboratory, The General Hospital of Western Theater Command, Chengdu, People’s Republic of China
| | - Chengming Li
- School of Clinical Medicine, Chengdu University of TCM, Chengdu, People’s Republic of China
- Basic Medical Laboratory, The General Hospital of Western Theater Command, Chengdu, People’s Republic of China
| | - Tao Luo
- Department of Ophthalmology, The General Hospital of Western Theater Command, Chengdu, People’s Republic of China
| | - Tian Yue
- School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, People’s Republic of China
| | - Wenjing Xiao
- Department of Pharmacy, The General Hospital of Western Theater Command, Chengdu, People’s Republic of China
| | - Ling Yang
- School of Clinical Medicine, Chengdu University of TCM, Chengdu, People’s Republic of China
- Basic Medical Laboratory, The General Hospital of Western Theater Command, Chengdu, People’s Republic of China
| | - Zaiyuan Zhang
- College of Medicine, Southwest Jiaotong University, Chengdu, People’s Republic of China
| | - Fei Han
- Department of Ophthalmology, The General Hospital of Western Theater Command, Chengdu, People’s Republic of China
| | - Pan Long
- Department of Ophthalmology, The General Hospital of Western Theater Command, Chengdu, People’s Republic of China
| | - Yonghe Hu
- College of Medicine, Southwest Jiaotong University, Chengdu, People’s Republic of China
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Xie N, Fan F, Jiang S, Hou Y, Zhang Y, Cairang N, Wang X, Meng X. Rhodiola crenulate alleviates hypobaric hypoxia-induced brain injury via adjusting NF-κB/NLRP3-mediated inflammation. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2022; 103:154240. [PMID: 35691080 DOI: 10.1016/j.phymed.2022.154240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/15/2022] [Accepted: 06/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Rhodiola crenulate (R. crenulate), a famous Tibetan medicine, has been demonstrated to possess superiorly protective effects in high-altitude hypoxic brain injury (HHBI). However, its mechanisms on HHBI are still largely unknown. METHODS Herein, the protective effects and underlying mechanisms of R. crenulate on HHBI of BABL/c mice were explored through in vivo experiments. The mice model of HHBI was established using an animal hypobaric and hypoxic chamber. R. crenulate extract (RCE) (0.5, 1.0 and 2.0 g/kg) was given by gavage for 7 days. Pathological changes and neuronal viability of mice hippocampus and cortex were evaluated using H&E and Nissl staining, respectively. The brain water content (BWC) in mice was determined by calculating the ratio of dry to wet weight of brain tissue. And serum of malondialdehyde (MDA), superoxide dismutase (SOD), glutathione (GSH-Px) and lactate dehydrogenase (LDH) were detected via commercial biochemical kits. Synchronously, the contents of total antioxidant capacity (T-AOC), lactic acid (LA), adenosine triphosphate (ATP), succinate dehydrogenase (SDH), pyruvate kinase (PK), Ca2+-Mg2+-ATPcase, Na+-K+-ATPcase, TNF-α, IL-1β and IL-6 in brain tissue were quantitative analysis by corresponding ELISA assay. Subsequently, NLRP3, ZO-1, claudin-5, occluding, p-p65, p65, ASC, cleaved-caspase-1, caspase-1 and IL-18 were determined by immunofluorescent and western blot analyses. RESULTS The results demonstrated that RCE remarkably alleviated pathological damage, BWC, as well enhanced neuronal viability. Furthermore, the oxidative stress injuries were reversely abrogated after RCE treatment, evidenced by the increases of SOD, GSH-Px and T-AOC, while the decreases of MDA and LDH contents. Marvelously, the administration of RCE rectified and balanced the abnormal energy metabolism via elevating the levels of ATP, SDH, PK, Ca2+-Mg2+-ATPcase and Na+-K+-ATPcase, and lowering LA. Simultaneously, the expression of tight junction proteins (ZO-1, claudin-5 and occludin) was enhanced, illustrating RCE treatment might maintain the integrity of blood-brain barrier (BBB). Additionally, RCE treatment confined the contents of IL-6, IL-1β and TNF-α, and attenuated fluorescent signal of NLRP3 protein. Concurrently, the results of western blot indicated that RCE treatment dramatically restrained p-p65/p65, ASC, NLRP3, cleaved-caspase-1/caspase-1 and IL-18 protein expressions in brain tissues of mice. CONCLUSION RCE may afford a protectively intervention in HHBI of mice through suppressing the oxidative stress, improving energy metabolism and the integrity of BBB, and subsiding inflammatory responses via the NF-κB/NLRP3 signaling pathway. As a promising agent for the treatment of mice HHBI, the deep-crossing molecular mechanisms of R. crenulate still needs to be further elucidated to identify novel core hub targets.
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Affiliation(s)
- Na Xie
- School of Pharmacy, and Research Institute of Integrated TCM & Western Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China; State Key Laboratory of Southwestern Chinese Medicine Resources, and Innovative Institute of Chinese Medicine and Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Fangfang Fan
- School of Ethnic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Shengnan Jiang
- School of Pharmacy, and Research Institute of Integrated TCM & Western Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Ya Hou
- School of Pharmacy, and Research Institute of Integrated TCM & Western Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Yi Zhang
- State Key Laboratory of Southwestern Chinese Medicine Resources, and Innovative Institute of Chinese Medicine and Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China; School of Ethnic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | | | - Xiaobo Wang
- School of Pharmacy, and Research Institute of Integrated TCM & Western Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China.
| | - Xianli Meng
- School of Pharmacy, and Research Institute of Integrated TCM & Western Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China; State Key Laboratory of Southwestern Chinese Medicine Resources, and Innovative Institute of Chinese Medicine and Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China.
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Dynamic cerebral blood flow changes with FOXOs stimulation are involved in neuronal damage associated with high-altitude cerebral edema in mice. Brain Res 2022; 1790:147987. [PMID: 35724762 DOI: 10.1016/j.brainres.2022.147987] [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: 03/06/2022] [Revised: 05/21/2022] [Accepted: 06/14/2022] [Indexed: 11/22/2022]
Abstract
Acute hypobaric hypoxia (AHH) exposure causes altitude mountain sickness (AMS) and life-threatening high altitude cerebral edema (HACE). Despite decades of research, the role of cerebral blood flow (CBF) changes in the pathophysiology of severe AMS remains unclear. The current study evaluated spatiotemporal responses of CBF associated with HACE in mice during the early stages of ascent to high altitudes. First, mice were exposed to AHH to test their tolerance to increasing altitudes (3000-8000 m). Because of its significant influence on both locomotor activity and rotarod behavior tests in mice, further observations were initiated at an altitude of 6000 m to investigate the specific pathophysiology of AMS. Compared with controls, laser speckle contrast imaging (LSCI) revealed a significant decrease in CBF during the early stage (0.5-24 h) at an altitude of 6000 m that was accompanied by a significant increase in brain water content (BWC). Moreover, observations of brain lipid oxidative damage and oxidative stress during the early stage of AHH exposure revealed DNA and cellular damage in cortical and hippocampal regions. Transcriptome profiling of the hippocampus revealed upregulation of forkhead box transcription factors. Similarly, western blot assays revealed upregulation of FOXO1a, FOXO3a, caspase-3 and Bax, and downregulation of Bcl-2, indicating a temporal influence of AHH on mitochondrial function and neuronal apoptosis. Thus, we found that the pathophysiology of HACE occurred with dynamic CBF changes, which triggered oxidative stress and neuronal damage in the mouse brain after AHH exposure. Our findings provide potential strategies for treatment of AHH in the future.
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Geng Y, Yang J, Cheng X, Han Y, Yan F, Wang C, Jiang X, Meng X, Fan M, Zhao M, Zhu L. A bioactive gypenoside (GP-14) alleviates neuroinflammation and blood brain barrier (BBB) disruption by inhibiting the NF-κB signaling pathway in a mouse high-altitude cerebral edema (HACE) model. Int Immunopharmacol 2022; 107:108675. [PMID: 35299003 DOI: 10.1016/j.intimp.2022.108675] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/16/2022] [Accepted: 02/28/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neuroinflammation caused by peripheral lipopolysaccharides (LPS) under hypoxia is a key contributor to the development of high altitude cerebral edema (HACE). Our previous studies have shown that gypenosides and their bioactive compounds prevent hypoxia-induced neural injuries in vitro and in vivo. However, their effect on neuroinflammation-related HACE remains to be illustrated. The present study aimed to investigate the effects of GP-14 in HACE mouse model. METHODS HACE mice were treated with GP-14 (100 and 200 mg/kg) for 7 days. After the treatments, the level of serum inflammation cytokines and the transcription of inflammatory factors in brain tissue were determined. The activation of microglia, astrocyte and the changes of IgG leakage and the protein levels of tight junction proteins were detected. Furthermore, the inflammatory factors and nuclear factor-κB (NF-κB) signaling pathway in BV-2 cells and primary microglia were detected. RESULTS GP-14 pretreatment alleviated both the serum and neural inflammatory responses caused by LPS stimulation combined with hypobaric hypoxia exposure. In addition, GP-14 pretreatment inhibited microglial activation, accompanied by a decrease in the M1 phenotype and an increase in the M2 phenotype. Moreover, the disruption of the blood brain barrier (BBB) integrity, including increased IgG leakage and decreased expression of tight junction proteins, was attenuated by GP-14 pretreatment. Based on the BV-2 and primary microglial models, the inflammatory response and activation of the NF-κB signaling pathway were also inhibited by GP-14 pretreatment. CONCLUSION Taken together, our results demonstrated that GP-14 exhibited prominent protective roles against neuroinflammation and BBB disruption in a mouse HACE model. GP-14 could be a potential choice for the treatment of HACE in the future.
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Affiliation(s)
- Yanan Geng
- Beijing Institute of Basic Medical Sciences, Beijing 100850, China; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing 100069, China
| | - Junli Yang
- CAS Key Laboratory of Chemistry of Northwestern Plant Resources and Key Laboratory for Natural Medicine of Gansu Province, Lanzhou Institute of Chemical Physics (LICP), Chinese Academy of Sciences (CAS), Lanzhou 730000, China
| | - Xiang Cheng
- Beijing Institute of Basic Medical Sciences, Beijing 100850, China
| | - Ying Han
- Beijing Institute of Basic Medical Sciences, Beijing 100850, China
| | - Feng Yan
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing 100069, China
| | - Chengbo Wang
- CAS Key Laboratory of Chemistry of Northwestern Plant Resources and Key Laboratory for Natural Medicine of Gansu Province, Lanzhou Institute of Chemical Physics (LICP), Chinese Academy of Sciences (CAS), Lanzhou 730000, China
| | - Xiufang Jiang
- Beijing Institute of Basic Medical Sciences, Beijing 100850, China
| | - Xianhua Meng
- CAS Key Laboratory of Chemistry of Northwestern Plant Resources and Key Laboratory for Natural Medicine of Gansu Province, Lanzhou Institute of Chemical Physics (LICP), Chinese Academy of Sciences (CAS), Lanzhou 730000, China
| | - Ming Fan
- Beijing Institute of Basic Medical Sciences, Beijing 100850, China; Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing 100069, China
| | - Ming Zhao
- Beijing Institute of Basic Medical Sciences, Beijing 100850, China.
| | - Lingling Zhu
- Beijing Institute of Basic Medical Sciences, Beijing 100850, China; Co-Innovation Center of Neuroregeneration, Nantong University, Nantong 226019, China; College of Life Sciences, Anhui Medical University, Hefei 230032, China; School of Pharmaceutical Sciences, University of South China, Hengyang 421001, China.
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Zelmanovich R, Pierre K, Felisma P, Cole D, Goldman M, Lucke-Wold B. High Altitude Cerebral Edema: Improving Treatment Options. BIOLOGICS (BASEL, SWITZERLAND) 2022; 2:81-91. [PMID: 35425940 PMCID: PMC9006955 DOI: 10.3390/biologics2010007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
High altitude illness in its most severe form can lead to high altitude cerebral edema (HACE). Current strategies have focused on prevention with graduated ascents, pharmacologic prophylaxis, and descent at first signs of symptoms. Little is understood regarding treatment with steroids and oxygenation being commonly utilized. Pre-clinical studies with turmeric derivatives have offered promise due to its anti-inflammatory and antioxidant properties, but they warrant validation clinically. Ongoing work is focused on better understanding the disease pathophysiology with an emphasis on the glymphatic system and venous outflow obstruction. This review highlights what is known regarding diagnosis, treatment, and prevention, while also introducing novel pathophysiology mechanisms warranting further investigation.
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Affiliation(s)
| | - Kevin Pierre
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
| | - Patrick Felisma
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
| | - Dwayne Cole
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
| | - Matthew Goldman
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
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Baumann J, Tsao CC, Patkar S, Huang SF, Francia S, Magnussen SN, Gassmann M, Vogel J, Köster-Hegmann C, Ogunshola OO. Pericyte, but not astrocyte, hypoxia inducible factor-1 (HIF-1) drives hypoxia-induced vascular permeability in vivo. Fluids Barriers CNS 2022; 19:6. [PMID: 35033138 PMCID: PMC8760662 DOI: 10.1186/s12987-021-00302-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/22/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Ways to prevent disease-induced vascular modifications that accelerate brain damage remain largely elusive. Improved understanding of perivascular cell signalling could provide unparalleled insight as these cells impact vascular stability and functionality of the neurovascular unit as a whole. Identifying key drivers of astrocyte and pericyte responses that modify cell-cell interactions and crosstalk during injury is key. At the cellular level, injury-induced outcomes are closely entwined with activation of the hypoxia-inducible factor-1 (HIF-1) pathway. Studies clearly suggest that endothelial HIF-1 signalling increases blood-brain barrier permeability but the influence of perivascular HIF-1 induction on outcome is unknown. Using novel mouse lines with astrocyte and pericyte targeted HIF-1 loss of function, we herein show that vascular stability in vivo is differentially impacted by perivascular hypoxia-induced HIF-1 stabilization. METHODS To facilitate HIF-1 deletion in adult mice without developmental complications, novel Cre-inducible astrocyte-targeted (GFAP-CreERT2; HIF-1αfl/fl and GLAST-CreERT2; HIF-1αfl/fl) and pericyte-targeted (SMMHC-CreERT2; HIF-1αfl/fl) transgenic animals were generated. Mice in their home cages were exposed to either normoxia (21% O2) or hypoxia (8% O2) for 96 h in an oxygen-controlled humidified glove box. All lines were similarly responsive to hypoxic challenge and post-Cre activation showed significantly reduced HIF-1 target gene levels in the individual cells as predicted. RESULTS Unexpectedly, hypoxia-induced vascular remodelling was unaffected by HIF-1 loss of function in the two astrocyte lines but effectively blocked in the pericyte line. In correlation, hypoxia-induced barrier permeability and water accumulation were abrogated only in pericyte targeted HIF-1 loss of function mice. In contrast to expectation, brain and serum levels of hypoxia-induced VEGF, TGF-β and MMPs (genes known to mediate vascular remodelling) were unaffected by HIF-1 deletion in all lines. However, in agreement with the permeability data, immunofluorescence and electron microscopy showed clear prevention of hypoxia-induced tight junction disruption in the pericyte loss of function line. CONCLUSION This study shows that pericyte but not astrocyte HIF-1 stabilization modulates endothelial tight junction functionality and thereby plays a pivotal role in hypoxia-induced vascular dysfunction. Whether the cells respond similarly or differentially to other injury stimuli will be of significant relevance.
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Affiliation(s)
- Julia Baumann
- Institute of Veterinary Physiology and Center for Clinical Studies, University of Zurich, Vetsuisse Faculty, Winterthurerstrasse 260, CH-8057, Zurich, Switzerland
| | - Chih-Chieh Tsao
- Institute of Veterinary Physiology and Center for Clinical Studies, University of Zurich, Vetsuisse Faculty, Winterthurerstrasse 260, CH-8057, Zurich, Switzerland
| | - Shalmali Patkar
- Institute of Veterinary Physiology and Center for Clinical Studies, University of Zurich, Vetsuisse Faculty, Winterthurerstrasse 260, CH-8057, Zurich, Switzerland
| | - Sheng-Fu Huang
- Institute of Veterinary Physiology and Center for Clinical Studies, University of Zurich, Vetsuisse Faculty, Winterthurerstrasse 260, CH-8057, Zurich, Switzerland
| | - Simona Francia
- Institute of Veterinary Physiology and Center for Clinical Studies, University of Zurich, Vetsuisse Faculty, Winterthurerstrasse 260, CH-8057, Zurich, Switzerland
| | - Synnøve Norvoll Magnussen
- Institute of Medical Biology, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Max Gassmann
- Institute of Veterinary Physiology and Center for Clinical Studies, University of Zurich, Vetsuisse Faculty, Winterthurerstrasse 260, CH-8057, Zurich, Switzerland
| | - Johannes Vogel
- Institute of Veterinary Physiology and Center for Clinical Studies, University of Zurich, Vetsuisse Faculty, Winterthurerstrasse 260, CH-8057, Zurich, Switzerland
| | - Christina Köster-Hegmann
- Institute of Veterinary Physiology and Center for Clinical Studies, University of Zurich, Vetsuisse Faculty, Winterthurerstrasse 260, CH-8057, Zurich, Switzerland
| | - Omolara O Ogunshola
- Institute of Veterinary Physiology and Center for Clinical Studies, University of Zurich, Vetsuisse Faculty, Winterthurerstrasse 260, CH-8057, Zurich, Switzerland.
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10
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Wang X, Cui L, Ji X. Cognitive impairment caused by hypoxia: from clinical evidences to molecular mechanisms. Metab Brain Dis 2022; 37:51-66. [PMID: 34618295 DOI: 10.1007/s11011-021-00796-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/09/2021] [Indexed: 12/23/2022]
Abstract
Hypoxia is a state of reduced oxygen supply and excessive oxygen consumption. According to the duration of hypoxic period, it can be classified as acute and chronic hypoxia. Both acute and chronic hypoxia could induce abundant neurological deficits. Although there have been significant advances in the pathophysiological injuries, few studies have focused on the cognitive dysfunction. In this review, we focused on the clinical evidences and molecular mechanisms of cognitive impairment under acute and chronic hypoxia. Hypoxia can impair several cognitive domains such as attention, learning and memory, procession speed and executive function, which are similar in acute and chronic hypoxia. The severity of cognitive deficit correlates with the duration and degree of hypoxia. Recovery can be achieved after acute hypoxia, while sequelae or even dementia can be observed after chronic hypoxia, perhaps due to the different molecular mechanisms. Cardiopulmonary compensatory response, glycolysis, oxidative stress, calcium overload, adenosine, mitochondrial disruption, inflammation and excitotoxicity contribute to the molecular mechanisms of cognitive deficit after acute hypoxia. During the chronic stage of hypoxia, different adaptive responses, impaired neurovascular coupling, apoptosis, transcription factors-mediated inflammation, as well as Aβ accumulation and tau phosphorylation account for the neurocognitive deficit. Moreover, brain structural changes with hippocampus and cortex atrophy, ventricle enlargement, senile plaque and neurofibrillary tangle deposition can be observed under chronic hypoxia rather than acute hypoxia.
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Affiliation(s)
- Xiaoyin Wang
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Lili Cui
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xunming Ji
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, No 45, Changchun Street, Beijing, 100053, Xicheng District, China.
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11
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Dunn JF, Isaacs AM. The impact of hypoxia on blood-brain, blood-CSF, and CSF-brain barriers. J Appl Physiol (1985) 2021; 131:977-985. [PMID: 34264124 DOI: 10.1152/japplphysiol.00108.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The blood-brain barrier (BBB), blood-cerebrospinal fluid (CSF) barrier (BCSFB), and CSF-brain barriers (CSFBB) are highly regulated barriers in the central nervous system comprising complex multicellular structures that separate nerves and glia from blood and CSF, respectively. Barrier damage has been implicated in the pathophysiology of diverse hypoxia-related neurological conditions, including stroke, multiple sclerosis, hydrocephalus, and high-altitude cerebral edema. Much is known about the damage to the BBB in response to hypoxia, but much less is known about the BCSFB and CSFBB. Yet, it is known that these other barriers are implicated in damage after hypoxia or inflammation. In the 1950s, it was shown that the rate of radionucleated human serum albumin passage from plasma to CSF was five times higher during hypoxic than normoxic conditions in dogs, due to BCSFB disruption. Severe hypoxia due to administration of the bacterial toxin lipopolysaccharide is associated with disruption of the CSFBB. This review discusses the anatomy of the BBB, BCSFB, and CSFBB and the impact of hypoxia and associated inflammation on the regulation of those barriers.
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Affiliation(s)
- Jeff F Dunn
- Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Albert M Isaacs
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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12
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Rand D, Ravid O, Atrakchi D, Israelov H, Bresler Y, Shemesh C, Omesi L, Liraz-Zaltsman S, Gosselet F, Maskrey TS, Schnaider Beeri M, Wipf P, Cooper I. Endothelial Iron Homeostasis Regulates Blood-Brain Barrier Integrity via the HIF2α-Ve-Cadherin Pathway. Pharmaceutics 2021; 13:pharmaceutics13030311. [PMID: 33670876 PMCID: PMC7997362 DOI: 10.3390/pharmaceutics13030311] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/18/2021] [Accepted: 02/24/2021] [Indexed: 12/14/2022] Open
Abstract
The objective of this study was to investigate the molecular response to damage at the blood-brain barrier (BBB) and to elucidate critical pathways that might lead to effective treatment in central nervous system (CNS) pathologies in which the BBB is compromised. We have used a human, stem-cell derived in-vitro BBB injury model to gain a better understanding of the mechanisms controlling BBB integrity. Chemical injury induced by exposure to an organophosphate resulted in rapid lipid peroxidation, initiating a ferroptosis-like process. Additionally, mitochondrial ROS formation (MRF) and increase in mitochondrial membrane permeability were induced, leading to apoptotic cell death. Yet, these processes did not directly result in damage to barrier functionality, since blocking them did not reverse the increased permeability. We found that the iron chelator, Desferal© significantly decreased MRF and apoptosis subsequent to barrier insult, while also rescuing barrier integrity by inhibiting the labile iron pool increase, inducing HIF2α expression and preventing the degradation of Ve-cadherin specifically on the endothelial cell surface. Moreover, the novel nitroxide JP4-039 significantly rescued both injury-induced endothelium cell toxicity and barrier functionality. Elucidating a regulatory pathway that maintains BBB integrity illuminates a potential therapeutic approach to protect the BBB degradation that is evident in many neurological diseases.
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Affiliation(s)
- Daniel Rand
- The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer 52621, Israel; (D.R.); (O.R.); (D.A.); (H.I.); (Y.B.); (C.S.); (L.O.); (S.L.-Z.); (M.S.B.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel
| | - Orly Ravid
- The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer 52621, Israel; (D.R.); (O.R.); (D.A.); (H.I.); (Y.B.); (C.S.); (L.O.); (S.L.-Z.); (M.S.B.)
| | - Dana Atrakchi
- The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer 52621, Israel; (D.R.); (O.R.); (D.A.); (H.I.); (Y.B.); (C.S.); (L.O.); (S.L.-Z.); (M.S.B.)
| | - Hila Israelov
- The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer 52621, Israel; (D.R.); (O.R.); (D.A.); (H.I.); (Y.B.); (C.S.); (L.O.); (S.L.-Z.); (M.S.B.)
| | - Yael Bresler
- The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer 52621, Israel; (D.R.); (O.R.); (D.A.); (H.I.); (Y.B.); (C.S.); (L.O.); (S.L.-Z.); (M.S.B.)
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel
| | - Chen Shemesh
- The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer 52621, Israel; (D.R.); (O.R.); (D.A.); (H.I.); (Y.B.); (C.S.); (L.O.); (S.L.-Z.); (M.S.B.)
| | - Liora Omesi
- The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer 52621, Israel; (D.R.); (O.R.); (D.A.); (H.I.); (Y.B.); (C.S.); (L.O.); (S.L.-Z.); (M.S.B.)
| | - Sigal Liraz-Zaltsman
- The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer 52621, Israel; (D.R.); (O.R.); (D.A.); (H.I.); (Y.B.); (C.S.); (L.O.); (S.L.-Z.); (M.S.B.)
- Department of Pharmacology, The Institute for Drug Research, The Hebrew University of Jerusalem, Jerusalem 97905, Israel
- Department of Sports Therapy, Institute for Health and Medical Professions, Ono Academic College, Kiryat Ono 55000, Israel
| | - Fabien Gosselet
- Blood-Brain Barrier Laboratory (LBHE), Artois University, UR 2465, F-62300 Lens, France;
| | - Taber S. Maskrey
- Department of Chemistry and Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15260, USA; (T.S.M.); (P.W.)
| | - Michal Schnaider Beeri
- The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer 52621, Israel; (D.R.); (O.R.); (D.A.); (H.I.); (Y.B.); (C.S.); (L.O.); (S.L.-Z.); (M.S.B.)
- Department of Psychiatry, The Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- School of Psychology, Interdisciplinary Center (IDC), Herzliya 4610101, Israel
| | - Peter Wipf
- Department of Chemistry and Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15260, USA; (T.S.M.); (P.W.)
| | - Itzik Cooper
- The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer 52621, Israel; (D.R.); (O.R.); (D.A.); (H.I.); (Y.B.); (C.S.); (L.O.); (S.L.-Z.); (M.S.B.)
- School of Psychology, Interdisciplinary Center (IDC), Herzliya 4610101, Israel
- The Nehemia Rubin Excellence in Biomedical Research—The TELEM Program, Sheba Medical Center, Tel-Hashomer 5262000, Israel
- Correspondence:
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13
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Dzhalilova D, Makarova O. Differences in Tolerance to Hypoxia: Physiological, Biochemical, and Molecular-Biological Characteristics. Biomedicines 2020; 8:E428. [PMID: 33080959 PMCID: PMC7603118 DOI: 10.3390/biomedicines8100428] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 02/07/2023] Open
Abstract
Hypoxia plays an important role in the development of many infectious, inflammatory, and tumor diseases. The predisposition to such disorders is mostly provided by differences in basic tolerance to oxygen deficiency, which we discuss in this review. Except the direct exposure of different-severity hypoxia in decompression chambers or in highland conditions, there are no alternative methods for determining organism tolerance. Due to the variability of the detection methods, differences in many parameters between tolerant and susceptible organisms are still not well-characterized, but some of them can serve as biomarkers of susceptibility to hypoxia. At the moment, several potential biomarkers in conditions after hypoxic exposure have been identified both in experimental animals and humans. The main potential biomarkers are Hypoxia-Inducible Factor (HIF)-1, Heat-Shock Protein 70 (HSP70), and NO. Due to the different mechanisms of various high-altitude diseases, biomarkers may not be highly specific and universal. Therefore, it is extremely important to conduct research on hypoxia susceptibility biomarkers. Moreover, it is important to develop a method for the evaluation of organisms' basic hypoxia tolerance without the necessity of any oxygen deficiency exposure. This can contribute to new personalized medicine approaches' development for diagnostics and the treatment of inflammatory and tumor diseases, taking into account hypoxia tolerance differences.
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Affiliation(s)
- Dzhuliia Dzhalilova
- Department of Immunomorphology of Inflammation, Federal State Budgetary Institution ‘Research Institute of Human Morphology’, Moscow 117418, Russia;
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14
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Pan Y, Zhang Y, Yuan J, Ma X, Zhao Y, Li Y, Li F, Gong X, Zhao J, Tang H, Wang J. Tetrahydrocurcumin mitigates acute hypobaric hypoxia-induced cerebral oedema and inflammation through the NF-κB/VEGF/MMP-9 pathway. Phytother Res 2020; 34:2963-2977. [PMID: 32573860 DOI: 10.1002/ptr.6724] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/07/2020] [Accepted: 04/23/2020] [Indexed: 12/23/2022]
Abstract
High-altitude cerebral oedema (HACE) is a potentially fatal manifestation of high-altitude sickness and is caused partly by inflammation and the blood-brain barrier disruption. Tetrahydrocurcumin (THC) has been reported to exert effective antioxidative and anti-inflammatory effects; This study sought to elucidate the underlying mechanism of THC in mitigating HACE using a mouse model. Our results revealed that prophylactic administration of THC (40 mg/kg) for 3 days significantly alleviated the increase in brain water content (BWC), interleukin-1β (IL-1β) and TNF-α levels caused by acute hypobaric hypoxia (AHH). Additionally, superoxide dismutase (SOD) activity was increased by THC to enhance the ability to resist hypoxia. Histological and ultrastructural analysis of the cerebrum revealed that THC administration mitigated AHH-induced pericellular oedema and reduced the perivascular space, resulting in the simultaneous remission of oedema and protection of mitochondria in the cerebrum. In vitro, astrocytes exposed to hypoxia (4% O2 ) for 24 hr exhibited and increase in IL-1β expression followed by an increase in vascular endothelial growth factor (VEGF) levels. Furthermore, THC administration remarkably downregulated VEGF, matrix metallopeptidase-9 (MMP-9), and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) expression, both in vivo and in vitro. Our data highlight the potential prophylactic activity of THC in HACE, it effectively mitigates AHH-induced cerebral oedema and inflammation is associated with the inhibition of the NF-κB/ VEGF/MMP-9 pathways.
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Affiliation(s)
- Yang Pan
- Department of Chinese Materia Medica and Natural Medicines, School of Pharmacy, The Air Force Medical University, Xi'an, China
| | - Yan Zhang
- Shaanxi University of Chinese Medicine, Xianyang, China
| | - Jiani Yuan
- Department of Chinese Materia Medica and Natural Medicines, School of Pharmacy, The Air Force Medical University, Xi'an, China
| | - Xuexinyu Ma
- Shaanxi University of Chinese Medicine, Xianyang, China
| | - Yani Zhao
- Shaanxi University of Chinese Medicine, Xianyang, China
| | - Yao Li
- Faculty of Life Science & Medicine, Northwest University, Xi'an, China
| | - Fei Li
- Department of Pharmacy, Xijing Hospital, The Air Force Medical University, Xi'an, China
| | - Xiaoli Gong
- Center for translational Chinese Medicine, Sichuan Academy of Chinese Medicine Sciences, Chengdu, China
| | - Junning Zhao
- Center for translational Chinese Medicine, Sichuan Academy of Chinese Medicine Sciences, Chengdu, China
| | - Haifeng Tang
- Department of Chinese Materia Medica and Natural Medicines, School of Pharmacy, The Air Force Medical University, Xi'an, China
| | - Jianbo Wang
- Department of Chinese Materia Medica and Natural Medicines, School of Pharmacy, The Air Force Medical University, Xi'an, China.,Center for translational Chinese Medicine, Sichuan Academy of Chinese Medicine Sciences, Chengdu, China
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15
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Shi J, Wang J, Zhang J, Li X, Tian X, Wang W, Wang P, Li M. Polysaccharide extracted from Potentilla anserina L ameliorate acute hypobaric hypoxia-induced brain impairment in rats. Phytother Res 2020; 34:2397-2407. [PMID: 32298011 DOI: 10.1002/ptr.6691] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/15/2020] [Accepted: 03/20/2020] [Indexed: 12/24/2022]
Abstract
High altitude cerebral edema (HACE) is a high altitude malady caused by acute hypobaric hypoxia (AHH), in which pathogenesis is associated with oxidative stress and inflammatory cytokines. Potentilla anserina L is mainly distributed in Tibetan Plateau, and its polysaccharide possesses many physiological and pharmacological properties. In the present study, the protective effect and potential treatment mechanism of Potentilla anserina L polysaccharide (PAP) in HACE were explored. First, we measured the brain water content and observed the pathological changes in brain tissues, furthermore, malondialdehyde (MDA), nitric oxide (NO), superoxide dismutase (SOD), and glutathione (GSH) were evaluated by kits. Finally, the protein contents and mRNA expressions of pro-inflammatory (IL-1β, IL-6, TNF-α, vascular endothelial cell growth factor [VEGF], NF-κB, and hypoxia inducible factor-1 α [HIF-1α]) were detected by ELISA kits, RT-PCR, and western blotting. The results demonstrated that PAP reduced the brain water content, alleviated brain tissue injury, reduce the levels of MDA and NO, and increased the activity of SOD and GSH level. In addition, PAP blocking the NF-κB and HIF-1α signaling pathway activation inhibited the generation of downstream pro-inflammatory cytokines (IL-1β, IL-6, TNF-α, and VEGF). Therefore, PAP has a potential to treat and prevent of HACE by suppression of oxidative stress and inflammatory response.
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Affiliation(s)
- Jipeng Shi
- Key Laboratory of the Prevention and Treatment for Injury in Plateau of PLA, Department of Pharmacy, The 940th Hospital of Joint Logistic Support Force of Chinese PLA, Lanzhou, China.,Department of Biochemistry, College of Life Science, Northwest Normal University, Lanzhou, China.,Department of Biochemistry, Bioactive Products Engineering Research Center for Gansu Distinctive Plants, Lanzhou, China
| | - Jinhui Wang
- Department of Pharmacy, Affiliated Hospital of Gansu University of Chinese Medicine, Lanzhou, Gansu, China
| | - Ji Zhang
- Department of Biochemistry, College of Life Science, Northwest Normal University, Lanzhou, China.,Department of Biochemistry, Bioactive Products Engineering Research Center for Gansu Distinctive Plants, Lanzhou, China
| | - Xiaolin Li
- Key Laboratory of the Prevention and Treatment for Injury in Plateau of PLA, Department of Pharmacy, The 940th Hospital of Joint Logistic Support Force of Chinese PLA, Lanzhou, China.,Department of Pharmacy, College of Pharmacy, Gansu University of Chinese Medicine, Lanzhou, China
| | - Xiuyu Tian
- Key Laboratory of the Prevention and Treatment for Injury in Plateau of PLA, Department of Pharmacy, The 940th Hospital of Joint Logistic Support Force of Chinese PLA, Lanzhou, China.,Department of Pharmacy, College of Pharmacy, Lanzhou University, Lanzhou, China
| | - Weigang Wang
- Key Laboratory of the Prevention and Treatment for Injury in Plateau of PLA, Department of Pharmacy, The 940th Hospital of Joint Logistic Support Force of Chinese PLA, Lanzhou, China.,Department of Pharmacy, College of Pharmacy, Gansu University of Chinese Medicine, Lanzhou, China
| | - Peng Wang
- Key Laboratory of the Prevention and Treatment for Injury in Plateau of PLA, Department of Pharmacy, The 940th Hospital of Joint Logistic Support Force of Chinese PLA, Lanzhou, China.,Department of Pharmacy, College of Pharmacy, Gansu University of Chinese Medicine, Lanzhou, China
| | - Maoxing Li
- Key Laboratory of the Prevention and Treatment for Injury in Plateau of PLA, Department of Pharmacy, The 940th Hospital of Joint Logistic Support Force of Chinese PLA, Lanzhou, China.,Department of Pharmacy, College of Pharmacy, Gansu University of Chinese Medicine, Lanzhou, China.,Department of Pharmacy, College of Pharmacy, Lanzhou University, Lanzhou, China
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16
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Zhang P, Chen JS, Li QY, Sheng LX, Gao YX, Lu BZ, Zhu WB, Zhan XY, Li Y, Yuan ZB, Xu G, Qiu BT, Yan M, Guo CX, Wang YQ, Huang YJ, Zhang JX, Liu FY, Tang ZW, Lin SZ, Cooper DN, Yang HM, Wang J, Gao YQ, Yin W, Zhang GJ, Yan GM. Neuroprotectants attenuate hypobaric hypoxia-induced brain injuries in cynomolgus monkeys. Zool Res 2020; 41:3-19. [PMID: 31840949 PMCID: PMC6956719 DOI: 10.24272/j.issn.2095-8137.2020.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Hypobaric hypoxia (HH) exposure can cause serious brain injury as well as life-threatening cerebral edema in severe cases. Previous studies on the mechanisms of HH-induced brain injury have been conducted primarily using non-primate animal models that are genetically distant to humans, thus hindering the development of disease treatment. Here, we report that cynomolgus monkeys (Macacafascicularis) exposed to acute HH developed human-like HH syndrome involving severe brain injury and abnormal behavior. Transcriptome profiling of white blood cells and brain tissue from monkeys exposed to increasing altitude revealed the central role of the HIF-1 and other novel signaling pathways, such as the vitamin D receptor (VDR) signaling pathway, in co-regulating HH-induced inflammation processes. We also observed profound transcriptomic alterations in brains after exposure to acute HH, including the activation of angiogenesis and impairment of aerobic respiration and protein folding processes, which likely underlie the pathological effects of HH-induced brain injury. Administration of progesterone (PROG) and steroid neuroprotectant 5α-androst-3β,5,6β-triol (TRIOL) significantly attenuated brain injuries and rescued the transcriptomic changes induced by acute HH. Functional investigation of the affected genes suggested that these two neuroprotectants protect the brain by targeting different pathways, with PROG enhancing erythropoiesis and TRIOL suppressing glutamate-induced excitotoxicity. Thus, this study advances our understanding of the pathology induced by acute HH and provides potential compounds for the development of neuroprotectant drugs for therapeutic treatment.
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Affiliation(s)
- Pei Zhang
- State Key Laboratory of Genetic Resources and Evolution, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan 650223, China.,BGI-Shenzhen, Shenzhen, Guangdong 518083, China.,Section for Ecology and Evolution, Department of Biology, University of Copenhagen, Copenhagen DK-2100, Denmark
| | - Jie-Si Chen
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Qi-Ye Li
- BGI-Shenzhen, Shenzhen, Guangdong 518083, China
| | - Long-Xiang Sheng
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Yi-Xing Gao
- Institute of Medicine and Hygienic Equipment for High Altitude Region, College of High Altitude Military Medicine, Third Military Medical University, Chongqing 400038, China.,Key Laboratory of High Altitude Medicine of People's Liberation Army, Chongqing 400038, China.,Key Laboratory of High Altitude Environmental Medicine, Third Military Medical University, Ministry of Education, Chongqing 400038, China
| | - Bing-Zheng Lu
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Wen-Bo Zhu
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | | | - Yuan Li
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Zhi-Bing Yuan
- Institute of Medicine and Hygienic Equipment for High Altitude Region, College of High Altitude Military Medicine, Third Military Medical University, Chongqing 400038, China.,Key Laboratory of High Altitude Medicine of People's Liberation Army, Chongqing 400038, China.,Key Laboratory of High Altitude Environmental Medicine, Third Military Medical University, Ministry of Education, Chongqing 400038, China
| | - Gang Xu
- Institute of Medicine and Hygienic Equipment for High Altitude Region, College of High Altitude Military Medicine, Third Military Medical University, Chongqing 400038, China.,Key Laboratory of High Altitude Medicine of People's Liberation Army, Chongqing 400038, China.,Key Laboratory of High Altitude Environmental Medicine, Third Military Medical University, Ministry of Education, Chongqing 400038, China
| | - Bi-Tao Qiu
- Section for Ecology and Evolution, Department of Biology, University of Copenhagen, Copenhagen DK-2100, Denmark
| | - Min Yan
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | | | - You-Qiong Wang
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Yi-Jun Huang
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Jing-Xia Zhang
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, Guangdong 510006, China
| | - Fu-Yu Liu
- Institute of Medicine and Hygienic Equipment for High Altitude Region, College of High Altitude Military Medicine, Third Military Medical University, Chongqing 400038, China.,Key Laboratory of High Altitude Medicine of People's Liberation Army, Chongqing 400038, China.,Key Laboratory of High Altitude Environmental Medicine, Third Military Medical University, Ministry of Education, Chongqing 400038, China
| | - Zhong-Wei Tang
- Institute of Medicine and Hygienic Equipment for High Altitude Region, College of High Altitude Military Medicine, Third Military Medical University, Chongqing 400038, China.,Key Laboratory of High Altitude Medicine of People's Liberation Army, Chongqing 400038, China.,Key Laboratory of High Altitude Environmental Medicine, Third Military Medical University, Ministry of Education, Chongqing 400038, China
| | - Sui-Zhen Lin
- Guangzhou Cellprotek Pharmaceutical Co. Ltd., Guangzhou, Guangdong 510663, China
| | - David N. Cooper
- Institute of Medical Genetics, School of Medicine, Cardiff University, Cardiff CF14 4XN, UK
| | - Huan-Ming Yang
- BGI-Shenzhen, Shenzhen, Guangdong 518083, China.,James D. Watson Institute of Genome Sciences, Hangzhou, Zhejiang 310058, China
| | - Jian Wang
- BGI-Shenzhen, Shenzhen, Guangdong 518083, China.,James D. Watson Institute of Genome Sciences, Hangzhou, Zhejiang 310058, China
| | - Yu-Qi Gao
- Institute of Medicine and Hygienic Equipment for High Altitude Region, College of High Altitude Military Medicine, Third Military Medical University, Chongqing 400038, China.,Key Laboratory of High Altitude Medicine of People's Liberation Army, Chongqing 400038, China.,Key Laboratory of High Altitude Environmental Medicine, Third Military Medical University, Ministry of Education, Chongqing 400038, China. E-mail:
| | - Wei Yin
- Department of Biochemistry, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China. E-mail:
| | - Guo-Jie Zhang
- State Key Laboratory of Genetic Resources and Evolution, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan 650223, China.,Section for Ecology and Evolution, Department of Biology, University of Copenhagen, Copenhagen DK-2100, Denmark.,Center for Excellence in Animal Evolution and Genetics, Chinese Academy of Sciences, Kunming, Yunnan 650223, China.,China National Genebank, BGI-Shenzhen, Shenzhen, Guangdong 518120, China. E-mail:
| | - Guang-Mei Yan
- Department of Pharmacology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China. E-mail:
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17
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Wei L, Zhang B, Zhang J, Tan Q, Zhang Y, Fan Y, Wang F, Tao Y, Chen Z, Lin C, Zhu G. Application of a Grading System in the Treatment of Frontal Lobe Contusion in High-Altitude Regions. World Neurosurg 2018; 116:e975-e982. [PMID: 29857217 DOI: 10.1016/j.wneu.2018.05.144] [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: 04/06/2018] [Revised: 05/19/2018] [Accepted: 05/19/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE With the development of frontal contusion, patients may rapidly deteriorate or even die. Experience in the treatment of frontal contusion in high-altitude regions is limited; thus, we explore a grading system for the treatment of frontal lobe contusion. METHODS A total of 446 patients with frontal contusions in a high-altitude regions were reviewed retrospectively. We combined the patients' computed tomography scans of the head and clinical features for grading. The score determined the treatment and whether the bone flap was removed. If the patient's condition deteriorated, and the score was greater than 1, the patient was treated surgically. At the same time, the risk factors of deterioration were analyzed. Finally, the Glasgow Outcome Scale of conservative treatment and surgical treatment groups was analyzed. RESULTS Among the 446 patients, 254 were conservatively treated, and 28 worsened and underwent surgical treatment. In total, 122 patients received an operation. Logistic regression analysis indicated that scattered hematoma, anterior angle of the ventricle, and hemoglobin concentration were risk factors. The postoperative Glasgow Outcome Scale of conservative treatment and surgical treatment groups was analyzed; the good healing rate of the conservative treatment group was 91.12%, the good healing rate of the retain-bone flap surgical group was 75%, and the good healing rate of the remove-bone flap surgical group was 63.33%. The failure rates of the groups were 9.38% and 7.78%, respectively. CONCLUSIONS This grading system could guide frontal contusion treatment, which could help patients to achieve a good healing rate and reduce the failure rate.
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Affiliation(s)
- Linjie Wei
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Bo Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Jianbo Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Qiang Tan
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Yu Zhang
- Department of Neurosurgery, PLA 115th Hospital, Lin zhi Tibet, People's Republic of China
| | - Yinlei Fan
- Department of Neurosurgery, PLA 115th Hospital, Lin zhi Tibet, People's Republic of China
| | - Fei Wang
- Department of Neurosurgery, PLA 115th Hospital, Lin zhi Tibet, People's Republic of China
| | - Yihao Tao
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Zhi Chen
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China
| | - Chi Lin
- Department of Neurosurgery, The First People's Hospital of Honghe State, Yunnan, People's Republic of China
| | - Gang Zhu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, People's Republic of China.
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18
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Sun ZL, Jiang XF, Cheng YC, Liu YF, Yang K, Zhu SL, Kong XB, Tu Y, Bian KF, Liu ZL, Chen XY. Exendin-4 inhibits high-altitude cerebral edema by protecting against neurobiological dysfunction. Neural Regen Res 2018; 13:653-663. [PMID: 29722317 PMCID: PMC5950675 DOI: 10.4103/1673-5374.230291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The anti-inflammatory and antioxidant effects of exendin-4 (Ex-4) have been reported previously. However, whether (Ex-4) has anti-inflammatory and antioxidant effects on high-altitude cerebral edema (HACE) remains poorly understood. In this study, two rat models of HACE were established by placing rats in a hypoxic environment with a simulated altitude of either 6000- or 7000-m above sea level (MASL) for 72 hours. An altitude of 7000 MASL with 72-hours of hypoxia was found to be the optimized experimental paradigm for establishing HACE models. Then, in rats where a model of HACE was established by introducing them to a 7000 MASL environment with 72-hours of hypoxia treatment, 2, 10 and, 100 μg of Ex-4 was intraperitoneally administrated. The open field test and tail suspension test were used to test animal behavior. Routine methods were used to detect change in inflammatory cells. Hematoxylin-eosin staining was performed to determine pathological changes to brain tissue. Wet/dry weight ratios were used to measure brain water content. Evans blue leakage was used to determine blood-brain barrier integrity. Enzyme-linked immunosorbent assay (ELISA) was performed to measure markers of inflammation and oxidative stress including superoxide dismutase, glutathione, and malonaldehyde values, as well as interleukin-6, tumor necrosis factor-alpha, cyclic adenosine monophosphate levels in the brain tissue. Western blot analysis was performed to determine the levels of occludin, ZO-1, SOCS-3, vascular endothelial growth factor, EPAC1, nuclear factor-kappa B, and aquaporin-4. Our results demonstrate that Ex-4 preconditioning decreased brain water content, inhibited inflammation and oxidative stress, alleviated brain tissue injury, maintain blood-brain barrier integrity, and effectively improved motor function in rat models of HACE. These findings suggest that Ex-4 exhibits therapeutic potential in the treatment of HACE.
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Affiliation(s)
- Zhong-Lei Sun
- Affiliated Hospital of Logistics University of Chinese People's Armed Police Forces, Institute of Traumatic Brain Trauma and Neurological of CAPF, Neurotrauma Repair Key Laboratory of Tianjin, Tianjin; Jinzhou Medical University, Jinzhou, Liaoning Province, China
| | - Xian-Feng Jiang
- Affiliated Hospital of Logistics University of Chinese People's Armed Police Forces, Institute of Traumatic Brain Trauma and Neurological of CAPF, Neurotrauma Repair Key Laboratory of Tianjin; Tianjin Medical University, Tianjin, China
| | - Yuan-Chi Cheng
- Central Hospital of Fengxian District of Shanghai, Shanghai, China
| | - Ying-Fu Liu
- Logistics University of People's Armed Police Force, Tianjin, China
| | - Kai Yang
- The No. 2 Hospital of Nanjing, Nanjing, Jiangsu Province, China
| | | | - Xian-Bin Kong
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yue Tu
- Affiliated Hospital of Logistics University of Chinese People's Armed Police Forces, Institute of Traumatic Brain Trauma and Neurological of CAPF, Neurotrauma Repair Key Laboratory of Tianjin, Tianjin, China
| | - Ke-Feng Bian
- Logistics University of People's Armed Police Force, Tianjin, China
| | - Zhen-Lin Liu
- Affiliated Hospital of Logistics University of Chinese People's Armed Police Forces, Institute of Traumatic Brain Trauma and Neurological of CAPF, Neurotrauma Repair Key Laboratory of Tianjin, Tianjin, China
| | - Xu-Yi Chen
- Affiliated Hospital of Logistics University of Chinese People's Armed Police Forces, Institute of Traumatic Brain Trauma and Neurological of CAPF, Neurotrauma Repair Key Laboratory of Tianjin, Tianjin, China
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19
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Hypoxia augments LPS-induced inflammation and triggers high altitude cerebral edema in mice. Brain Behav Immun 2017; 64:266-275. [PMID: 28433745 DOI: 10.1016/j.bbi.2017.04.013] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/06/2017] [Accepted: 04/17/2017] [Indexed: 11/20/2022] Open
Abstract
High altitude cerebral edema (HACE) is a life-threatening illness that develops during the rapid ascent to high altitudes, but its underlying mechanisms remain unclear. Growing evidence has implicated inflammation in the susceptibility to and development of brain edema. In the present study, we investigated the inflammatory response and its roles in HACE in mice following high altitude hypoxic injury. We report that acute hypobaric hypoxia induced a slight inflammatory response or brain edema within 24h in mice. However, the lipopolysaccharide (LPS)-induced systemic inflammatory response rapidly aggravated brain edema upon acute hypobaric hypoxia exposure by disrupting blood-brain barrier integrity and activating microglia, increasing water permeability via the accumulation of aquaporin-4 (AQP4), and eventually leading to impaired cognitive and motor function. These findings demonstrate that hypoxia augments LPS-induced inflammation and induces the occurrence and development of cerebral edema in mice at high altitude. Here, we provide new information on the impact of systemic inflammation on the susceptibility to and outcomes of HACE.
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20
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MacInnis MJ, Koehle MS. Evidence for and Against Genetic Predispositions to Acute and Chronic Altitude Illnesses. High Alt Med Biol 2016; 17:281-293. [PMID: 27500591 DOI: 10.1089/ham.2016.0024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
MacInnis, Martin J., and Michael S. Koehle. Evidence for and against genetic predispositions to acute and chronic altitude illnesses. High Alt Med Biol. 17:281-293, 2016.-Humans exhibit marked variation in their responses to hypoxia, with susceptibility to acute and chronic altitude illnesses being a prominent and medically important example. Many have hypothesized that genetic differences are the cause of these variable responses to hypoxia; however, until recently, these hypotheses were based primarily on small (and sometimes anecdotal) reports pertaining to apparent differences in altitude illness susceptibility between populations, the notion that a history of altitude illness is indicative of subsequent risk, the heritability of hypoxia-related traits, and candidate gene association studies. In the past 5 years, the use of genomic techniques has helped bolster the claim that susceptibility to some altitude illnesses is likely the result of genetic variation. For each of the major altitude illnesses, we summarize and evaluate the evidence stemming from three important characteristics of a genetic trait: (1) individual susceptibility and repeatability across assessments, (2) biogeographical differences and familial aggregation, and (3) association(s) with genetic variants. Evidence to support a genetic basis for susceptibilities to acute mountain sickness (AMS) and high-altitude cerebral edema (HACE) is limited, owing partially to the subjective and unclear phenotype of AMS and the rarity and severity of HACE. In contrast, recent genomic studies have identified genes that influence susceptibility to high-altitude pulmonary edema, chronic mountain sickness, and high-altitude pulmonary hypertension. The collection of more individual, familial, and biogeographical susceptibility data should improve our understanding of the extent to which genetic variation contributes to altitude illness susceptibility, and genomic and molecular investigations have the potential to elucidate the mechanisms that underpin altitude illness susceptibility.
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Affiliation(s)
| | - Michael S Koehle
- 2 School of Kinesiology, University of British Columbia , Vancouver, Canada .,3 Allan McGavin Sport Medicine Clinic, Department of Family Practice, University of British Columbia , Vancouver, Canada
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