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Huang C, Zheng X, Yan S, Zhang Z. Advances in Clinical Therapies for Huntington's Disease and the Promise of Multi-Targeted/Functional Drugs Based on Clinicaltrials.gov. Clin Pharmacol Ther 2024. [PMID: 38863261 DOI: 10.1002/cpt.3341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/27/2024] [Indexed: 06/13/2024]
Abstract
Huntington's disease (HD) is a dominantly inherited neurodegenerative disorder characterized by a triad of motor, cognitive, and psychiatric problems. Caused by CAG repeat expansion in the huntingtin gene (HTT), the disease involves a complex network of pathogenic mechanisms, including synaptic dysfunction, impaired autophagy, neuroinflammation, oxidative damage, mitochondrial dysfunction, and extrasynaptic excitotoxicity. Although current therapies targeting the pathogenesis of HD primarily aim to reduce mHTT levels by targeting HTT DNA, RNA, or proteins, these treatments only ameliorate downstream pathogenic effects. While gene therapies, such as antisense oligonucleotides, small interfering RNAs and gene editing, have emerged in the field of HD treatment, their safety and efficacy are still under debate. Therefore, pharmacological therapy remains the most promising breakthrough, especially multi-target/functional drugs, which have diverse pharmacological effects. This review summarizes the latest progress in HD drug development based on clinicaltrials.gov search results (Search strategy: key word "Huntington's disease" in HD clinical investigational drugs registered as of December 31, 2023), and highlights the key role of multi-target/functional drugs in HD treatment strategies.
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Affiliation(s)
- Chunhui Huang
- School of Medicine, Jinan University, Guangzhou, China
- Guangdong Key Laboratory of Non-Human Primate Models, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
- State Key Laboratory of Bioactive Molecules and Druggability Assessment, Guangdong Province Key Laboratory of Pharmacodynamic, Constituents of TCM and New Drugs Research and Institute of New Drug Research, College of Pharmacy, Jinan University, Guangzhou, China
| | - Xiao Zheng
- Stomatological Hospital, Southern Medical University, Guangzhou, China
| | - Sen Yan
- School of Medicine, Jinan University, Guangzhou, China
- Guangdong Key Laboratory of Non-Human Primate Models, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
- State Key Laboratory of Bioactive Molecules and Druggability Assessment, Guangdong Province Key Laboratory of Pharmacodynamic, Constituents of TCM and New Drugs Research and Institute of New Drug Research, College of Pharmacy, Jinan University, Guangzhou, China
| | - Zaijun Zhang
- State Key Laboratory of Bioactive Molecules and Druggability Assessment, Guangdong Province Key Laboratory of Pharmacodynamic, Constituents of TCM and New Drugs Research and Institute of New Drug Research, College of Pharmacy, Jinan University, Guangzhou, China
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Zhong R, Rua MT, Wei-LaPierre L. Targeting mitochondrial Ca 2+ uptake for the treatment of amyotrophic lateral sclerosis. J Physiol 2024; 602:1519-1549. [PMID: 38010626 PMCID: PMC11032238 DOI: 10.1113/jp284143] [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: 09/06/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a rare adult-onset neurodegenerative disease characterized by progressive motor neuron (MN) loss, muscle denervation and paralysis. Over the past several decades, researchers have made tremendous efforts to understand the pathogenic mechanisms underpinning ALS, with much yet to be resolved. ALS is described as a non-cell autonomous condition with pathology detected in both MNs and non-neuronal cells, such as glial cells and skeletal muscle. Studies in ALS patient and animal models reveal ubiquitous abnormalities in mitochondrial structure and function, and disturbance of intracellular calcium homeostasis in various tissue types, suggesting a pivotal role of aberrant mitochondrial calcium uptake and dysfunctional calcium signalling cascades in ALS pathogenesis. Calcium signalling and mitochondrial dysfunction are intricately related to the manifestation of cell death contributing to MN loss and skeletal muscle dysfunction. In this review, we discuss the potential contribution of intracellular calcium signalling, particularly mitochondrial calcium uptake, in ALS pathogenesis. Functional consequences of excessive mitochondrial calcium uptake and possible therapeutic strategies targeting mitochondrial calcium uptake or the mitochondrial calcium uniporter, the main channel mediating mitochondrial calcium influx, are also discussed.
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Affiliation(s)
- Renjia Zhong
- Department of Applied Physiology and Kinesiology, College of Health and Human Performance, University of Florida, Gainesville, FL, 32611
- Department of Emergency Medicine, the First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China, 110001
| | - Michael T. Rua
- Department of Applied Physiology and Kinesiology, College of Health and Human Performance, University of Florida, Gainesville, FL, 32611
| | - Lan Wei-LaPierre
- Department of Applied Physiology and Kinesiology, College of Health and Human Performance, University of Florida, Gainesville, FL, 32611
- Myology Institute, University of Florida, Gainesville, FL 32611
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Funaki M, Nio-Kobayashi J, Suzuki R, Bando Y. Galectin-3 Plays a Role in Neuroinflammation in the Visual Pathway in Experimental Optic Neuritis. Cells 2024; 13:612. [PMID: 38607051 PMCID: PMC11011492 DOI: 10.3390/cells13070612] [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: 01/24/2024] [Revised: 03/18/2024] [Accepted: 03/30/2024] [Indexed: 04/13/2024] Open
Abstract
Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS) featuring numerous neuropathologies, including optic neuritis (ON) in some patients. However, the molecular mechanisms of ON remain unknown. Galectins, β-galactoside-binding lectins, are involved in various pathophysiological processes. We previously showed that galectin-3 (gal-3) is associated with the pathogenesis of experimental autoimmune encephalomyelitis (EAE), an animal model of MS. In the current study, we investigated the expression of gal-3 in the visual pathway in EAE mice to clarify its role in the pathogenesis of ON. Immunohistochemical analysis revealed upregulation of gal-3 in the visual pathway of the EAE mice during the peak stage of the disease, compared with naïve and EAE mice during the chronic stage. Gal-3 was detected mainly in microglia/macrophages and astrocytes in the visual pathway in EAE mice. In addition, gal-3+/Iba-1+ cells, identified as phagocytic by immunostaining for cathepsin D, accumulated in demyelinating lesions in the visual pathway during the peak disease stage of EAE. Moreover, NLRP3 expression was detected in most gal-3+/Iba-1+ cells. These results strongly suggest that gal-3 regulates NLRP3 signaling in microglia/macrophages and neuroinflammatory demyelination in ON. In astrocytes, gal-3 was expressed from the peak to the chronic disease stages. Taken together, our findings suggest a critical role of gal-3 in the pathogenesis of ON. Thus, gal-3 in glial cells may serve as a potential therapeutic target for ON.
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Affiliation(s)
- Masako Funaki
- Department of Anatomy, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | - Junko Nio-Kobayashi
- Department of Functional Glycobiology in Infectious Diseases, National Research Center for the Control and Prevention of Infectious Diseases, Nagasaki University, Nagasaki 852-8523, Japan
| | - Ryoji Suzuki
- Department of Anatomy, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | - Yoshio Bando
- Department of Anatomy, Akita University Graduate School of Medicine, Akita 010-8543, Japan
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Villa BR, George AG, Shutt TE, Sullivan PG, Rho JM, Teskey GC. Postictal hypoxia involves reactive oxygen species and is ameliorated by chronic mitochondrial uncoupling. Neuropharmacology 2023; 238:109653. [PMID: 37422182 DOI: 10.1016/j.neuropharm.2023.109653] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/10/2023]
Abstract
Prolonged severe hypoxia follows brief seizures and represents a mechanism underlying several negative postictal manifestations without interventions. Approximately 50% of the postictal hypoxia phenomenon can be accounted for by arteriole vasoconstriction. What accounts for the rest of the drop in unbound oxygen is unclear. Here, we determined the effect of pharmacological modulation of mitochondrial function on tissue oxygenation in the hippocampus of rats after repeatedly evoked seizures. Rats were treated with mitochondrial uncoupler 2,4 dinitrophenol (DNP) or antioxidants. Oxygen profiles were recorded using a chronically implanted oxygen-sensing probe, before, during, and after seizure induction. Mitochondrial function and redox tone were measured using in vitro mitochondrial assays and immunohistochemistry. Postictal cognitive impairment was assessed using the novel object recognition task. Mild mitochondrial uncoupling by DNP raised hippocampal oxygen tension and ameliorated postictal hypoxia. Chronic DNP also lowered mitochondrial oxygen-derived reactive species and oxidative stress in the hippocampus during postictal hypoxia. Uncoupling the mitochondria exerts therapeutic benefits on postictal cognitive dysfunction. Finally, antioxidants do not affect postictal hypoxia, but protect the brain from associated cognitive deficits. We provided evidence for a metabolic component of the prolonged oxygen deprivation that follow seizures and its pathological sequelae. Furthermore, we identified a molecular underpinning of this metabolic component, which involves excessive oxygen conversion into reactive species. Mild mitochondrial uncoupling may be a potential therapeutic strategy to treat the postictal state where seizure control is absent or poor.
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Affiliation(s)
- Bianca R Villa
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 4N1, Canada; Department of Cell Biology and Anatomy, University of Calgary, Calgary, AB, T2N 4N1, Canada.
| | - Antis G George
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 4N1, Canada; Department of Cell Biology and Anatomy, University of Calgary, Calgary, AB, T2N 4N1, Canada.
| | - Timothy E Shutt
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 4N1, Canada; Departments of Medical Genetics and Biochemistry & Molecular Biology, Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 4N1, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 4N1, Canada.
| | - Patrick G Sullivan
- Department of Anatomy and Neurobiology, and Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY, 40536, USA.
| | - Jong M Rho
- Department of Neurosciences, Pediatrics and Pharmacology, University of California San Diego, Rady Children's Hospital, San Diego, CA, 92037, USA.
| | - G Campbell Teskey
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 4N1, Canada; Department of Cell Biology and Anatomy, University of Calgary, Calgary, AB, T2N 4N1, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, T2N 4N1, Canada.
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Kohle F, Ackfeld R, Klein I, Svačina MKR, Schneider C, van Beers T, Grandoch A, Fink GR, Lehmann HC, Barham M. 2,4-Dinitrophenol does not exert neuro-regenerative potential in experimental autoimmune neuritis. Neurosci Lett 2023; 814:137456. [PMID: 37648059 DOI: 10.1016/j.neulet.2023.137456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/07/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE We evaluated the potential neuro-regenerative effects of the mitochondrial uncoupler 2,4-Dinitrophenol in experimental autoimmune neuritis, an animal model for an acute autoimmune neuropathy. METHODS Experimental autoimmune neuritis was induced in Lewis rats. Different concentrations of 2,4-Dinitrophenol (1 mg/kg, 0.1 mg/kg and 0.01 mg/kg) were applied during the recovery phase of the neuritis (at days 18, 22 and 26) and compared to the vehicle. Any effects were assessed through functional, electrophysiological, and morphological analysis via electron microscopy of all groups at day 30. Additional immune-histochemical analysis of inflammation markers and remyelination of the sciatic nerves were performed for the dosage of 1 mg/kg and control. RESULTS No enhancement of functional or electrophysiological recovery was observed in all 2,4-Dinitrophenol-treated groups. Cellular inflammation markers of T cells (CD3+) were comparable to control, and an increase of macrophages (IbA1+) invasion in the sciatic nerves was observed. Treatment with 2,4-Dinitrophenol reduced axonal swelling in myelinated and unmyelinated fibers with an increased production of brain-derived neurotrophic factor. CONCLUSION Our findings do not support the hypothesis that repurposing of the mitochondrial uncoupler 2,4-Dinitrophenol exerts functionally relevant neuro-regenerative effects in autoimmune neuritis.
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Affiliation(s)
- Felix Kohle
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany.
| | - Robin Ackfeld
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany
| | - Ines Klein
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany
| | - Martin K R Svačina
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany
| | - Christian Schneider
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany
| | - Tim van Beers
- Department of Molecular Cell Biology, Institute I for Anatomy, Faculty of Medicine, University Hospital Cologne and University of Cologne, Cologne, Germany
| | - Andrea Grandoch
- Department for Oral and Craniomaxillofacial and Plastic Surgery, Faculty of Medicine, University of Cologne and University Hospital of Cologne, Cologne, Germany
| | - Gereon R Fink
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany; Cognitive Neuroscience, Research Center Juelich, Institute of Neuroscience and Medicine (INM-3), Juelich, Germany
| | - Helmar C Lehmann
- Department of Neurology, Hospital Leverkusen, Leverkusen, Germany
| | - Mohammed Barham
- Department II of Anatomy, Faculty of Medicine, University of Cologne and University Hospital of Cologne, Cologne, Germany
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Takano C, Takano T, Masumura M, Nakamura R, Koda S, Bochimoto H, Yoshida S, Bando Y. Involvement of Degenerating 21.5 kDa Isoform of Myelin Basic Protein in the Pathogenesis of the Relapse in Murine Relapsing-Remitting Experimental Autoimmune Encephalomyelitis and MS Autopsied Brain. Int J Mol Sci 2023; 24:ijms24098160. [PMID: 37175866 PMCID: PMC10179612 DOI: 10.3390/ijms24098160] [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: 03/31/2023] [Revised: 04/22/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
Multiple sclerosis (MS) is the chronic inflammatory demyelinating disease of the CNS. Relapsing-remitting MS (RRMS) is the most common type of MS. However, the mechanisms of relapse and remission in MS have not been fully understood. While SJL mice immunized with proteolipid protein (PLP) develop relapsing-remitting experimental autoimmune encephalomyelitis (RR-EAE), we have recently observed that some of these mice were resistant to the active induction of relapsing EAE after initial clinical and histological symptoms of EAE with a severity similar to the relapsing EAE mice. To clarify the mechanism of relapsing, we examined myelin morphology during PLP139-151-induced RR-EAE in the SJL mice. While RR-EAE mice showed an increased EAE severity (relapse) with CNS inflammation, demyelination with abnormal myelin morphology in the spinal cord, the resistant mice exhibited a milder EAE phenotype with diminished relapse. Compared with the RR-EAE mice, the resistant mice showed less CNS inflammation, demyelination, and abnormalities of the myelin structure. In addition, scanning electron microscopic (SEM) analysis with the osmium-maceration method displayed ultrastructural abnormalities of the myelin structure in the white matter of the RR-EAE spinal cord, but not in that of the resistant mice. While the intensity of myelin staining was reduced in the relapsing EAE spinal cord, immunohistochemistry and immunoblot analysis revealed that the 21.5 kDa isoform of degenerating myelin basic protein (MBP) was specifically induced in the relapsing EAE spinal cord. Taken together, the neuroinflammation-induced degenerating 21 kDa isoform of MBP sheds light on the development of abnormal myelin on the relapse of MS pathogenesis.
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Affiliation(s)
- Chie Takano
- Department of Functional Anatomy and Neuroscience, Asahikawa Medical University, Asahikawa 078-8510, Japan
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa 078-8510, Japan
| | - Takuma Takano
- Department of Functional Anatomy and Neuroscience, Asahikawa Medical University, Asahikawa 078-8510, Japan
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa 078-8510, Japan
| | - Makoto Masumura
- Institute for Social Innovation and Cooperation, Niigata University, Niigata 951-8510, Japan
| | | | | | - Hiroki Bochimoto
- Department of Cell Physiology, The Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Shigetaka Yoshida
- Department of Functional Anatomy and Neuroscience, Asahikawa Medical University, Asahikawa 078-8510, Japan
| | - Yoshio Bando
- Department of Functional Anatomy and Neuroscience, Asahikawa Medical University, Asahikawa 078-8510, Japan
- Department of Anatomy, Akita University Graduate School of Medicine, Hondo 1-1-1, Akita 010-8543, Japan
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Allanach JR, Farrell JW, Mésidor M, Karimi-Abdolrezaee S. Current status of neuroprotective and neuroregenerative strategies in multiple sclerosis: A systematic review. Mult Scler 2022; 28:29-48. [PMID: 33870797 PMCID: PMC8688986 DOI: 10.1177/13524585211008760] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 03/13/2021] [Accepted: 03/21/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Immune-mediated demyelination and consequent degeneration of oligodendrocytes and axons are hallmark features of multiple sclerosis (MS). Remyelination declines in progressive MS, causing permanent axonal loss and irreversible disabilities. Strategies aimed at enhancing remyelination are critical to attenuate disease progression. OBJECTIVE We systematically reviewed recent advances in neuroprotective and regenerative therapies for MS, covering preclinical and clinical studies. METHODS We searched three biomedical databases using defined keywords. Two authors independently reviewed articles for inclusion based on pre-specified criteria. The data were extracted from each study and assessed for risk of bias. RESULTS Our search identified 7351 studies from 2014 to 2020, of which 221 met the defined criteria. These studies reported 262 interventions, wherein 92% were evaluated in animal models. These interventions comprised protein, RNA, lipid and cellular biologics, small molecules, inorganic compounds, and dietary and physiological interventions. Small molecules were the most highly represented strategy, followed by antibody therapies and stem cell transplantation. CONCLUSION While significant strides have been made to develop regenerative treatments for MS, the current evidence illustrates a skewed representation of the types of strategies that advance to clinical trials. Further examination is thus required to address current barriers to implementing experimental treatments in clinical settings.
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Affiliation(s)
- Jessica R Allanach
- Department of Microbiology and Immunology, The University of British Columbia, Vancouver, BC, Canada
| | - John W. Farrell
- Department of Health and Human Performance, Texas State University, San Marcos, TX, USA
| | - Miceline Mésidor
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, QC, Canada/Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC, Canada
| | - Soheila Karimi-Abdolrezaee
- Department of Physiology and Pathophysiology, Regenerative Medicine Program, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada/Children’s Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
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Ahluwalia M, Kumar M, Ahluwalia P, Rahimi S, Vender JR, Raju RP, Hess DC, Baban B, Vale FL, Dhandapani KM, Vaibhav K. Rescuing mitochondria in traumatic brain injury and intracerebral hemorrhages - A potential therapeutic approach. Neurochem Int 2021; 150:105192. [PMID: 34560175 PMCID: PMC8542401 DOI: 10.1016/j.neuint.2021.105192] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 02/07/2023]
Abstract
Mitochondria are dynamic organelles responsible for cellular energy production. Besides, regulating energy homeostasis, mitochondria are responsible for calcium homeostasis, signal transmission, and the fate of cellular survival in case of injury and pathologies. Accumulating reports have suggested multiple roles of mitochondria in neuropathologies, neurodegeneration, and immune activation under physiological and pathological conditions. Mitochondrial dysfunction, which occurs at the initial phase of brain injury, involves oxidative stress, inflammation, deficits in mitochondrial bioenergetics, biogenesis, transport, and autophagy. Thus, development of targeted therapeutics to protect mitochondria may improve functional outcomes following traumatic brain injury (TBI) and intracerebral hemorrhages (ICH). In this review, we summarize mitochondrial dysfunction related to TBI and ICH, including the mechanisms involved, and discuss therapeutic approaches with special emphasis on past and current clinical trials.
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Affiliation(s)
- Meenakshi Ahluwalia
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, USA.
| | - Manish Kumar
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Pankaj Ahluwalia
- Department of Pathology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Scott Rahimi
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - John R Vender
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Raghavan P Raju
- Department of Pharmacology and Toxicology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - David C Hess
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Babak Baban
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, GA, USA
| | - Fernando L Vale
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Krishnan M Dhandapani
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Kumar Vaibhav
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, USA; Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, GA, USA.
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