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Markus RP, Sousa KS, Ulrich H, Ferreira ZS. Partners in health and disease: pineal gland and purinergic signalling. Purinergic Signal 2024:10.1007/s11302-024-10037-8. [PMID: 39031242 DOI: 10.1007/s11302-024-10037-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 07/02/2024] [Indexed: 07/22/2024] Open
Abstract
In mammal's pineal glands, ATP interacts with the high-affinity P2Y1 and the low-affinity P2X7 receptors. ATP released from sympathetic nerve terminals potentiates noradrenaline-induced serotonin N-acetyltransferase (Snat) transcription, N-acetylserotonin (NAS), and melatonin (MLT) synthesis. Circulating melatonin impairs the expression of adhesion molecules in endothelial cells, blocking the migration of leukocytes. Acute defence response induced by pathogen- and danger/damage-associated molecular patterns (PAMPs and DAMPs) triggers the NF-κB pathway in pinealocytes and blocks the transcription of Snat. Therefore, the darkness hormone is not released, and neutrophils and monocytes migrate to the lesion sites. ATP released in high amounts from apoptotic and death cells was considered a DAMP, and the blockage of P2X7 receptors was tested as a new class of drugs for treating brain damage. However, this is not a simple equation. High ATP injected in a lateral ventricle blocked MLT, but not NAS, synthesis as it impairs the transcription of acetyl serotonin N-methyltransferase. NAS is released in the plasma and the cerebral spinal fluid. NAS also blocks the rolling and adhesion of leukocytes to endothelial cells. Otherwise, it is metabolised specifically in each brain area to provide the requested concentration of MLT as a neuroprotector. As observed in physiological conditions, high extracellular ATP, different from the other DAMPs, reports the environmental light/dark cycle rhythm because NAS substitutes MLT as the nocturnal chemical indicator, the darkness hormone. Thus, blocking the P2X7R should not be considered a universal therapy for improving acute strokes, as MLT and ATP are partners in health and disease.
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Affiliation(s)
- Regina P Markus
- Laboratory of Chronopharmacology, Department of Physiology, Institute of Biosciences, University of São Paulo, São Paulo, Brazil.
| | - Kassiano S Sousa
- Laboratory of Chronopharmacology, Department of Physiology, Institute of Biosciences, University of São Paulo, São Paulo, Brazil
| | - Henning Ulrich
- Department of Biochemistry, Institute of Chemistry, University of São Paulo, São Paulo, Brazil
| | - Zulma S Ferreira
- Laboratory of Chronopharmacology, Department of Physiology, Institute of Biosciences, University of São Paulo, São Paulo, Brazil.
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Shi H, Song L, Wu Y, Shen R, Zhang C, Liao X, Wang Q, Zhu J. Edaravone Alleviates Traumatic Brain Injury by Inhibition of Ferroptosis via FSP1 Pathway. Mol Neurobiol 2024:10.1007/s12035-024-04216-2. [PMID: 38733490 DOI: 10.1007/s12035-024-04216-2] [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: 01/28/2024] [Accepted: 05/04/2024] [Indexed: 05/13/2024]
Abstract
Traumatic brain injury (TBI) is a highly severe form of trauma with complex series of reactions in brain tissue which ultimately results in neuronal damage. Previous studies proved that neuronal ferroptosis, which was induced by intracranial haemorrhage and other reasons, was one of the most primary causes of neuronal damage following TBI. However, the association between neuronal mechanical injury and ferroptosis in TBI and relevant treatments remain unclear. In the present study, we first demonstrated the occurrence of neuronal ferroptosis in the early stage of TBI and preliminarily elucidated that edaravone (EDA), a cerebroprotective agent that eliminates oxygen radicals, was able to inhibit ferroptosis induced by TBI. A cell scratching model was established in PC12 cells, and it was confirmed that mechanical injury induced ferroptosis in neurons at the early stage of TBI. Ferroptosis suppressor protein 1 (FSP1) plays a significant role in inhibiting ferroptosis, and we found that iFSP, a ferroptosis agonist which is capable to inhibit FSP1 pathway, attenuated the anti-ferroptosis effect of EDA. In conclusion, our results suggested that EDA inhibited neuronal ferroptosis induced by mechanical injury in the early phase of TBI by activating FSP1 pathway, which could provide evidence for future research on prevention and treatment of TBI.
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Affiliation(s)
- Haoyu Shi
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University (The 904th Hospital of PLA)/Fifth Clinical Medical College of Anhui Medical University, Wuxi, 214044, Jiangsu Province, China
| | - Libiao Song
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University (The 904th Hospital of PLA)/Fifth Clinical Medical College of Anhui Medical University, Wuxi, 214044, Jiangsu Province, China
| | - Yonghui Wu
- Department of Neurosurgery, The Second People's Hospital of Lu'an, Lu'an, 237000, Anhui Province, China
| | - Ruonan Shen
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University (The 904th Hospital of PLA)/Fifth Clinical Medical College of Anhui Medical University, Wuxi, 214044, Jiangsu Province, China
| | - Chenxu Zhang
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University (The 904th Hospital of PLA)/Fifth Clinical Medical College of Anhui Medical University, Wuxi, 214044, Jiangsu Province, China
| | - Xingzhi Liao
- Department of Anaesthesiology, Wuxi Clinical College of Anhui Medical University (The 904th Hospital of PLA)/Fifth Clinical Medical College of Anhui Medical University, Wuxi, 214044, Jiangsu Province, China
| | - Qiuhong Wang
- Department of Ophthalmology, Wuxi Second Hospital Affiliated to Jiangnan University, Wuxi, 214002, Jiangsu Province, China
| | - Jie Zhu
- Department of Neurosurgery, Wuxi Clinical College of Anhui Medical University (The 904th Hospital of PLA)/Fifth Clinical Medical College of Anhui Medical University, Wuxi, 214044, Jiangsu Province, China.
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Ali NH, Al‐Kuraishy HM, Al‐Gareeb AI, Alexiou A, Papadakis M, AlAseeri AA, Alruwaili M, Saad HM, Batiha GE. BDNF/TrkB activators in Parkinson's disease: A new therapeutic strategy. J Cell Mol Med 2024; 28:e18368. [PMID: 38752280 PMCID: PMC11096816 DOI: 10.1111/jcmm.18368] [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: 10/18/2023] [Revised: 03/22/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Parkinson's disease (PD) is a neurodegenerative disorder of the brain and is manifested by motor and non-motor symptoms because of degenerative changes in dopaminergic neurons of the substantia nigra. PD neuropathology is associated with mitochondrial dysfunction, oxidative damage and apoptosis. Thus, the modulation of mitochondrial dysfunction, oxidative damage and apoptosis by growth factors could be a novel boulevard in the management of PD. Brain-derived neurotrophic factor (BDNF) and its receptor tropomyosin receptor kinase type B (TrkB) are chiefly involved in PD neuropathology. BDNF promotes the survival of dopaminergic neurons in the substantia nigra and enhances the functional activity of striatal neurons. Deficiency of the TrkB receptor triggers degeneration of dopaminergic neurons and accumulation of α-Syn in the substantia nigra. As well, BDNF/TrkB signalling is reduced in the early phase of PD neuropathology. Targeting of BDNF/TrkB signalling by specific activators may attenuate PD neuropathology. Thus, this review aimed to discuss the potential role of BDNF/TrkB activators against PD. In conclusion, BDNF/TrkB signalling is decreased in PD and linked with disease severity and long-term complications. Activation of BDNF/TrkB by specific activators may attenuate PD neuropathology.
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Affiliation(s)
- Naif H. Ali
- Department of Internal Medicine, Medical CollegeNajran UniversityNajranSaudi Arabia
| | - Hayder M. Al‐Kuraishy
- Department of Clinical Pharmacology and Medicine, College of MedicineMustansiriyah UniversityBaghdadIraq
| | | | - Athanasios Alexiou
- University Centre for Research and Development, Chandigarh UniversityMohaliPunjabIndia
- Department of Research and DevelopmentFunogenAthensGreece
- Department of Research and DevelopmentAFNP MedWienAustria
- Department of Science and EngineeringNovel Global Community Educational FoundationHebershamNew South WalesAustralia
| | - Marios Papadakis
- Department of Surgery IIUniversity Hospital Witten‐Herdecke, University of Witten‐HerdeckeWuppertalGermany
| | - Ali Abdullah AlAseeri
- Department of Internal MedicineCollege of Medicine, Prince Sattam bin Abdulaziz UniversityAl‐KharjSaudi Arabia
| | - Mubarak Alruwaili
- Department of Internal Medicine, College of MedicineJouf UniversitySakakaSaudi Arabia
| | - Hebatallah M. Saad
- Department of Pathology, Faculty of Veterinary MedicineMatrouh UniversityMatrouhEgypt
| | - Gaber El‐Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary MedicineDamanhour UniversityDamanhourEgypt
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Sakul AA, Balcikanli Z, Ozsoy NA, Orhan C, Sahin N, Tuzcu M, Juturu V, Kilic E, Sahin K. A highly bioavailable curcumin formulation ameliorates inflammation cytokines and neurotrophic factors in mice with traumatic brain injury. Chem Biol Drug Des 2024; 103:e14439. [PMID: 38230778 DOI: 10.1111/cbdd.14439] [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: 04/27/2023] [Revised: 12/06/2023] [Accepted: 12/19/2023] [Indexed: 01/18/2024]
Abstract
A novel curcumin formulation increases relative absorption by 46 times (CurcuWIN®) of the total curcuminoids over the unformulated standard curcumin form. However, the exact mechanisms by which curcumin demonstrates its neuroprotective effects are not fully understood. This study aimed to investigate the impact of a novel formulation of curcumin on the expression of brain-derived neurotrophic factor (BDNF), glial fibrillary acidic protein (GFAP), a main component of the glial scar and growth-associated protein-43 (GAP-43), a signaling molecule in traumatic brain injury (TBI). Mice (adult, male, C57BL/6j) were randomly divided into three groups as follows: TBI group (TBI-induced mice); TBI + CUR group (TBI mice were injected i.p. curcumin just after TBI); TBI+ CurcuWIN® group (TBI mice were injected i.p. CurcuWIN® just after TBI). Brain injury was induced using a cold injury model. Injured brain tissue was stained with Cresyl violet to evaluate infarct volume and brain swelling, analyzed, and measured using ImageJ by Bethesda (MD, USA). Western blot analysis was performed to determine the protein levels related to injury. While standard curcumin significantly reduced brain injury, CurcuWIN® showed an even greater reduction associated with reductions in glial activation, NF-κB, and the inflammatory cytokines IL-1β and IL-6. Additionally, both standard curcumin and CurcuWIN® led to increased BDNF, GAP-43, ICAM-1, and Nrf2 expression. Notably, CurcuWIN® enhanced their expression more than standard curcumin. This data suggests that highly bioavailable curcumin formulation has a beneficial effect on the traumatic brain in mice.
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Affiliation(s)
- Ayse Arzu Sakul
- Department of Pharmacology, School of Medicine, University of Istanbul Medipol, Istanbul, Turkey
| | - Zeynep Balcikanli
- Department of Physiology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Nilay Ates Ozsoy
- Department of Pharmacology, School of Medicine, University of Istanbul Medipol, Istanbul, Turkey
- Regenerative and Restorative Medical Research Center, Experimental Neurology Laboratory, Istanbul Medipol University, Istanbul, Turkey
| | - Cemal Orhan
- Department of Animal Nutrition, Faculty of Veterinary Medicine, Firat University, Elazig, Turkey
| | - Nurhan Sahin
- Department of Animal Nutrition, Faculty of Veterinary Medicine, Firat University, Elazig, Turkey
| | - Mehmet Tuzcu
- Department of Biology, Faculty of Science, Firat University Elazig, Elazig, Turkey
| | - Vijaya Juturu
- Scientific and Clinical Affairs, Research, and Development, OmniActives Health Technologies Inc., Morristown, New Jersey, USA
| | - Ertugrul Kilic
- Department of Physiology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Kazim Sahin
- Department of Animal Nutrition, Faculty of Veterinary Medicine, Firat University, Elazig, Turkey
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Zhang L, Gao M, Zhao Y, Yin Y, Zhang X, Zhou S, Wang X, Wang X, Zhao Y. N-Acetylserotonin Alleviates Retinal Autophagy via TrkB/AKT/Nrf2 Signaling Pathway in Retinal Ischemia-Reperfusion Injury Rats. Ophthalmic Res 2023; 67:125-136. [PMID: 38128509 DOI: 10.1159/000535786] [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: 04/16/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION The objective of this study was to investigate the impact of N-acetylserotonin (NAS) on the autophagy of retinal cells in rats with retinal ischemia-reperfusion injury (RIRI) and to explore the mechanisms by which NAS administration can alleviate RIRI through the tropomyosin-related kinase receptor B (TrkB)/protein kinase B (Akt)/nuclear factor erythroid-derived factor 2-related factor (Nrf2) signaling pathway. METHODS Healthy adult male rats were randomly assigned to four groups: sham, RIRI, RIRI+NAS, and RIRI+NAS+ANA-12. The RIRI group was induced by elevating intraocular pressure, and changes in retinal structure and edema were assessed using H&E staining. The RIRI+NAS and RIRI+NAS+ANA-12 groups received intraperitoneal injections of NAS before and after modeling. The RIRI+NAS+ANA-12 group was also administered ANA-12, a TrkB antagonist. Immunohistochemical staining and Western blot analysis were used to evaluate phosphorylated TrkB (p-TrkB), phosphorylated Akt (p-Akt), Nrf2, sequestosome 1 (P62), and microtubule-associated protein 1 light chain 3 (LC3-II) levels in the retinas of each group. Electroretinogram was recorded to detect retinal function in each group of rats 24 h after modeling. RESULTS The RIRI+NAS group had a thinner retina and more retinal ganglion cells (RGCs) than RIRI and RIRI+NAS+ANA-12 groups (p < 0.05). Immunohistochemical staining and Western blot results showed that p-TrkB, p-Akt, n-Nrf2, and P62 levels in the RIRI+NAS group were higher compared with those in RIRI and RIRI+NAS+ANA-12 groups (p < 0.05). Also, lower LC3-II levels were observed in the RIRI+NAS group compared with that in RIRI and RIRI+NAS+ANA-12 groups (p < 0.05). Electroretinogram recording results showed that 24 h after retinal ischemia-reperfusion, the magnitude of b-wave changes was attenuated in the RIRI+NAS group compared with the RIRI group (p < 0.05). CONCLUSION The administration of NAS activates the TrkB/Akt/Nrf2 signaling pathway, reduces autophagy, alleviates retinal edema, promotes the survival of retinal ganglion cells (RGCs), and provides neuroprotection against retinal injury.
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Affiliation(s)
- Luming Zhang
- School of Medical Imaging, Weifang Medical University, Weifang, China
| | - Meng Gao
- Department of Ophthalmology, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Yuze Zhao
- Department of Ophthalmology, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Yi Yin
- Department of Ophthalmology, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Xuening Zhang
- School of Medical Imaging, Weifang Medical University, Weifang, China
| | - Shuanhu Zhou
- Harvard Medical School, Boston, Massachusetts, USA
| | - Xin Wang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Xiaoli Wang
- School of Medical Imaging, Weifang Medical University, Weifang, China
- Medical Imaging Center, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Yansong Zhao
- Department of Ophthalmology, Affiliated Hospital of Weifang Medical University, Weifang, China
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Yidian W, Jihe K, Xudong G, Daxue Z, Mingqiang L, Xuewen K. N-Acetylserotonin Protects Rat Nucleus Pulposus Cells Against Oxidative Stress Injury by Activating the PI3K/AKT Signaling Pathway. World Neurosurg 2023; 176:e109-e124. [PMID: 37169069 DOI: 10.1016/j.wneu.2023.05.010] [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: 03/01/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Current studies suggest that the pathogenesis of intervertebral disc degeneration (IDD) is related to oxidative stress damage in nucleus pulposus cells (NPCs). N-acetylserotonin (NAS) is an effective scavenger of reactive oxygen species, but its role in IDD and its underlying mechanisms are not yet clear. Therefore, the aim of this study was to investigate the effect of NAS on oxidative stress injury in NPCs and its mechanism. METHODS NP tissue of rat intervertebral disc was collected and NPCs were isolated. NPCs were treated with H2O2 to simulate the state of oxidative stress. The effects of NAS on cell viability, apoptosis, senescence, extracellular matrix (ECM), redox status and PI3K/AKT signal pathway were evaluated by cell counting kit-8, western blot, immunofluorescence, flow cytometry and SA-β-gal staining. Finally, the changes of the above indexes were further observed after the inhibition of PI3K pathway by LY294002. RESULTS Flow cytometry showed that NAS reduced H2O2-induced apoptosis of NPCs. SA-β-Gal staining showed that H2O2-induced senescence of NP cells was reversed by NAS. Immunofluorescence staining showed that NAS inhibited H2O2-induced ECM degradation. Western blotting analysis revealed that NAS significantly decreased apoptosis, senescence and ECM degradation. Further analysis showed that NAS treatment activated the PI3K/AKT pathway in H2O2-stimulated NPCs. However, these protected effects were inhibited after LY294002 treatment. CONCLUSIONS The results of the present study suggest that NAS inhibits H2O2-induced NPCs degeneration by activating PI3K/AKT pathway, suggesting that NAS has the potential to treat IDD.
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Affiliation(s)
- Wang Yidian
- The Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, PR China; Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Kang Jihe
- The Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, PR China
| | - Guo Xudong
- The Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, PR China
| | - Zhu Daxue
- The Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, PR China
| | - Liu Mingqiang
- The Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, PR China
| | - Kang Xuewen
- The Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, PR China; Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou, Gansu, PR China; The International Cooperation Base of Gansu Province for The Pain Research in Spinal Disorders, Lanzhou, Gansu, PR China.
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Kang JH, Guo XD, Wang YD, Kang XW. Neuroprotective Effects of N-acetylserotonin and Its Derivative. Neuroscience 2023; 517:18-25. [PMID: 36893983 DOI: 10.1016/j.neuroscience.2023.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 02/12/2023] [Accepted: 02/20/2023] [Indexed: 03/09/2023]
Abstract
N-acetylserotonin (NAS) is a chemical intermediate in melatonin biosynthesis. NAS and its derivative N-(2-(5-hydroxy-1H-indol-3-yl) ethyl)-2-oxopiperidine-3-carboxamide (HIOC) are potential therapeutic agents for traumatic brain injury, autoimmune encephalomyelitis, hypoxic-ischemic encephalopathy, and other diseases. Evidence shows that NAS and its derivative HIOC have neuroprotective properties, and can exert neuroprotective effects by inhibiting oxidative stress, anti-apoptosis, regulating autophagy dysfunction, and anti-inflammatory. In this review, we discussed the neuroprotective effects and related mechanisms of NAS and its derivative HIOC to provide a reference for follow-up research and applications.
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Affiliation(s)
- Ji-He Kang
- Orthopedics Department, the Second Hospital of Lanzhou University, Lanzhou, China; Orthopedics Department, the Second Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Xu-Dong Guo
- Orthopedics Department, the Second Hospital of Lanzhou University, Lanzhou, China
| | - Yi-Dian Wang
- Orthopedics Department, School of Medicine, Honghui-hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xue-Wen Kang
- Orthopedics Department, the Second Hospital of Lanzhou University, Lanzhou, China.
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Cheng Y, Gao Y, Li J, Rui T, Li Q, Chen H, Jia B, Song Y, Gu Z, Wang T, Gao C, Wang Y, Wang Z, Wang F, Tao L, Luo C. TrkB agonist N-acetyl serotonin promotes functional recovery after traumatic brain injury by suppressing ferroptosis via the PI3K/Akt/Nrf2/Ferritin H pathway. Free Radic Biol Med 2023; 194:184-198. [PMID: 36493983 DOI: 10.1016/j.freeradbiomed.2022.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/19/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
Ferroptosis is a form of regulated cell death that is mainly triggered by iron-dependent lipid peroxidation. A growing body of evidence suggests that ferroptosis is involved in the pathophysiology of traumatic brain injury (TBI), and tropomyosin-related kinase B (TrkB) deficiency would mediate TBI pathologies. As an agonist of TrkB and an immediate precursor of melatonin, N-acetyl serotonin (NAS) exerts several beneficial effects on TBI, but there is no information regarding the role of NAS in ferroptosis after TBI. Here, we examined the effect of NAS treatment on TBI-induced functional outcomes and ferroptosis. Remarkably, the administration of NAS alleviated TBI-induced neurobehavioral deficits, lesion volume, and neurodegeneration. NAS also rescued TBI-induced mitochondrial shrinkage, the changes in ferroptosis-related molecule expression, and iron accumulation in the ipsilateral cortex. Similar results were obtained with a well-established ferroptosis inhibitor, liproxstatin-1. Furthermore, NAS activated the TrkB/PI3K/Akt/Nrf2 pathway in the mouse model of TBI, while inhibition of PI3K and Nrf2 weakened the protection of NAS against ferroptosis both in vitro and in vivo, suggesting that a possible pathway linking NAS to the action of anti-ferroptosis was TrkB/PI3K/Akt/Nrf2. Given that ferritin H (Fth) is a known transcription target of Nrf2, we then investigated the effects of NAS on neuron-specific Fth knockout (Fth-KO) mice. Strikingly, Fth deletion almost abolished the protective effects of NAS against TBI-induced ferroptosis and synaptic damage, although Fth deletion-induced susceptibility toward ferroptosis after TBI was reversed by an iron chelator, deferoxamine. Taken together, these data indicate that the TrkB agonist NAS treatment appears to improve brain function after TBI by suppressing ferroptosis, at least in part, through activation of the PI3K/Akt/Nrf2/Fth pathway, providing evidence that NAS is likely to be a promising anti-ferroptosis agent for further treatment for TBI.
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Affiliation(s)
- Ying Cheng
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Yuan Gao
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Jing Li
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Tongyu Rui
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Qianqian Li
- School of Forensic Medicine, Wannan Medical College, Wuhu, 241002, China
| | - Huan Chen
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Bowen Jia
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Yiting Song
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Zhiya Gu
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Tao Wang
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Cheng Gao
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Ying Wang
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Zufeng Wang
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China
| | - Fudi Wang
- The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, 310058, China.
| | - Luyang Tao
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China.
| | - Chengliang Luo
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou, 215123, China.
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Kang J, Wang Y, Guo X, He X, Liu W, Chen H, Wang Z, Lin A, Kang X. N-acetylserotonin protects PC12 cells from hydrogen peroxide induced damage through ROS mediated PI3K / AKT pathway. Cell Cycle 2022; 21:2268-2282. [PMID: 35758219 DOI: 10.1080/15384101.2022.2092817] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
N-acetylserotonin (NAS) exerts neuroprotective, antioxidant, and anti-apoptotic effects. Oxidative stress and apoptosis are the primary causes of spinal cord injury (SCI). Herein, we explored potential protective effects and mechanisms of NAS in a neuron oxidative damage model in vitro. We established an oxidative damage model in PC12 cells induced by hydrogen peroxide (H2O2) and treated these cells with NAS. NAS enhanced the activity of superoxide dismutase and halted the increase in reactive oxygen species (ROS) and the expression of inducible nitric oxide synthase. Additionally, NAS promoted protein expression of Bcl-2, but inhibited protein expressions of Fas, FADD, cytochrome c, Bax, cleaved caspase-9, and cleaved caspase-3, namely, decreasing protein expression of the Fas and mitochondrial pathways. Furthermore, it reduced the rate of apoptosis and necroptosis-related protein expressions of MLKL and p-MLKL. Moreover, NAS promoted the protein expression of p-PI3K and p-AKT, and the addition of the PI3K inhibitor LY294002 partially attenuated the antioxidant stress and anti-apoptotic effects of NAS in H2O2 stimulated PC12 cells. In conclusion, NAS protected PC12 cells from apoptosis and oxidative stress induced by H2O2 by inhibiting ROS activity and activating the PI3K/AKT signaling pathway.
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Affiliation(s)
- Jihe Kang
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Yidian Wang
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Xudong Guo
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Xuegang He
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Wenzhao Liu
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Haiwei Chen
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Zhaoheng Wang
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Aixin Lin
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Xuewen Kang
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China.,Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou, China
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Contó MB, Pautassi RM, Camarini R. Rewarding and Antidepressant Properties of Ketamine and Ethanol: Effects on the Brain-Derived Neurotrophic Factor and TrkB and p75 NTR Receptors. Neuroscience 2022; 493:1-14. [PMID: 35469972 DOI: 10.1016/j.neuroscience.2022.04.015] [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: 01/02/2022] [Revised: 04/12/2022] [Accepted: 04/18/2022] [Indexed: 10/18/2022]
Abstract
There is a high level of comorbidity between depression and alcohol use disorder. Subanesthetic doses of ketamine induce short-acting and enduring antidepressant effects after a single or a few administrations. Considering such comorbidity, we assessed, in Swiss male mice, if ketamine-induced antidepressant-like effects would alter ethanol's rewarding effects; and, if ethanol pretreatment would alter the rewarding and antidepressant effects of ketamine. The role of the brain-derived neurotrophic factor (BDNF) and its high and low affinity receptors TrkB and p75NTR, respectively, in both reward and depression-related behaviors is well established. The present study assessed, in outbred Swiss male mice, the expression of these proteins in the prefrontal cortex and hippocampus. Ketamine did not alter the development of ethanol-induced conditioned place preference (CPP), yet ethanol inhibited the expression of CPP induced by 50 mg/kg ketamine. The antidepressant action of 50 mg/kg ketamine was attenuated after repeated treatment (i.e., developed tolerance), an effect blocked by ethanol preexposure; ethanol also inhibited the antidepressant effect of 30 mg/kg ketamine. Ketamine (50 mg/kg) and Ethanol-Ketamine (50 mg/kg) groups showed lower levels of 145 kDa TrkB in the hippocampus than Saline-treated group. Ethanol-Ketamine (50 mg/kg) decreased the hippocampal expression of p75NTR compared to Saline-Saline and Saline-Ethanol groups. Ketamine (50 mg/kg) induced hippocampal downregulation of 145 kDa TrkB may contribute to ketamine-induced antidepressant tolerance. Likewise, a relationship between low hippocampal levels of p75NTR in the Ethanol-Ketamine (50 mg/kg) and ketamine-induced CPP blockade may be considered. The findings underscore potential ethanol-ketamine interactions likely to undermine ketamine putative antidepressant effects.
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Affiliation(s)
- Marcos Brandão Contó
- Departamento de Farmacologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo 05508-900, Brasil.
| | - Ricardo Marcos Pautassi
- Instituto de Investigación Médica M. y M. Ferreyra (INIMEC-CONICET-Universidad Nacional de Córdoba), Córdoba C.P. 5000, Argentina; Facultad de Psicología, Universidad Nacional de Córdoba, Córdoba C.P. 5000 Argentina
| | - Rosana Camarini
- Departamento de Farmacologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo 05508-900, Brasil.
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11
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Zhang KK, Chen LJ, Li JH, Liu JL, Wang LB, Xu LL, Yang JZ, Li XW, Xie XL, Wang Q. Methamphetamine Disturbs Gut Homeostasis and Reshapes Serum Metabolome, Inducing Neurotoxicity and Abnormal Behaviors in Mice. Front Microbiol 2022; 13:755189. [PMID: 35509309 PMCID: PMC9058162 DOI: 10.3389/fmicb.2022.755189] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 03/25/2022] [Indexed: 01/01/2023] Open
Abstract
As an illicit psychostimulant, repeated methamphetamine (MA) exposure results in addiction and causes severe neurotoxicity. Studies have revealed complex interactions among gut homeostasis, metabolism, and the central nervous system (CNS). To investigate the disturbance of gut homeostasis and metabolism in MA-induced neurotoxicity, 2 mg/kg MA or equal volume saline was intraperitoneally (i.p.) injected into C57BL/6 mice. Behavioral tests and western blotting were used to evaluate neurotoxicity. To determine alterations of colonic dysbiosis, 16s rRNA gene sequencing was performed to analyze the status of gut microbiota, while RNA-sequencing (RNA-seq) and Western Blot analysis were performed to detect colonic damage. Serum metabolome was profiled by LC–MS analysis. We found that MA induced locomotor sensitization, depression-, and anxiety-like behaviors in mice, along with dysfunction of the dopaminergic system and stimulation of autophagy as well as apoptosis in the striatum. Notably, MA significantly decreased microbial diversity and altered the component of microbiota. Moreover, findings from RNA-seq implied stimulation of the inflammation-related pathway after MA treatment. Western blotting confirmed that MA mediated colonic inflammation by activating the TLR4-MyD88-NF-κB pathway and impaired colonic barrier. In addition, serum metabolome was reshaped after MA treatment. Specifically, bacteroides-derived sphingolipids and serotonin were obviously altered, which were closely correlated with locomotor sensitization, depression-, and anxiety-like behaviors. These findings suggest that MA disrupts gut homeostasis by altering its microbiome and arousing inflammation, and reshapes serum metabolome, which provide new insights into understanding the interactions between gut homeostasis and MA-induced neurotoxicity.
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Affiliation(s)
- Kai-Kai Zhang
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Li-Jian Chen
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Jia-Hao Li
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Jia-Li Liu
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Li-Bin Wang
- Department of Toxicology, School of Public Health, Southern Medical University, Guangzhou, China
| | - Ling-Ling Xu
- Department of Toxicology, School of Public Health, Southern Medical University, Guangzhou, China
| | - Jian-Zheng Yang
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Xiu-Wen Li
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China
| | - Xiao-Li Xie
- Department of Toxicology, School of Public Health, Southern Medical University, Guangzhou, China
- *Correspondence: Xiao-Li Xie,
| | - Qi Wang
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China
- Qi Wang, ;
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12
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Cheng Y, Qu W, Li J, Jia B, Song Y, Wang L, Rui T, Li Q, Luo C. Ferristatin II, an Iron Uptake Inhibitor, Exerts Neuroprotection against Traumatic Brain Injury via Suppressing Ferroptosis. ACS Chem Neurosci 2022; 13:664-675. [PMID: 35143157 DOI: 10.1021/acschemneuro.1c00819] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
As a specific ferroptosis marker, transferrin receptor 1 (TfR1) expression is increased following traumatic brain injury (TBI), but the precise role of TfR1 in TBI-induced ferroptosis and neurodegeneration remains to be determined. To further identify more potent ferroptosis inhibitors and effective targets for treating TBI, our study aims at investigating the effects of TfR1 on ferroptosis in a mouse TBI model using ferristatin II (an iron uptake and TfR1 inhibitor). The effect of ferristatin II was first verified in the HT-22 cell line in vitro and showed antiferroptotic action when exposed to ferric citrate (FAC), which is in parallel with the results obtained from the positive controls, including deferoxamine (DFO) and liproxstatin-1 (Lip-1). In vivo, ferristatin II administration reduced the expression of TfR1 at 12 h after TBI, and immunofluorescence experiments further confirmed that this decreased TfR1-positive cells were neurons. Importantly, ferristatin II suppressed TBI-induced iron homeostatic imbalance by decreasing the content of Fe (III) and iron-positive deposits and reversed the expression of iron homeostasis-related proteins. Moreover, ferristatin II attenuated TBI-induced lipid peroxidation by reversing the expression of lipid peroxidative genes and proteins, as well as the increase in malondialdehyde (MDA) level following TBI. Finally, ferristatin II alleviated TBI-induced neuronal injury and neurodegeneration, as detected by staining with Nissl and Fluoro-Jade B, thereby exerting a neuroprotective effect. In summary, these data indicated that ferristatin II might be a potential strategy to restrain ferroptosis and develop novel therapeutic agents against TBI.
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Affiliation(s)
- Ying Cheng
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou 215123, China
| | - Wenhao Qu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Jing Li
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou 215123, China
| | - Bowen Jia
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou 215123, China
| | - Yiting Song
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou 215123, China
| | - Liyu Wang
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou 215123, China
| | - Tongyu Rui
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou 215123, China
| | - Qianqian Li
- School of Forensic Medicine, Wannan Medical College, Wuhu 241002, China
| | - Chengliang Luo
- Department of Forensic Medicine, School of Basic Medicine and Biological Sciences, Soochow University, Suzhou 215123, China
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13
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Rui T, Wang H, Li Q, Cheng Y, Gao Y, Fang X, Ma X, Chen G, Gao C, Gu Z, Song S, Zhang J, Wang C, Wang Z, Wang T, Zhang M, Min J, Chen X, Tao L, Wang F, Luo C. Deletion of ferritin H in neurons counteracts the protective effect of melatonin against traumatic brain injury-induced ferroptosis. J Pineal Res 2021; 70:e12704. [PMID: 33206394 DOI: 10.1111/jpi.12704] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 12/16/2022]
Abstract
Accumulating evidence demonstrates that ferroptosis may be important in the pathophysiological process of traumatic brain injury (TBI). As a major hormone of the pineal gland, melatonin exerts many beneficial effects on TBI, but there is no information regarding the effects of melatonin on ferroptosis after TBI. As expected, TBI resulted in the time-course changes of ferroptosis-related molecules expression and iron accumulation in the ipsilateral cortex. Importantly, we found that treating with melatonin potently rescued TBI induced the changes mentioned above and improved functional deficits versus vehicle. Similar results were obtained with a ferroptosis inhibitor, liproxstatin-1. Moreover, the protective effect of melatonin is likely dependent on melatonin receptor 1B (MT2). Although ferritin plays a vital role in iron metabolism by storing excess cellular iron, its precise function in the brain, and whether it involves melatonin's neuroprotection remain unexplored. Considering ferritin H (Fth) is expressed predominantly in the neurons and global loss of Fth in mice induces early embryonic lethality, we then generated neuron-specific Fth conditional knockout (Fth-KO) mice, which are viable and fertile but have altered iron metabolism. In addition, Fth-KO mice were more susceptible to ferroptosis after TBI, and the neuroprotection by melatonin was largely abolished in Fth-KO mice. In vitro siFth experiments further confirmed the results mentioned above. Taken together, these data indicate that melatonin produces cerebroprotection, at least partly by inhibiting neuronal Fth-mediated ferroptosis following TBI, supporting the notion that melatonin is an excellent ferroptosis inhibitor and its anti-ferroptosis provides a potential therapeutic target for treating TBI.
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Affiliation(s)
- Tongyu Rui
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Haochen Wang
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Qianqian Li
- School of Forensic Medicine, Wannan Medical College, Wuhu, China
| | - Ying Cheng
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Yuan Gao
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Xuexian Fang
- The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuying Ma
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Guang Chen
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Cheng Gao
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Zhiya Gu
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Shunchen Song
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Jian Zhang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chunling Wang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, China
| | - Zufeng Wang
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Tao Wang
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Mingyang Zhang
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Junxia Min
- The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiping Chen
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Luyang Tao
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
| | - Fudi Wang
- The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Chengliang Luo
- Department of Forensic Medicine, Medical College of Soochow University, Suzhou, China
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14
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Fletcher JL, Dill LK, Wood RJ, Wang S, Robertson K, Murray SS, Zamani A, Semple BD. Acute treatment with TrkB agonist LM22A-4 confers neuroprotection and preserves myelin integrity in a mouse model of pediatric traumatic brain injury. Exp Neurol 2021; 339:113652. [PMID: 33609501 DOI: 10.1016/j.expneurol.2021.113652] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/03/2021] [Accepted: 02/15/2021] [Indexed: 02/08/2023]
Abstract
Young children have a high risk of sustaining a traumatic brain injury (TBI), which can have debilitating life-long consequences. Importantly, the young brain shows particular vulnerability to injury, likely attributed to ongoing maturation of the myelinating nervous system at the time of insult. Here, we examined the effect of acute treatment with the partial tropomyosin receptor kinase B (TrkB) agonist, LM22A-4, on pathological and neurobehavioral outcomes after pediatric TBI, with the hypothesis that targeting TrkB would minimize tissue damage and support functional recovery. We focused on myelinated tracts-the corpus callosum and external capsules-based on recent evidence that TrkB activation potentiates oligodendrocyte remyelination. Male mice at postnatal day 21 received an experimental TBI or sham surgery. Acutely post-injury, extensive cell death, a robust glial response and disruption of compact myelin were evident in the injured brain. TBI or sham mice then received intranasal saline vehicle or LM22A-4 for 14 days. Behavior testing was performed from 4 weeks post-injury, and brains were collected at 5 weeks for histology. TBI mice showed hyperactivity, reduced anxiety-like behavior, and social memory impairments. LM22A-4 ameliorated the abnormal anxiolytic phenotype but had no effect on social memory deficits. Use of spectral confocal reflectance microscopy detected persistent myelin fragmentation in the external capsule of TBI mice at 5 weeks post-injury, which was accompanied by regionally distinct deficits in oligodendrocyte progenitor cells and post-mitotic oligodendrocytes, as well as chronic reactive gliosis and atrophy of the corpus callosum and injured external capsule. LM22A-4 treatment ameliorated myelin deficits in the perilesional external capsule, as well as tissue volume loss and the extent of reactive gliosis. However, there was no effect of this TrkB agonist on oligodendroglial populations detected at 5 weeks post-injury. Collectively, our results demonstrate that targeting TrkB immediately after TBI during early life confers neuroprotection and preserves myelin integrity, and this was associated with some improved neurobehavioral outcomes as the pediatric injured brain matures.
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Affiliation(s)
- Jessica L Fletcher
- Department of Anatomy and Neuroscience, University of Melbourne, Parkville, VIC, Australia
| | - Larissa K Dill
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Rhiannon J Wood
- Department of Anatomy and Neuroscience, University of Melbourne, Parkville, VIC, Australia
| | - Sharon Wang
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Kate Robertson
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Simon S Murray
- Department of Anatomy and Neuroscience, University of Melbourne, Parkville, VIC, Australia
| | - Akram Zamani
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Bridgette D Semple
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Parkville, VIC, Australia.
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