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Mick G, Douek P. Clinical Benefits and Safety of Medical Cannabis Products: A Narrative Review on Natural Extracts. Pain Ther 2024:10.1007/s40122-024-00643-0. [PMID: 39096481 DOI: 10.1007/s40122-024-00643-0] [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: 05/24/2024] [Accepted: 07/23/2024] [Indexed: 08/05/2024] Open
Abstract
Interest in medical cannabis and cannabis-based medicinal products (CBMPs) has increased greatly in recent years. Two cannabinoids are of principal importance; delta-9-tetrahydrocannabinol (∆9-THC), the primary psychoactive component, and also cannabidiol (CBD), considered non-intoxicating. Each has distinct mechanisms of action and different therapeutic potentials. CBMPs differ in their ∆9-THC and CBD components; predominantly ∆9-THC, balanced formulations with equivalent ∆9-THC and CBD elements, and CBD-predominant products. In this narrative review, we evaluate the published evidence for the clinical benefits of CBMPs and overall benefits in well-being. We also review the overall safety profile and discuss the potential for dependence with CBMPs. Evidence can be drawn from a wide range of randomized and other controlled studies and from observational real-world studies. Most data from observational registry studies are supportive of ∆9-THC-based products (∆9-THC-predominant or balanced CBMPs) in the management of chronic neuropathic pain. Balanced products are also effective in reducing spasticity in multiple sclerosis. Most CBMPs show benefit in providing symptomatic benefits in reducing anxiety, nausea, and in improving sleep, but the place of specific products is more subtle, and choice guided by specific circumstances. Symptomatic improvements are accompanied by improved quality of life and well-being. Safety data indicate that CBMPs are generally well tolerated in most patients without specific contraindications. The majority of adverse effects are non-serious, and transient; most are principally associated with ∆9-THC and are dose-dependent. In contrast to recreational cannabis use, there is little evidence from clinical studies that CBMPs have any potential for dependence.
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Affiliation(s)
- Gérard Mick
- Pain Center, Voiron Hospital, CHU Grenoble-Alpes-Voiron, Voiron, 38500, Grenoble, France.
- CETD, Hôpital Neurologique Pierre Wertheimer, CHU de Lyon-Hospices Civils de Lyon (HCL), 69500, Bron, France.
- Health Systemic Process (P2S) Laboratory, Research Unit 4129, Université Claude Bernard Lyon 1, 69008, Lyon, France.
- THEMAS Team, TIMC Laboratory, Université Grenoble Alpes, 38000, Grenoble, France.
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Motamedy S, Soltani B, Kameshki H, Kermani AA, Amleshi RS, Nazeri M, Shabani M. The Therapeutic Potential and Molecular Mechanisms Underlying the Neuroprotective Effects of Sativex ® - A Cannabis-derived Spray. Mini Rev Med Chem 2024; 24:1427-1448. [PMID: 38318827 DOI: 10.2174/0113895575285934240123110158] [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: 11/16/2023] [Revised: 12/29/2023] [Accepted: 01/05/2024] [Indexed: 02/07/2024]
Abstract
Sativex is a cannabis-based medicine that comes in the form of an oromucosal spray. It contains equal amounts of Δ9-tetrahydrocannabinol and cannabidiol, two compounds derived from cannabis plants. Sativex has been shown to have positive effects on symptoms of amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), and sleep disorders. It also has analgesic, antiinflammatory, antitumoral, and neuroprotective properties, which make it a potential treatment option for other neurological disorders. The article reviews the results of recent preclinical and clinical studies that support the therapeutic potential of Sativex and the molecular mechanisms behind its neuroprotective benefits in various neurological disorders. The article also discusses the possible advantages and disadvantages of using Sativex as a neurotherapeutic agent, such as its safety, efficacy, availability, and legal status.
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Affiliation(s)
- Sina Motamedy
- Neuroscience Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
| | - Bahareh Soltani
- Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Halimeh Kameshki
- Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | | | - Reza Saboori Amleshi
- Neuroscience Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
| | - Masoud Nazeri
- Department of Anesthesiology, Friedrich-Alexander-University Erlangen-Nuremberg, University Hospital Erlangen, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Mohammad Shabani
- Neuroscience Research Center, Neuropharmacology Institute, Kerman University of Medical Sciences, Kerman, Iran
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Gómez-Cañas M, Rodríguez-Cueto C, Satta V, Hernández-Fisac I, Navarro E, Fernández-Ruiz J. Endocannabinoid-Binding Receptors as Drug Targets. Methods Mol Biol 2023; 2576:67-94. [PMID: 36152178 DOI: 10.1007/978-1-0716-2728-0_6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Cannabis plant has been used from ancient times with therapeutic purposes for treating human pathologies, but the identification of the cellular and molecular mechanisms underlying the therapeutic properties of the phytocannabinoids, the active compounds in this plant, occurred in the last years of the past century. In the late 1980s and early 1990s, seminal studies demonstrated the existence of cannabinoid receptors and other elements of the so-called endocannabinoid system. These G protein-coupled receptors (GPCRs) are a key element in the functions assigned to endocannabinoids and appear to serve as promising pharmacological targets. They include CB1, CB2, and GPR55, but also non-GPCRs can be activated by endocannabinoids, like ionotropic receptor TRPV1 and even nuclear receptors of the PPAR family. Their activation, inhibition, or simply modulation have been associated with numerous physiological effects at both central and peripheral levels, which may have therapeutic value in different human pathologies, then providing a solid experimental explanation for both the ancient medicinal uses of Cannabis plant and the recent advances in the development of cannabinoid-based specific therapies. This chapter will review the scientific knowledge generated in the last years around the research on the different endocannabinoid-binding receptors and their signaling mechanisms. Our intention is that this knowledge may help readers to understand the relevance of these receptors in health and disease conditions, as well as it may serve as the theoretical basis for the different experimental protocols to investigate these receptors and their signaling mechanisms that will be described in the following chapters.
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Affiliation(s)
- María Gómez-Cañas
- Instituto Universitario de Investigación en Neuroquímica, Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Carmen Rodríguez-Cueto
- Instituto Universitario de Investigación en Neuroquímica, Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Valentina Satta
- Instituto Universitario de Investigación en Neuroquímica, Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Inés Hernández-Fisac
- Instituto Universitario de Investigación en Neuroquímica, Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Elisa Navarro
- Instituto Universitario de Investigación en Neuroquímica, Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Javier Fernández-Ruiz
- Instituto Universitario de Investigación en Neuroquímica, Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad Complutense, Madrid, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain.
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.
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Dykukha I, Essner U, Schreiber H, Raithel LM, Penner IK. Effects of Sativex Ⓡ on cognitive function in patients with multiple sclerosis: A systematic review and meta-analysis. Mult Scler Relat Disord 2022; 68:104173. [PMID: 36174323 DOI: 10.1016/j.msard.2022.104173] [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: 01/05/2022] [Revised: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cognitive impairment is a common manifestation of multiple sclerosis (MS). OBJECTIVE To assess by systematic review and meta-analysis available evidence regarding the impact of nabiximols oromucosal spray on cognition in patients with MS. METHODS A systematic literature search of clinical studies (all types, any comparator) that measured cognitive function in patients with MS spasticity treated with nabiximols. Meta-analysis for cognitive endpoints was not possible due to heterogenous measurement instruments and outcomes. Meta-analysis was performed for adverse events (AEs) of special interest (cognition disorders) reported in randomized controlled trials (RCTs) of nabiximols versus placebo in patients with MS (with or without spasticity). Certainty of evidence and risk of bias were assessed. RESULTS Seven clinical studies (three RCTs) directly assessing cognitive function were included in the qualitative analysis. There was no consistent evidence to suggest that nabiximols causes cognitive impairment as assessed by a range of specific psychometric instruments across cognitive domains. Thirteen double-blind, placebo-controlled RCTs (nabiximols, n = 964; placebo, n = 904) were included in the meta-analysis of cognitive AEs. Most cognitive AEs (30 of 32 events, 93.8%) reported with nabiximols in MS patients occurred with not in-label use, i.e., dosage >12 sprays per day and/or not administered primarily for treatment of spasticity. CONCLUSIONS Within the limitations of the review, we can conclude that no detrimental effects of nabiximols on cognitive function were observed in patients with MS spasticity during up to 12 months follow-up and that cognitive AEs were rare and occurred only when nabiximols was not used according to its approved label.
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Affiliation(s)
- Igor Dykukha
- Medical Affairs, Almirall Hermal GmbH, Reinbek, Germany
| | - Ute Essner
- O. Meany Consultancy GmbH, Hamburg, Germany
| | - Herbert Schreiber
- Neurological Practice Center, Neuropoint Academy, NTD & Neurosys, Ulm, Germany
| | - Lina Marie Raithel
- COGITO Center for Applied Neurocognition and Neuropsychological Research, Düsseldorf, Germany
| | - Iris-Katharina Penner
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.
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Rosa GM, Puce L, Mori L, Currà A, Fattapposta F, Porto I, Bragazzi NL, Trompetto C, Marinelli L. Nabiximols effect on blood pressure and heart rate in post-stroke patients of a randomized controlled study. Front Cardiovasc Med 2022; 9:990188. [PMID: 36386386 PMCID: PMC9650544 DOI: 10.3389/fcvm.2022.990188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/11/2022] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Cannabinoids may be useful to treat pain, epilepsy and spasticity, although they may bear an increased risk of cardiovascular events. This study aims to evaluate the cardiovascular safety of nabiximols, a cannabis-based drug, in patients with spasticity following stroke, thus presenting an increased cardiovascular risk. METHODS This is an ancillary study stemming from the SativexStroke trial: a randomized double-blind, placebo-controlled, crossover study aimed at assessing the effect of nabiximols on post-stroke spasticity. Patients were treated with nabiximols oromucosal spray or placebo and assessed before and after two phases of 1-month duration each. Only the phase with the active treatment was considered for each patient who completed the study. The average values of blood pressure (diastolic, systolic, differential) and heart rate from the first 5 days of the phase (lowest nabiximols dosage) were compared to the average values recorded during the last 5 days at the end of the phase (highest nabiximols dosage). Baseline comparisons between gender, stroke type and affected side and correlation between age and blood pressure and heart rate were performed. The study was registered with the EudraCT number 2016-001034-10. RESULTS Thirty-four patients completed the study and were included in the analysis. Thirty-one were taking antihypertensive drugs and, among these, 12 were taking beta-blockers. During the study, no arrhythmic events were recorded, blood pressure and heart rate did not show pathological fluctuations, and no cardiovascular or cerebrovascular events occurred. At baseline blood pressure and heart rate were comparable concerning gender, stroke type and affected side. A significant direct correlation emerged between differential blood pressure and age and an inverse correlation between diastolic blood pressure and age. No correlation emerged between systolic blood pressure or heart rate and age. Blood pressure and heart rate did not change during nabiximols treatment compared to the baseline condition. CONCLUSION This ancillary study adds evidence that, in patients who already underwent a cerebrovascular accident, nabiximols does not determine significant blood pressure and heart rate variation or cardiovascular complications. These data support the cardiovascular safety of nabiximols, encouraging more extensive studies involving cannabinoids characterized by slow absorption rates.
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Affiliation(s)
- Gian Marco Rosa
- Cardiology Clinic, Department of Internal Medicine and Medical Specialties, University of Genoa, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Luca Puce
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
| | - Laura Mori
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
| | - Antonio Currà
- Department of Medical-Surgical Sciences and Biotechnologies, A. Fiorini Hospital, Sapienza University of Rome, Latina, Italy
| | | | - Italo Porto
- Cardiology Clinic, Department of Internal Medicine and Medical Specialties, University of Genoa, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Nicola Luigi Bragazzi
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON, Canada
| | - Carlo Trompetto
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
| | - Lucio Marinelli
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genova, Italy
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Henson JD, Vitetta L, Hall S. Tetrahydrocannabinol and cannabidiol medicines for chronic pain and mental health conditions. Inflammopharmacology 2022; 30:1167-1178. [PMID: 35796920 PMCID: PMC9294022 DOI: 10.1007/s10787-022-01020-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 06/13/2022] [Indexed: 01/07/2023]
Abstract
Combination tetrahydrocannabinol (THC)/cannabidiol (CBD) medicines or CBD-only medicines are prospective treatments for chronic pain, stress, anxiety, depression, and insomnia. THC and CBD increase signaling from cannabinoid receptors, which reduces synaptic transmission in parts of the central and peripheral nervous systems and reduces the secretion of inflammatory factors from immune and glial cells. The overall effect of adding CBD to THC medicines is to enhance the analgesic effect but counteract some of the adverse effects. There is substantial evidence for the effectiveness of THC/CBD combination medicines for chronic pain, especially neuropathic and nociplastic pain or pain with an inflammatory component. For CBD-only medication, there is substantial evidence for stress, moderate evidence for anxiety and insomnia, and minimal evidence for depression and pain. THC/CBD combination medicines have a good tolerability and safety profile relative to opioid analgesics and have negligible dependence and abuse potential; however, should be avoided in patients predisposed to depression, psychosis and suicide as these conditions appear to be exacerbated. Non-serious adverse events are usually dose-proportional, subject to tachyphylaxis and are rarely dose limiting when patients are commenced on a low dose with gradual up-titration. THC and CBD inhibit several Phase I and II metabolism enzymes, which increases the exposure to a wide range of drugs and appropriate care needs to be taken. Low-dose CBD that appears effective for chronic pain and mental health has good tolerability and safety, with few adverse effects and is appropriate as an initial treatment.
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Affiliation(s)
- Jeremy D Henson
- Prince of Wales Clinical School, University of NSW, Sydney, NSW, 2052, Australia. .,Medlab Clinical Ltd, Sydney, NSW, 2015, Australia.
| | - Luis Vitetta
- Prince of Wales Clinical School, University of NSW, Sydney, NSW, 2052, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Sean Hall
- Medlab Clinical Ltd, Sydney, NSW, 2015, Australia
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Chan A, Silván CV. Evidence-based management of multiple sclerosis spasticity with nabiximols oromucosal spray in clinical practice: a 10-year recap. Neurodegener Dis Manag 2022; 12:141-154. [PMID: 35377770 DOI: 10.2217/nmt-2022-0002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Effective symptomatic management of multiple sclerosis (MS) spasticity remains an unmet need for many patients. The second-line option nabiximols is the most widely investigated of the noninvasive antispasticity medications in this patient population. Clinical evidence accumulated with nabiximols since it was first approved in Europe in 2010 suggests that about 40% of initial responders (i.e., those with ≥20% improvement in their baseline 0-10 Numerical Rating Scale score) may expect to achieve clinically meaningful (≥30% Numerical Rating Scale response) and durable symptomatic improvement in MS spasticity. During 10 years' routine use of nabiximols, no new safety signals have emerged. Nabiximols-associated improvement in MS spasticity-related symptoms such as pain and sleep disruption suggests a need to track possible therapeutic effects beyond muscle tone control.
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Affiliation(s)
- Andrew Chan
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Abyadeh M, Gupta V, Paulo JA, Gupta V, Chitranshi N, Godinez A, Saks D, Hasan M, Amirkhani A, McKay M, Salekdeh GH, Haynes PA, Graham SL, Mirzaei M. A Proteomic View of Cellular and Molecular Effects of Cannabis. Biomolecules 2021; 11:1411. [PMID: 34680044 PMCID: PMC8533448 DOI: 10.3390/biom11101411] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 12/17/2022] Open
Abstract
Cannabis (Cannabis sativa), popularly known as marijuana, is the most commonly used psychoactive substance and is considered illicit in most countries worldwide. However, a growing body of research has provided evidence of the therapeutic properties of chemical components of cannabis known as cannabinoids against several diseases including Alzheimer's disease (AD), multiple sclerosis (MS), Parkinson's disease, schizophrenia and glaucoma; these have prompted changes in medicinal cannabis legislation. The relaxation of legal restrictions and increased socio-cultural acceptance has led to its increase in both medicinal and recreational usage. Several biochemically active components of cannabis have a range of effects on the biological system. There is an urgent need for more research to better understand the molecular and biochemical effects of cannabis at a cellular level, to understand fully its implications as a pharmaceutical drug. Proteomics technology is an efficient tool to rigorously elucidate the mechanistic effects of cannabis on the human body in a cell and tissue-specific manner, drawing conclusions associated with its toxicity as well as therapeutic benefits, safety and efficacy profiles. This review provides a comprehensive overview of both in vitro and in vivo proteomic studies involving the cellular and molecular effects of cannabis and cannabis-derived compounds.
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Affiliation(s)
- Morteza Abyadeh
- ProGene Technologies Pty Ltd., Macquarie Park, Sydney, NSW 2113, Australia;
| | - Vivek Gupta
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
| | - Joao A. Paulo
- Department of Cell Biology, Harvard Medical School, Boston, MA 02115, USA;
| | - Veer Gupta
- School of Medicine, Deakin University, Geelong, VIC 2600, Australia;
| | - Nitin Chitranshi
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
| | - Angela Godinez
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
| | - Danit Saks
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
| | - Mafruha Hasan
- School of Life and Environmental Sciences, University of Sydney, Sydney, NSW 2006, Australia;
| | - Ardeshir Amirkhani
- Australian Proteome Analysis Facility, Macquarie University, Sydney, NSW 2109, Australia;
| | - Matthew McKay
- Bowel Cancer and Biomarker Laboratory, Kolling Institute, Northern Clinical School, The University of Sydney, Sydney, NSW 2006, Australia;
| | - Ghasem H. Salekdeh
- Department of Molecular Sciences, Macquarie University, Macquarie Park, Sydney, NSW 2109, Australia; (G.H.S.); (P.A.H.)
| | - Paul A. Haynes
- Department of Molecular Sciences, Macquarie University, Macquarie Park, Sydney, NSW 2109, Australia; (G.H.S.); (P.A.H.)
| | - Stuart L. Graham
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
| | - Mehdi Mirzaei
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, North Ryde, Sydney, NSW 2109, Australia; (N.C.); (A.G.); (D.S.); (S.L.G.)
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