Lung targeted liposomes for treating ARDS

Acute Respiratory Distress Syndrome (ARDS), associated with Covid-19 infections, is characterized by diffuse lung damage, inflammation and alveolar collapse that impairs gas exchange, leading to hypoxemia and patient’ mortality rates above 40%. Here, we describe the development and assessment of 100-nm liposomes that are tailored for pulmonary delivery for treating ARDS, as a model for lung diseases. The liposomal lipid composition (primarily DPPC) was optimized to mimic the lung surfactant composition, and the drug loading process of both methylprednisolone (MPS), a steroid, and N-acetyl cysteine (NAC), a mucolytic agent, reached an encapsulation efficiency of 98% and 92%, respectively. In vitro, treating lipopolysaccharide (LPS)-stimulated RAW 264.7 macrophages with the liposomes decreased TNFα and nitric oxide (NO) secretion, while NAC increased the penetration of nanoparticles through the mucus. In vivo, we used LPS-induced lung inflammation model to assess the accumulation and therapeutic efficacy of the liposomes in C57BL/6 mice, either by intravenous (IV), endotracheal (ET) or IV plus ET nanoparticles administrations.

Using both administration methods, liposomes exhibited an increased accumulation profile in the inflamed lungs over 48 h. Interestingly, while IV-administrated liposomes distributed widely throughout the lung, ET liposomes were present in lungs parenchyma but were not detected at some distal regions of the lungs, possibly due to imperfect airflow regimes. Twenty hours after the different treatments, lungs were assessed for markers of inflammation. We found that the nanoparticle treatment had a superior therapeutic effect compared to free drugs in treating ARDS, reducing inflammation and TNFα, IL-6 and IL-1β cytokine secretion in bronchoalveolar lavage (BAL), and that the combined treatment, delivering nanoparticles IV and ET simultaneously, had the best outcome of all treatments. Interestingly, also the DPPC lipid component alone played a therapeutic role in reducing inflammatory markers in the lungs. Collectively, we show that therapeutic nanoparticles accumulate in inflamed lungs holding potential for treating lung disorders.

Significance

In this study we compare intravenous versus intratracheal delivery of nanoparticles for treating lung disorders, specifically, acute respiratory distress syndrome (ARDS). By co-loading two medications into lipid nanoparticles, we were able to reduce both inflammation and mucus secretion in the inflamed lungs. Both modes of delivery resulted in high nanoparticle accumulation in the lungs, intravenously administered nanoparticles reached lung endothelial while endotracheal delivery reached lung epithelial. Combining both delivery approaches simultaneously provided the best ARDS treatment outcome.

[Pharmacoresistance to psychotropic drugs in children and adolescents: Pharmacogenetic anomalies of cytochrome P450 2D6]

OBJECTIVES

Some patients in child and adolescent psychiatry present resistance to psychotropic drugs, often resulting in polytherapy, an increased risk of adverse events, and more frequent and longer hospitalisation. Psychotropic drugs are mainly metabolised in the liver, in particular by the CYP2D6 subunit of cytochrome P450. Anomalies such as a duplication of the CYP2D6 gene related to an ultra-rapid metaboliser phenotype has been described to be linked to clinical efficacy. However, little research has been done in child and adolescent psychiatry.

METHODS

A multi-centric cross-sectional study in the southeast of France explored the relation between pharmaco-resistance to psychotropic drugs and the prevalence of duplications or polymorphisms of CYP2D6 associated with an ultra-rapid phenotype in children and adolescents with severe mental health disease.

RESULTS

Twenty-two patients have been included. The presence of an ultra-rapid phenotype concerns one patient in our study. A second patient presents a slow metaboliser phenotype.

CONCLUSIONS

This study allows a clinical characterisation of the population of pediatric drug-resistant patients whose severity and the impact of their pathology are major and require long-term care associated with repeated hospitalisations, multiple drug prescriptions and numerous side effects. However, a link between drug resistance to psychotropic drugs and CYP2D6 UFM abnormalities could not be confirmed. An additional pharmacogenetic analysis by a panel of genes applied in the metabolism, transport and action of psychotropic drugs should be considered to answer questions about the resistance and independent effects of CYP2D6.

[Carbamazepine and psychotropic treatment interaction: Two case studies of carbamazepine overdosage]

Drug interaction is a frequent situation in pediatrics and child psychiatry. Carbamazepine (CBZ) is an antiepileptic drug used as a mood stabilizer in child psychiatry. CBZ is known to be a potent inducer of various CYP isoenzymes of cytochrome P450, which might result in a decrease in the plasma concentration of associated treatments. We describe two cases of CBZ overdosage in adolescent inpatients (14 and 16 years). The patients were treated with risperidone associated with fluoxetine in one and with loxapine in the other case, and CBZ was introduced as a mood stabilizer. Patients presented typical clinical symptoms (fatigue, dizziness, gastrointestinal signs, blurred vision). Overdosage was confirmed by an elevated CBZ plasma concentration (17 and 15.5 mg/L, therapeutic range 4-12 mg/L). We recommend introducing CBZ very progressively in patients treated with psychotropics, particularly when it is associated to several treatments. An intensification of clinical and biological follow-up with early plasma concentration testing should allow for better treatment adjustment.

Pomegranate (Punica granatum) as Host of the Broomrapes Phelipanche aegyptiaca and Orobanche crenata in Israel

Orobanche and Phelipanche, commonly known as broomrape, are dicotyledonous holoparasitic flowering plants that cause heavy economic losses in a wide variety of plant species. Egyptian broomrape (Phelipanche aegyptiaca Pomel.) parasitizes more than 30 food and ornamental crops, including tomato, sunflower, tobacco, chickpea and many others in different parts of the world. Crenate broomrape (Orobanche crenata Forsk.) parasitizes important legume crops, such as lentil, faba bean, chickpea, pea, vetches, and grass pea, as well as some apiaceous crops, such as carrot (4). This is the first report of pomegranate (Punica granatum L.) as a new host for broomrape. This is also the first report of broomrape parasitism on a Lythraceae family member. Because of their high value for human health, the demand for pomegranate fruits has increased tremendously in the last few years and the extent of pomegranate growth has increased significantly in many regions throughout the world. In March 2013, heavy broomrape infection of a 10-year-old pomegranate orchard near the village Kfar Pines was reported. The infected area of about 2 ha was located in the middle of a big pomegranate orchard (variety 116). Broomrape inflorescence counts in the infected area revealed 14 and 0.6 P. aegyptiaca and O. crenata shoots per m², respectively. Both broomrape species were uniformly distributed over all the infected area. No differences of infection rate between the pomegranate trees could be observed. The inflorescences of the two species were normal and healthy and produced germinable seeds. Digging up the inflorescences verified a direct connection between the parasites and the pomegranate roots. The parasite species were identified morphologically according to Flora Europea (2) and Flora Palaestina (3). Detailed description of the two parasites may be found in (4). Identification was confirmed using unique DNA marker based on the photosynthetic gene rbcL of O. crenata. rbcL primers were able to distinguish between the above two species according to differences in PCR products yielding 390 bp for P. aegyptiaca and 300 bp for O. crenata (1). This was the first time that broomrapes had appeared in the orchard since its establishment, on fields that had been intensively used for processing tomato. No legume cropping history in the infected areas is known. It may be hypothesized that the broomrape seeds were dormant in the soil for over 10 years (4).The extremely wet and hot weather conditions of winter 2012/13 induced their germination. A total of 730 mm of rainfall was measured for that year as compared to the annual average of 560 mm for the region. High-level infestations with P. aegyptiaca and O. crenata were also reported from two other pomegranate orchards, Givat Ada and Evron, 11 km west and 81 km north of Kfar Pines, respectively. Neither symptoms nor visible qualitative or quantitative damage could be observed on the infected vs. non-infected pomegranate trees. However, pomegranate appears to be an alternate host for P. aegyptiaca and O. crenata serving as a seed inoculum source for nearby sensitive field crops. References: (1) R. Aly et al. Joint Workshop of the EWRS Working Groups, 29 September - 3 October, Chania, Crete, Greece, 2013. (2) A. O. Chater and D. A. Webb. Orobanche. Page 285 in: Flora Europaea, Vol. 3. T. G. Tutin et al., eds. University Press, Cambridge, 1972. (3) N. Feinbrun-Dothan. Page 210 in: Flora Palaestina, Vol. 3. Israel Academy of Sciences and Humanities, Jerusalem, 1978. (4) D. M. Joel et al., eds. Parasitic Orobanchaceae: Parasitic Mechanisms and Control Strategies. Springer Verlag Berlin Heidelberg, 2013.

[Catatonia in a 14 year-old girl: treatment with clorazepam and carbamazepine, a 10-year follow-up]

INTRODUCTION

Child and adolescent catatonia has been poorly investigated. Moreover, diagnosis criteria only exist for adult psychiatry, and there are no therapeutic guidelines. The aim of this paper is to describe the case of a 14-year-old girl presenting an overlap between psychogenic and neuroleptic induced catatonia, acute treatment and ten year's follow-up.

CASE REPORT

A 14-year-old Caucasian French girl, Elsa, was admitted in February 1998 to a University adolescent mental health center with an acute psychotic disorder. She showed agitation, impulsivity (sudden engagement in inappropriate behaviour), paranoid delusions, visual and auditory hallucinations, diurnal and nocturnal urinary incontinence, lack of self-care, inadequate food intake because of fear of poisoning, and vomiting after meals leading to rapid weight loss of 5 kg. Clinical examination, laboratory tests, EEG and RMI were normal. Toxicological tests were negative. Her IQ, assessed six months before admission, was in the dull average range (70-75). Elsa was treated with loxapine 150 mg per day for one week without improvement and this was then replaced by haloperidol 30 mg per day. One week after the start of haloperidol her agitation, impulsivity, and hallucinatory symptoms decreased. Twenty four days after loxapine introduction and 17 days after the haloperidol, her condition deteriorated rapidly over less than 48 hours. She exhibited immobility, minimal response to stimuli, staring and catalepsy with waxy flexibility. The diagnosis of catatonia was established. Examination revealed tremulous extremities, tachychardia (110 pm) and apyrexia. Creatine phosphokinase levels were 106 UI/l (normal range 0-250). Human immunodeficiency virus, hepatitis, listeria and Lyme serology were negative. Cerebrospinal fluid analysis was normal. Haloperidol was stopped and intravenous clonazepam 5mg/kg was begun. It was not possible to obtain signed consent from the two parents for Electroconvulsive therapy. The patient was transferred to a pediatric intensive care unit. The treatment was standard parenteral nutrition, nursing, intravenous clonazepam 0.05 mg/kg, with regular attendance by a child psychiatrist. Elsa stayed three weeks in this condition. She then began to notice the child psychiatrist, and a few days later she was able to carry out simple requests. Elsa was transferred to an adolescent psychiatric unit. As soon as she could eat by herself again, carbamazepine 400mg per day was begun. Her agitation reduced at a carbamazepine level of 7 mg/l. One month later her condition was stable. However, language difficulties persisted for a further six months. One year after the episode she scored 66 on a repeat IQ test and her RMI was normal. She exhibited no significant residual symptoms except some cognitive impairment. She integrated into a special education facility. These attempts to stop the carbamazepine were followed by depressed mood, aggressiveness and impulsivity; carbamazepine was finally stopped successfully after seven years. Ten years later, Elsa is the mother of two young children and is able to take care of them. She has never had a relapse of her psychotic disorder or catatonic state.

DISCUSSION

The etiopathogenic diagnosis is problematic. Some indices in the familial history may suggest a traumatic event. But one to the total residual amnesia it was never confirmed, and traumatic catatonia are extremely rare. Normal CPK levels, with autonomic disturbance limited to tachycardia and the lack of resolution after discontinuance of medication, argues against a diagnosis of neuroleptic malignant syndrome (NMS). But CPK levels are non specific, and NMS without pyrexia has been described. The occurrence of the catatonic syndrome 21 days after the first dose of a neuroleptic could be diagnostic. This case involved a non organic catatonic psychosis followed by neuroleptic induced catatonia. Catatonia is described as a risk factor for the development of NMS and some consider NMS to be a variant of malignant catatonia. The interest of this report is (1) it reinforces the need to be cautious before prescribing neuroleptics in adolescents presenting with symptoms of catatonia; (2) the complete recovery from catatonia after treatment with intensive care and more than three weeks of intravenous clonazepam without the use of ECT and (3) the effectiveness of carbamazepine over a long period of follow-up. Although trials on carbamazepine in catatonia are published, there are no data available for the control of residual symptoms or the long term prognosis, especially in child and adolescent psychiatry.

First Report of Orobanche crenata Parasitism on Ornamental Anemone (Anemone coronaria) in Israel

Broomrapes (Orobanche spp.) are obligatory parasitic weeds that infect roots of vegetables and field crops worldwide, resulting in severe damage. Orobanche crenata Forsk is common in agricultural fields in the Mediterranean Basin, Southern Europe, and the Middle East and is known as an important scourge of grain and forage legumes and of some Apiaceous crops such as carrot (Daucus carota L.) and celery (Apium graveolens L.) (3,4). To our knowledge, in this note, we report for the first time on Anemone coronaria L. (Ranunculaceae) as a new host for O. crenata and this is also the first report of Orobanche parasitism on a geophytic crop. Anemone (Anemone coronaria L.) is a high-value ornamental crop, which is commercially grown for cut flowers. Four anemone cultivars (Meron Red, Galil White, Jerusalem Blue, and Jerusalem Pink) were planted in September 2006 in a 2-ha field in Israel. The previous crop, broad bean (Vicia faba L.), was heavily infected during 2005 by O. crenata. In February 2007, O. crenata parasitized the anemone plants and developed numerous fertile flowering stalks throughout the field. The four anemone cultivars were equally infected by the parasite. Additional flowering stalks were still emerging on anemone plants during July 2007. Washing the root system clearly verified direct connection between the parasite and anemone roots. The parasite species was identified morphologically after Flora Europea (1) and Flora Palaestina (2). In addition, the stem had the fragrance typical of O. crenata. Neither symptoms nor visible qualitative or quantitative damage could be detected on infected anemone plants compared with noninfected plants. However, anemone appears to be an alternate host on which O. crenata can produce additional seed for the parasite seed bank. References: (1) A. O. Chater and D. A. Webb. Orobanche. Page 285 in: Flora Europaea. T. G. Tutin et al., eds. Vol. 3. University Press, Cambridge, 1972. (2) N. Feinbrun-Dothan. Page 210 in: Flora Palaestina. Vol. 3. Israel Academy of Sciences and Humanities, Jerusalem, 1978. (3) D. M. Joel et al. Hortic. Rev. 33:267, 2007. (4) C. Parker and C. R. Riches. Page 111 in: Parasitic Weeds of the World: Biology and Control. CAB International, Wallingford, Great Britain, 1993.

[For or contra Crédé's method? (author's transl)]

We no longer see newborn gonococcal endophtalmia. In France, it was the direct consequence of practical obligations. As gonococcic infection is growing up all over the world, is it wise to give up every prophylactic procedure? That is the question.