Toxoplasma gondii infects humans and other warm-blooded animals and establishes a chronic infection in the central nervous system after invasion. Studies showing a positive correlation between anti-Toxoplasma antibodies and incidences of brain cancer have led to the notion that Toxoplasma infections increase the risk of brain cancer. However, molecular events involved in Toxoplasma induced brain cancers are not well understood.The obligate intracellular protozoan parasite Toxoplasma gains control of host cell functions including proliferation and apoptosis by channelizing parasite proteins into the cell cytoplasm and some of the proteins are targeted to the host nucleus. Recent studies have shown that Toxoplasma is capable of manipulating host micro RNAs (miRNAs), which play a central role in post-transcriptional regulation of gene expression. Therefore, we hypothesize that Toxoplasma promotes brain carcinogenesis by altering the host miRNAome using parasitic proteins and/or miRNAs.Toxoplasma could be analyzed and compared with that of normal tissues as well as brain cancer tissues from Toxoplasma uninfected individuals to identify dysregulated miRNAs in Toxoplasma-driven brain cancer cells. Identified miRNAs will be further confirmed by studying cancer related miRNA profiles of the different types of brain cells before and after Toxoplasma infection using cell lines and experimental animals.The miRNA expression profiles of brain cancer specimens obtained from patients infected with Toxoplasma infection will be identified.The miRNAs specifically associated with brain cancers that are caused by Toxoplasma infection may promote initiation and progression of cancer by modifying the miRNAome in brain cells. If this hypothesis is true, the outcome of this research would lead to the development of novel biomarkers and therapeutic tools against Toxoplasma driven brain cancers. Toxoplasma gondii infection is one of the most prevalent parasitic infections in humans worldwide and nearly one-third of the population has been estimated to be carrying the parasite[T. gondii transforms into fast replicating tachyzoites and infects various organs of the body including the central nervous system (CNS). To evade host immune response, some of the tachyzoites differentiate in to bradyzoites, which are slow growing and form tissue cysts in the brain[T.gondii tissue-cysts persist for lifetime of the host without provoking any host immune attack[Chronic parasite,2. Upon he brain,4. Durine attack.T. gondii discharges proteins from its secretory organelles which include micronemes, rhoptries, and dense granules. Detection of parasitic proteins with kinase and phosphatase domains in the host nucleus suggests that the parasite modulates the host cell signaling and gene expression[Toxoplasma infection orchestrates the expression of host miRNAs which are deliberated as the key regulators of signaling pathways[Host cell invasion is an active process which is essential for survival and replication of parasites. While invading a host cell, pression. This nopathways.MicroRNAs (miRNAs) are short (19–24 nucleotides) non-protein coding RNAs endogenously regulate gene expression at the post-transcriptional level by binding with target mRNAs that trigger their degradation and/or translational inhibition. A single miRNA can regulate multiple mRNAs; therefore, miRNAs have imperative effects on cell signaling networks,9. SeverToxoplasma is an important non-viral pathogen shown to be associated with the occurrence of brain tumors. Previous investigations have revealed that T. gondii could cause gliomas in experimental animals[Toxoplasma is associated with meningioma. An epidemiological study analyzing data from 37 countries for the incidences of adult brain cancers and Toxoplasma infected people associated a nearly two-fold increase in the risk of brain cancers across the range of prevalence in Toxoplasma infection[Toxoplasma should be investigated further as a possible oncogenic pathogen in humans. A recent work conducted in France showed that mortality rates due to brain cancer correlated positively with the local sero-prevalence of Toxoplasma, particularly in the people who are 55 years of age or older[Toxoplasma is associated with brain cancer, it is unclear how the infection causes this debilitating cancer in humans. In this article, we present a hypothesis that Toxoplasma infection may have the ability to modulate the host miRNAs and could potentially promote the development of brain cancer. animals. Studies animals showed tnfection. These sor older. DespiteToxoplasma has an inherent ability to manipulate host cell signaling pathways and processes by interfering with the global gene expression profiles of the invaded cells[Toxoplasma invasion[Toxoplasma has established several strategies to neutralize the extrinsic and intrinsic cellular suicide programs of the infected cells[Toxoplasma turns host cells resistant to multiple inducers of apoptosis, including Fas-dependent and Fas-independent CTL-mediated cytotoxicity, IL-2 deprivation, gamma irradiation, UV irradiation, and calcium ionophorebeauvericin[Toxoplasma exerts different anti-apoptotic mechanisms for the successful establishment in different cell types[Toxoplasma significantly reduces Fas/CD95-triggered apoptosis by impairing activation of the initiator caspase 8 in type I cells[Toxoplasma targets activation of the pro-apoptotic Bax and Bak to inhibit the apoptogenic function of mitochondria[Toxoplasma infection has been shown to promote the expression of anti-apoptotic proteins: Bcl2, Bfl1, Bcl-Xl, Bcl-w, Mcl-1, Bad and Bax in host cells[Toxoplasma also modulates several cell signaling pathways including AKT and Phosphoinositide 3-kinases (PI3Ks) pathways[ed cells,17. Micrinvasion-20. Duried cells,21. Invauvericin. Toxoplall types,21,22. T I cells. While ichondria. Toxoplast cells-27. Toxopathways,29.Toxoplasma to interfere with the host cell functioning[. In addition, Toxoplasma infection has been shown to specifically increase levels of mature miR-17-92 derived miRNAs in primary human foreskin fibroblasts[Toxoplasma dependent up-regulation of the miR-17-92 promoter is at least partly responsible for this increase.In a search to identify the parasite effector molecules, proteins of rhoptry and dense granule secretory organelles were found to be secreted by the parasite during the invasion, that are capable of modulating host signaling pathways. Interesctioning,30. In aToxoplasma infection[Toxoplasma infection in brain cells could be activating AKT pathways which may result in the development of brain cancer.The miR-17-92 cluster is associated with brain cancers,32. Primnfection, an inteIn addition to miR-17-92, various other miRNAs are critically involved in development and progression of different types of brain cancers,34. GlioToxoplasma genome codes for ostentatious RNA silencing machinery and endogenous small silencing RNAs, including miRNAs[Toxoplasma may be using its own miRNAs to modify host cell functions, analogous to some mammalian viruses encoding their own miRNAs[Toxoplasma associated miRNA dysregulation may be playing a central role in the development of brain carcinogenesis, considering the significance of miRNAs in brain tumor development and progression [FigureFurthermore, the g miRNAs. Toxoplan miRNAs. In viewToxoplasma infection on the host cell miRNAs[Toxplasma may vary based on cell type. Thus the possibility that Toxoplamsa infection can alter expression of several other miRNAs along with miR-17-92 in different types of host cells cannot be ruled out. Therefore, it is essential to study miRNA profiles of various types of Toxoplasma positive brain cancer cells; especially GBM or medulloblastoma, the most prevalent brain cancers.To our knowledge, there is only one study that utilized primary human foreskin fibroblasts to elucidate the effect of l miRNAs. HoweverToxoplasma infection will be first studied. The details of the study have been summarized in FigureToxoplasma infection and the proportion of normal and tumor cells. Commercially available reagents containing concentrated chaotropic salts, such as guanidiniumthiocyanate  followed by silica column extraction will be used to extract high quality miRNA from brain tissue samples. Three major approaches are now commonly used for miRNA profiling: quantitative reverse transcription PCR (qRT-PCR), microarrays and high-throughput RNA sequencing. Additional new methods are emerging which will be applied for miRNA profiling in the future[Toxoplasma infected brain cancer cells. The identified global miRNAs profile will be further validated by qRT-PCR in different brain cell lines and brain cells of experimental animals before and after Toxoplasma infection. In addition, brains of the animals chronically infected with Toxoplasma will be monitored in vivo for malignant transformation and tumor growth using neuroimaging techniques[Toxoplasma driven brain cancer cells could be used as markers to classify these cancers. As briefly outlined, in FigureToxoplasma-modified miRNA expression on survival and death pathways of brain cancer cells. Thus, these studies could be very useful in the development of miRNA-based therapeutics.To test this hypothesis, miRNA profiles of normal brain and cancer tissues collected from brain cancer patients with and without e future. High thchniques,44. The Toxoplasma research has made us aware of the parasite’s ability to manipulate host cell signaling pathways. Though some parasite proteins were identified as effector molecules for this function, the underlying molecular mechanisms of Toxoplasma- mediated brain carcinogenesis are not clearly understood. Our hypothesis predicts that Toxoplasma-modified miRNAs may play a critical role in initiation and progression of brain carcinogenesis, though the outcome of the infection possibly depends on the mode of infection, parasitic strain, type of host cell and miRNA expression patterns of host cell and parasite proteins. If our hypothesis is true, miRNAs critically involved in the Toxoplasma driven cancers could be identified and they could be utilized as novel diagnostic and therapeutic targets. Thus, further research on the specific miRNA pathways affected by Toxoplasma in various brain cells would open new avenues in the diagnosis and treatment of brain cancers caused by Toxoplasma infection.Decades of The authors declare that they have no competing interests.ST, NR and MG developed the hypotheses and contributed to writing the manuscript. All authors read and approved the final manuscript.


The ultimate goal of human genetics is to understand the role of genome variation in elucidating human traits and diseases. Besides single nucleotide polymorphism (SNP), copy number variation (CNV), defined as gains or losses of a DNA segment larger than 1 kb, has recently emerged as an important tool in understanding heritable source of human genomic differences. It has been shown to contribute to genetic susceptibility of various common and complex diseases. Despite a handful of publications, its role in cardiovascular diseases remains largely unknown. Here, we deliberate on the currently available technologies for CNV detection. The possible utility and the potential roles of CNV in exploring the mechanisms of cardiac remodeling in hypertension will also be addressed. Finally, we discuss the challenges for investigations of CNV in cardiovascular diseases and its possible implications in diagnosis of hypertension-related left ventricular hypertrophy (LVH). Genetic variation in human genome exists in different forms, ranging from large, cytogenetically visible chromosomal alterations to submicroscopic variations including structural changes involving insertion/deletion of large DNA segment, segmental duplication, copy number changes and inversion, to the molecular level of presence/absence of transposable elements, variable number of tandem repeat (VNTR), and changes of a single base pair known as single nucleotide polymorphism (SNP).http://www.genome.gov/gwastudies/).SNP was thought to be the predominant form of variation in human genome and accounted for the majority of phenotypic variability . A numbeRecently, an alternative form of genetic variation has gained much interest namely, Copy Number Variation (CNV). Since the first report ,9, it haCNV is recognized as a form of structural variation, involving changes of copy number of a large segment of DNA >1 Kb) composed of duplications, deletions, and complex multi-site variants introduced by non-allelic homologous recombination ,11. It i Kb compoDespite technological limitations in CNV discovery, this genetic marker is estimated to cover ~12 – 15% of the human genome ,14. InteInitially, CNV was thought to be pathogenic to rare genomic disorders ,18,19. HCNV can be detected and analyzed by different technologies, both at the genome-wide scale and the locus specific level. Details of these technologies have been well described ,37.At the genome-wide level, the following methods are predominantly in use currently:i) array-Comparative Genomic Hybridization (aCGH). This assay uses an array of probes where differentially labeled test and reference DNA are jointly hybridized to the array ,37. Deteii) SNP array. Although this assay was originally developed for investigations of single nucleotide variation, it is increasingly being used to mine CNVs, based on the probe intensity information obtained. In SNP array, no reference DNA is being labeled. Instead, CNV is identified via comparing the probe intensities of the test DNA with different individuals. Two major platforms are available in the industry. Affymetrix produces high-density “hybrid” arrays, accommodating 1.8 million of SNP and CNV probes. Whilst the Illumina produces up to 5 million SNP probes in a single array, the highest density in the microarray technology thus far. Whilst SNP array provides both information of SNP and CNV with a higher density, aCGH has a better signal accuracy. Another advantage of SNP array/“hybrid” array over aCGH is its ability to identify the runs of homozygosity (ROH), providing a more informative analysis. ROH is defined as a large DNA segment  with the presence of uninterrupted homozygosity resulting from mutational events such as uniparental disomy (UPD), hemizygous deletion and loss of heterozygosity (LOH) . Often iFluorescent in situ Hybridization (FISH). This approach was initially used to detect various syndromic diseases involving larger scale chromosomal alternations. It hybridizes fluorescently labeled probes to the chromosomal regions showing high sequence complementary, subsequently visualized under fluorescent microscopy. However, one major limitation of FISH in CNV analysis is its low resolution, making it incapable of accurately detecting any CNV smaller than 5 Mb [iii) han 5 Mb , thus reAt the locus specific level, technologies being utilized in CNV quantification of a particular candidate gene including, but not restricted to, Multiplex Ligation-dependent Probe Amplification (MLPA), quantitative PCR (qPCR), and Paralogue Ratio Test (PRT). MLPA utilizes the principle of multiplex PCR and ligation, simultaneously detecting CNV in multiple regions in a single reaction, based on its PCR ligated products. The copy number of the sample is the measurement of the intensity of the product relative to control DNA . qPCR isThe introduction of high throughput next generation sequencing has significantly increased the resolution and sensitivity of CNV detection. However, the cost of experiment is considerably higher and may not be affordable by most laboratories.LVH is an independent risk factor for the development of clinical events such as heart failure, cardiac arrhythmias, stroke and cardiovascular mortality ,44. A reControl of hypertension and reversal of hypertension-related LVH is possible, resulting in improved prognosis. Identification of patients at risk for developing hypertension-related LVH may lead to early interventions to prevent its development, hence avoiding its sequelae and complications. This may further improve the prognosis and help increase adherence to treatment among these patients. Thus early diagnosis and improved understanding on the pathogenesis of LVH may lead to more effective therapeutic strategies .2+ triggers the calcineurin-calmodulin pathways, which activates various transcription factors including nucleus factor activated T cell (NFAT) and myocyte enhancer factor 2 (MEF2), JNKs, and GATAs [+/Ca2+-exchanger (NCX), and Na/H–exchanger (NHE) pathways. Activation of NHE pathway results in increased Na+, thus increasing the Ca2+ influx via NCX pathway, and initiating cardiac hypertrophy signaling. At the same time, NFAT transcription factor, which was triggered by calcineurin, interacts with the ANP/BNP pathways [The molecular and biochemical pathways of LVH pathogenesis have been well described ,47,50-52nd GATAs ,47,50,52pathways . Other sLVH can be reversed by specific anti-hypertensive agents. Losartan, an angiotensin receptor blocker, has shown clinical benefit of this reversal beyond controlling the blood pressure . AlthougSeveral observations can be made based on the genetic studies of LVH:i) Selection of candidate genes solely based on an understanding of the biochemical roles of encoded proteins is not comprehensive thus may lead to inappropriate selection of candidate genes or SNPs. Therefore, an unbiased approach (often with multiple hypotheses) such as genome-wide screening  is alwayth percentile versus the 90th percentile of the LV wall thickness measurement [ii) Precise phenotyping. The first generation of GWAS completed by the Wellcome Trust Case–control Consortium (WTCCC) failed to achieve a genome-wide significant level in hypertension  and up tsurement ,68.iii) Common traits  may be controlled by many genes or loci , each accounts a small portion of additive genetic effects on the phenotype. These common variants do not contribute to immediate effect to the deleterious phenotypes, rather to late onset common and complex diseases .iv) “Missing heritability”. The fact that the “unexplained reason(s)” of the relatively small fraction of individual disease risk (modest odd ratio of ~1.1-1.5) suggest that there are missing puzzles when explaining the trait heritability ,71. Instde novo CNVs are not counted - at least not with the current genotyping platform (except for next generation sequencing) because they normally do not follow the Mendelian inheritance. In addition, CNV allelic size is often not “taggable” by these SNPs [v) The influence of other forms of genome variations such as CNV. The potential of this variability is yet to be fully explored, therefore its impact on common diseases such as hypertension-related LVH is largely unknown. There has been arguments though, that common CNV is typable by tagSNP, therefore they contribute limited risk factor to disease susceptibility ,72. Howeese SNPs . Typicalese SNPs ,30-32,73http://projects.tcag.ca/variation/) (date: 17th May 2012)  could be developed in clinical practice.Investigations of CNV in complex diseases, while tempting, are still in its developing stage. Several challenges are noted currently and expected to resolve in the near future, especially with the availability of the massively parallel high throughput sequencing:i) Lack of replication in CNV callings and reference samples for comparison of results. Multiple commercial arrays available for CNV detection, each with different resolutions and analytic algorithms, bias towards the advantage of its own technology. This leads to a poor replication when reporting CNV, and lack of a standardized reference sample set further complicates the analysis efforts .ii) Limitation of the current array based technology . Due to limitation of the chemistry, the array-based platforms only allow CNV detection of gain or loss of two copies (CN = 0 – 4). Thus, analysis of multiple or complex CNV has always been a challenge.In view of the above mentioned difficulties, CNV is usually called by three algorithms, and the consensus of at least two is defined as “stringent” CNV call . In addiiii) Identification of precise breakpoint is a common issue of CNV study. Often, the non-identical, but overlapping copy number alleles is being assigned into one category, or being misinterpreted as the same allele. This will definitely affect tests of association between variation and disease, as different breakpoints may result in different biological consequences. DNA sequencing of the region of interest may resolve this problem. However, it is laborious in Sanger sequencing for such purpose ; the cosiv) Careful interpretation of the complex CNV data in both research and medical decision-making is essential especially when dealing with complex diseases. How CNV results are applied to research or medical decision-making needs to be considered according to the circumstances where it is observed especially with the awareness of interactions between single nucleotide alterations and CNVs . Unexplav) The need for an established database, both for “healthy” populations , or disease cohort (such as DECIPHER) will be essential, cataloging the information of genic content of the variant segment ,82. Thisvi) Cost consideration versus selection of technology. Effective running cost and ease of assay typing have always been the major hindrance for clinicians in CNV analysis. Although the cost for an array-based global CNV screening has dropped, it is unaffordable by most patients especially those from the lower income community. Although locus specific CNV genotyping assays are more cost effective, lower resolution and limited information obtained (as discussed in the earlier section) from such assays is a drawback. Therefore, comprehensive CNV mapping and identification of pathogenic CNV in LVH is needed to ensure that the findings be translated into clinical practice in the most cost effective manner.Molecular cardiological research with CNV provides ample possibilities for the development of more cardiac-specific pharmaceutical interventions, which could be tailor made to the pathology and genetic make-up of the individual patient. The application of CNV in complex diseases will continue to grow while array based technology will remain as the mainstay in the next future. Ongoing development of technological and sophisticated statistical tools in CNV analysis should warrant the extensive investigation of the genetics of LVH. However, the growth of this research area is still in its infancy stage and far from translating into medical implication, thus efficacy of such an approach should be carefully interpreted.The authors declare that they have no competing interests.HBP and KY wrote and edited the paper. All authors read and approved the final manuscript.


The management of patients with brain metastases from breast cancer continues to be a major clinical challenge. The standard initial therapeutic approach depends upon the size, location, and number of metastatic lesions and includes consideration of surgical resection, whole-brain radiotherapy, and stereotactic radiosurgery. As systemic therapies for control of extracranial disease improve, patients are surviving long enough to experience subsequent progression events in the brain. Therefore, there is an increasing need to identify both more effective initial treatments as well as to develop multiple lines of salvage treatments for patients with breast cancer brain metastases. This review summarises the clinical experience to date with respect to cytotoxic and targeted systemic therapies for the treatment of brain metastases, highlights ongoing and planned trials of novel approaches and identifies potential targets for future investigation. Historically, brain metastases were associated with very poor survival . While bBrain metastases are diagnosed in approximately 15% of unselected patients with advanced breast cancer . Over tiIn historical series, the median survival of unselected patients with breast cancer brain metastases treated with whole-brain radiotherapy (WBRT) has been reported at approximately five to six months . More reA full discussion of the current standard of care approaches is outside the scope of this review. Treatment guidelines for patients with brain metastases from solid tumours are available through the National Comprehensive Cancer Network (NCCN) and professional societies , 21. BecIn general, the initial management of patients with brain metastases depends on (a) the number, size, and location of brain lesions; (b) the presence or absence of neurological symptoms; (c) the patient’s performance status and medical comorbidities; (d) the status of systemic metastases; (e) the availability of systemic treatment options; and (f) patient preference. In general, initial management will include some combination of surgical resection, radiosurgery, and/or WBRT, depending on the above factors. Systemic therapy could be a consideration either on a clinical trial, in the context of minimal CNS disease burden with rapidly progressive extracranial disease, or in select, well-informed patients as an alternative to localised therapies with close follow-up . Among patients who have developed subsequent CNS progression after initial standard therapy, options include surgical resection, WBRT, stereotactic radiosurgery (SRS), off-label use of systemic therapy, consideration of a clinical trial, or best supportive care. Options will vary based on prior treatments received, response to prior treatments, location and number of the new or progressive CNS lesions, and the other patient and disease-related factors as listed above. For both initial and subsequent management decisions, a multidisciplinary approach is essential in making recommendations based upon an assessment of the patient in the context of their local therapy options, extracranial disease status, planned or ongoing systemic therapy, and clinical trial options.At present, there are no FDA-approved systemic therapies for the treatment of breast cancer brain metastases. A number of small, prospective trials of cytotoxic chemotherapy have been completed and are summarised in n=5) to participate. No objective responses were observed and the study was closed to further accrual due to lack of sufficient activity. A dose-dense temozolomide regimen has also been evaluated in a phase II study of solid tumour patients (n=51 with breast cancer) [Temozolomide has been examined in a phase II trial of the National Cancer Institute of Canada Clinical Trials Group (NCI-CTG) . This tr cancer) . The objCapecitabine is an active agent in patients with MBC. With respect to breast cancer brain metastases, capecitabine has been evaluated in a phase I study in combination with temozolomide, with a reported response rate of 18% . CNS actPlatinum agents have also been prospectively evaluated, although in combination with other cytotoxic agents rather than as monotherapy. In a phase II study evaluating the combination of cisplatin and temozolomide, six out of 15 (40%) of breast cancer patients achieved a partial CNS response . For theEpothilones are tubulin-stabilising agents with activity against multiple solid tumours. At present, only ixabepilone is commercially available and is approved for the treatment of refractory MBC. Negative results of a trial in patients with primary brain tumours and the existence of investigation alepothilones with excellent blood–brain barrier (BBB) permeability have limited efforts to formally test the effects of ixabepilone in patients with breast cancer brain metastases . SagopilFinally, some regimens, while not evaluated in prospective clinical trials, have reported efficacy in case series and include CMF , anthracycline-based regimens and high-dose intravenous methotrexate , 34.Endocrine therapies remain the oldest and most established targeted treatments for the management of patients with breast cancer. In the setting of CNS disease, there have been multiple case reports describing responses to tamoxifen, aromatase inhibitors and megestrol acetate, although no prospective trials have been conducted –37. Unfoet al, Lancet Oncology, in press) [Trastuzumab does not appear to cross the intact BBB . Althougn press) . ResultsLapatinib plus capecitabine has also been compared with trastuzumab plus capecitabine in the CEREBEL trial, with a primary endpoint of the development of CNS metastases . Of noteDespite some notable advances in recent years, there remains much progress to be made. Commercially available treatment options for patients with progressive brain metastases after surgical or radiotherapy approaches remain limited, and there are still no systemic regimens that have gained a formal indication in this setting. Fortunately, the landscape is changing. There are a number of novel agents of interest and an increasing number of trials designed to evaluate the efficacy of these compounds in the CNS .The ideal agent would reach therapeutic concentrations in the brain, be active against breast cancer in both intracranial and extracranial sites (including in patients who have received multiple prior lines of systemic therapy), have a favourable toxicity profile, and demonstrably benefit patients. Two examples are the third-generation taxane TPI-287 and the peptide-taxane conjugate GRN1005. TPI-287 is a microtubule-stabilising agent designed to circumvent the MDR-1 drug efflux resistance mechanism and is also highly permeable across the intact BBB. In a preclinical model using intracardiac injection of 231-BR cells, treatment with TPI-287 inhibited outgrowth of brain metastases, an effect that was not seen with paclitaxel, ixabepilone, or nab-paclitaxel . GRN1005In light of the activity observed with lapatinib, other HER2-directed tyrosine kinase inhibitors are also being evaluated for CNS activity. For example, neratinib has been evaluated in phase II trials in HER2-positive MBC patients for the treatment of extracranial disease. Approximately half of patients treated in the first-line setting achieved an objective response; in the refractory setting, the response rate was 24%, with a median PFS of 22 weeks . Based oBeyond HER2, other targets of interest include tumour-associated angiogenesis, the PI3K/mTOR pathway, and the DNA repair pathway. With respect to angiogenesis, it is well documented that breast cancer brain metastases are highly angiogenic and associated with abnormal tumour-associated vasculature . In precAnother pathway of considerable active interest in breast cancer is the PI3K/mTOR pathway. Earlier this year, everolimus, a rapamycin analogue that inhibits mTOR signalling, was approved in combination with exemestane for patients with ER-positive MBC, on the basis of a randomised trial demonstrating a substantial improvement in PFS . In a raIn tandem with ongoing studies evaluating mTOR inhibitors in breast cancer, there is a tremendous amount of effort being placed in evaluating pan- and alpha-specific PI3 kinase inhibitors. Approximately one-third of HER2-positive breast cancers contain a PIK3CA somatic mutation, and PTEN loss is present in up to half of triple-negative breast cancers . PIK3CA Finally, although the enthusiasm for PARP inhibitors waned somewhat with the presentation of the negative phase III iniparib trial, it now appears that iniparib is not a true PARP inhibitor . Other PAmong patients with leptomeningeal metastases, breast cancer is the most commonly represented solid tumour . Still, There are very few prospective trials to guide therapy. Unfortunately, survival remains poor across breast cancer subtypes . Intrathwww.clinicaltrials.gov; NCT01373710, NCT01325207) [From an investigational standpoint, given that HER2 amplification appears to be retained in patients with HER2-positive primary tumours and leptomeningeal involvement, intrathecal trastuzumab is the subject of two ongoing prospective trials in France and in the United States (1325207) . A numbe1325207) –89. At p1325207) . Newer a1325207) –93.Patients with brain metastases have historically been excluded from the vast majority of clinical trials in cancer. As patients with brain metastases are included in trials and as more trials are opened that specifically assess the CNS efficacy of novel treatments, there is an increasing need to standardise response criteria for assessment of brain metastases. Because neither the RECIST nor Macdonald criteria were developed for the specific purpose of evaluating patients with CNS metastases, there are some gaps and inconsistencies in how they are applied in brain metastasis studies, and many groups have either modified the criteria or developed new criteria. The Response Assessment in Neuro-Oncology (RANO) Metastatic Working Group is currently taking on the task of formulating new response guidelines in an effort to reduce this heterogeneity across studies.A traditional clinical trial paradigm has been to evaluate novel systemic approaches in the refractory setting  in patients with measurable disease and with objective response as the primary endpoint. Provocative data in a small study of patients treated with lapatinib and capecitabine as upfront therapy for HER2-positive brain metastases raise the question of whether systemic therapy might someday take the place of radiotherapy-based approaches and raise difficult questions as to what type of data would be required to comfortably make that shift . In partAnother trial design that has been proposed is to consider ‘secondary prevention’; that is, to assess the ability of novel approaches to prevent further CNS progression among patients with a limited number of brain metastases treated with SRS alone. To date, there have not been any clinical breast cancer studies utilising this model, although there is significant interest in launching such a study. Ultimately, it would be ideal to develop therapies that could prevent the occurrence of brain metastases altogether. For example, in preclinical models, targeting of polo-like kinase 1, α(V)-integrins, b-raf, and histone deacetylase decreases brain metastatic outgrowth and could be potentially directed translated into clinical trials in the future –98.Breast cancer brain metastases continue to pose a difficult challenge for patients and clinicians. For the majority of patients, the most appropriate initial therapy remains a radiotherapy-based approach, although select patients may benefit from surgery, and systemic therapy could be considered in some circumstances. Although there are still no systemic therapies with an FDA indication for the treatment of breast cancer brain metastases, there is emerging evidence of activity of a number of regimens, and there are an increasing number of clinical trials targeting this patient population.


Articular cartilage defects do not regenerate. Transplantation of autologous articular chondrocytes, which is clinically being performed since several decades, laid the foundation for the transplantation of genetically modified cells, which may serve the dual role of providing a cell population capable of chondrogenesis and an additional stimulus for targeted articular cartilage repair. Experimental data generated so far have shown that genetically modified articular chondrocytes and mesenchymal stem cells (MSC) allow for sustained transgene expression when transplanted into articular cartilage defects in vivo. Overexpression of therapeutic factors enhances the structural features of the cartilaginous repair tissue. Combined overexpression of genes with complementary mechanisms of action is also feasible, holding promises for further enhancement of articular cartilage repair. Significant benefits have been also observed in preclinical animal models that are, in principle, more appropriate to the clinical situation. Finally, there is convincing proof of concept based on a phase I clinical gene therapy study in which transduced fibroblasts were injected into the metacarpophalangeal joints of patients without adverse events. To realize the full clinical potential of this approach, issues that need to be addressed include its safety, the choice of the ideal gene vector system allowing for a long-term transgene expression, the identification of the optimal therapeutic gene(s), the transplantation without or with supportive biomaterials, and the establishment of the optimal dose of modified cells. As safe techniques for generating genetically engineered articular chondrocytes and MSCs are available, they may eventually represent new avenues for improved cell-based therapies for articular cartilage repair. This, in turn, may provide an important step toward the unanswered question of articular cartilage regeneration. In the early 1990s, Christopher H. Evans proposed and implemented the idea of using genetically modified cells for the treatment of arthritis . This stAn articular cartilage defect is an area of damaged or missing cartilage. Although often caused by acute trauma, cartilage defects may also occur as a result of osteoarthritis, osteonecrosis, osteochondritis dissecans, and other pathologies . While tSymptomatic cartilage defects require surgical treatment. Treatment options include marrow-stimulating techniques such as microfracture, Pridie drilling and abrasion arthroplasty, autologous chondrocyte transplantation, and the transfer of both autologous or allogeneic osteochondral transplants . AutologThe aim of this review is to outline options for genetic manipulation of target cells for articular cartilage repair, primarily articular chondrocytes and MSCs, and the current progress in adapting strategies based on chondrocyte transplantation for the delivery of genetically-modified cells for clinical use to treat focal articular cartilage defects and osteoarthritis.In the past two decades, articular chondrocytes and MSCs have been successfully transplanted into articular cartilage defects in patients, with the aim of improving articular cartilage repair. MSCs display some advantages compared with differentiated cells that make them attractive targets for manipulation in the goal of cartilage and bone regeneration. They can be easily isolated in a noninvasive and abundant manner from various tissues like the bone marrow, bone, adipose tissue, muscle, synovium, periosteum, and perichondrium ). They hGene transfer using various reporter gene sequences has been successfully achieved in all these cell types by application of either nonviral compounds -20 or ofKey principles applied for gene-based approaches include the stimulation of anabolic pathways to enhance chondrogenesis, eg, cell proliferation and synthesis of extracellular matrix and the inhibition of catabolic pathways to prevent degradation  7). Amo. Amo7). Transplantation of genetically engineered articular chondrocytes onto articular cartilage explants allows for the repopulation of articular cartilage and the creation of chimerical articular surfaces in vitro ,70,79,80The new tissue that forms is characterized by the presence of type-II collagen and proteoglycans and by the absence of type-I collagen. In this model, transplantation of chondrocytes overexpressing BMP-7 resulted in a thicker new tissue layer . OverexpGene transfer of transcription factors has received recent interest because of the impact of these molecules on chondrogenesis. Overexpression of SOX9 via retroviral transduction was shown to stimulate type-II collagen expression in pellet cultures of human osteoarthritic articular chondrocytes  and in hIn this section, a number of recent studies in the field of articular cartilage repair are highlighted, with an emphasis on preclinical approaches that appear to hold most promises for a possible clinical translation.Transplantation of genetically modified cells into articular cartilage defects in vivo has been performed in three-dimensional systems, including cell aggregates such as coagulated bone marrow aspirates , by enca7 cells/24 hours .A prerequisite for the transplantation of genetically modified cells for articular cartilage repair is their capability to secrete pharmacologically active amounts of the recombinant protein . Yet, th24 hours , while 9ransgene , less thelection . Normal Transgenes expressed via such ex vivo strategies remained active for about one month in the cartilage defects, significantly longer compared with the application of recombinant proteins. One of the earliest examples was provided by Mason et al who transferred the BMP-7 growth factor gene into a focal defect using periosteal cells transduced with a retroviral vector attached to a polyglycolic acid scaffold . As showMore recently, Ivkovic et al  implanteTaken together, the current literature supports several conclusions illustrating the recent progress that has been made in developing approaches for the transplantation of genetically modified cells  as a therapeutic option for human articular cartilage defects. First, there is convincing proof of principle that articular chondrocytes and MSCs modified by different nonviral and viral approaches can be transplanted into articular cartilage defects in vivo, allowing for sustained and clinically relevant transgene expression levels. Second, overexpression of therapeutic proteins enhances the structural features of the repair tissue of the articular cartilage and subchondral bone, being superior to unmodified or mock-transduced/-transfected cells. Third, combined overexpression of genes with complementary mechanisms of action  is feasible, holding promises for further enhancement of articular cartilage repair. Fourth, significant benefits have been observed in preclinical animal models that are, in principle, more appropriate to study the situation in patients.Ex vivo modified cells may be also applied for the resurfacing of the disrupted cartilage matrix in early stages of osteoarthritis. When transplanted onto the surface of osteoarthritic human cartilage, the modified chondrocytes may fill the gaps between the fissures, cracks, and other surface discontinuities . Since oBaragi et al were the first to show that transplantation of human osteoarthritic chondrocytes transduced with adenoviral vectors to overexpress the human IL-1Ra onto the articular surface of osteoarthritic cartilage explant cultures was capable of protecting the cartilage from IL-1-induced extracellular matrix degradation . RemarkaE.coli lacZ gene onto the articular surface of human osteoarthritic cartilage explant cultures 4. the delivery without  or with a supportive biomaterial ,5. the establishment of the optimal cell dose.For traumatic cartilage defects, single or combined overexpression of therapeutic genes, including growth and transcription factors, is feasible and results in structural improvements. Significant data have been collected in animal models of chondral and osteochondral defects. For osteoarthritis, transplantation approaches using genetically engineered cells have been less developed. Ex vivo models have already convincingly shown that genetically modified chondrocytes adhere to human osteoarthritic cartilage explants, and that inhibition of matrix degradation is possible. Animal studies using genetically modified cells for the treatment of osteoarthritis have mainly relied on the intra-articular injection of these cells, making a specific targeting of osteoarthritic areas difficult. Moreover, it remains to be seen whether areas of cartilage loss may be repopulated by such approaches, considering that the nature of the osteoarthritic loss of articular cartilage is unknown and since a simple injection of cells alone does not address other factors involved in the pathogenesis of osteoarthritis such as mechanical overload induced by axial malalignment.Several gene transfer systems are capable of successfully modifying articular chondrocytes and MSCs, the two most promising cell types for transplantation approaches. However, each of the individual vector system has intrinsic limitations with regard to their efficacy  and safety  for human clinical applications. Most experts predict that initial human gene therapy trials based on the transplantation of genetically modified cells for articular cartilage repair will be conducted using rAAV vectors. The development of novel (third generation) adenoviral vectors may be another option, although significantly less immunogenic responses might be elicited when using rAAV. Vectors showing a capacity for site-specific integration have been designed for the purpose of achieving long-term gene expression, such constructs have not been tested yet in articular cartilage repair settings.Supportive biomaterials may be used to deliver the genetically modified cells to focal articular cartilage defects, similar to the current clinical practice of treating cartilage lesions with matrix-assisted autologous chondrocyte transplantation, a technique in which the articular chondrocytes are attached to different types of scaffolds, eg, based on collagen types I/III, hyaluronic acid, polyglactin/poly-p-dioxanon, and fibrin-hyaluronan . Such a Possible side-effects have also to be considered. While intra-articular injection of an BMP-2 adenoviral vector resulted in the formation of osteophytes and spread of the vector DNA to the liver, lung, and spleen, no such effects were observed when an ex vivo approach was selected injecting modified cells overexpressing BMP-2 instead . In factThe selection of therapeutic genes to specifically address individual parameters of chondrogenesis will continue to be a challenge. Progress may come from more insights into the regulation of chondrogenesis, eg, using genomic and proteomic profiles.6 cells/cm2. When genetically modified articular chondrocytes overexpressing IGF-I were applied in a lapine model, about 75 × 106 cells/cm2 were applied, a 75-fold higher dose (6 (low dose), 1.5-5 × 106 (intermediate dose), and 6.5-10 × 106 (high dose) autologous synovial fibroblasts transduced with a retroviral vector encoding for an IL-1Ra cDNA were injected into metacarpophalangeal joints  and clinical knowledge (in the case of articular chondrocytes transplantation) and, as a result, to translate these progresses into clinical medicine is finally to establish a safe and efficient production line, including vector manufacturing, cell isolation, and genetic modification that meets all regulatory requirements.Ultimately, the clinical potential for genetically modified articular chondrocytes and MSCs for the treatment of articular cartilage defect is likely to be realized by advances in the following areas: 1) development of a safe, highly efficient gene delivery system with sustained duration of transgene expression, 2) identification of optimal therapeutic gene(s), 3) combination of genetically modified articular chondrocytes and/or MSCs with scaffolds that better support chondrogenesis in vivo. After safe techniques for generating these genetically engineered cells are available, such cells may eventually provide new avenues for improved cell-based therapies for articular cartilage repair. This, in turn, may provide a crucial step toward the unanswered question of articular cartilage regeneration.


Sleep facilitates the consolidation of fear extinction memory. Nightmares and insomnia are hallmark symptoms of posttraumatic stress disorder (PTSD), possibly interfering with fear extinction and compromising recovery. A perpetual circle may develop when sleep disturbances increase the risk for PTSD and vice versa. To date, therapeutic options for alleviating sleep disturbances in PTSD are limited.n=14) comparing the effect of prazosin and placebo on sleep disturbances in veterans with PTSD. In addition to these studies, we systematically reviewed the literature on treatment options for sleep disturbances in PTSD.We conducted three studies to examine the relationship between sleep and posttraumatic symptoms: (1) a prospective longitudinal cohort study examining the impact of pre-deployment insomnia symptoms and nightmares on the development of PTSD; (2) a cross-sectional study examining subjective sleep measures, polysomnography, endocrinological parameters, and memory in veterans with PTSD, veterans without PTSD, and healthy controls (HCs); (3) a randomized controlled trial (RCT)  levels, negatively correlated with growth hormone (GH) secretion, and the subjective perception of sleep depth. Also, heart rate was significantly increased in PTSD patients. Interestingly, plasma levels of GH during the night were decreased in PTSD. Furthermore, GH secretion and awakenings were independent predictors for delayed recall, which was lower in PTSD. In our RCT, prazosin was not associated with improvement of any subjective and objective sleep parameters. Only a few RCTs have been published. They show promising results for atypical antipsychotics and prazosin, the latter especially on nightmare reduction.Disturbed sleep due to nightmares increases the risk for PTSD. PTSD in turn leads to increased sleep fragmentation, decreased GH secretion, and frequent nightmares, which may again compromise fear extinction, synaptic plasticity, and recovery. This suggests that disturbed sleep is a precipitating and perpetuating factor in PTSD symptomatology, creating a perpetual circle. This dissertation suggests that activity of the hypothalamic–pituitary–adrenal axis and the sympathetic nervous system (SNS) is involved in disturbed sleep in patients with PTSD. This dissertation focuses on sleep in patients with a combat-related posttraumatic stress disorder (PTSD). Nightmares and insomnia are highly prevalent in patients with PTSD , enhances the process of fear extinction. Longitudinal studies have reported an association between sleep disturbances in the early aftermath of trauma and the development of PTSD  has been reported in patients with PTSD  axis and locus coeruleus (LC)/noradrenergic system is altered, which may be responsible for overstimulation of the amygdala and related limbic structures in the brain, as well as dysregulation of the negative feedbacks system that need to dampen stress responsivity  during sleep and the nocturnal secretion of melatonin, cortisol, and ACTH altered in PTSD and is this related to decreased objective and subjective sleep quality?What is the relationship between objective sleep parameters according to polysomnography and subjective sleep quality in patients with PTSD?Are growth hormone (GH) secretion and memory formation disturbed by PTSD and is this due to decreased objective sleep quality?1-adrenoceptor antagonist, on objective and subjective sleep quality in PTSD when compared to a placebo?What is the effect of prazosin, an αThis dissertation consists of several experimental studies designed to answer the following questions regarding the relationship between sleep and PTSD:Chapter 2 shows that nightmares, but not insomnia, are associated with an increased risk of developing PTSD symptoms after military deployment. This has been studied in a sample of 453 military service members who were deployed to Afghanistan. Screening for sleep disturbances and nightmares pre-deployment may contribute to early identification of those at risk of developing PTSD symptoms.Chapter 3 shows that disturbed sleep due to obstructive apneas may exert a negative effect on PTSD symptoms as PTSD patients with OSAS have more severe PTSD complaints. Obstructive sleep apnea (OSA) is not more common in patients with PTSD compared to trauma controls (TCs) and HCs.Chapter 4 shows that sleep is more fragmented and HR is increased in patients with PTSD compared to TCs and HCs. In this study, polysomnographic registrations and 20 min blood samples were obtained simultaneously. Plasma ACTH, cortisol, and melatonin concentrations are not significantly altered in PTSD, while a trend is seen for lower cortisol levels in the first half of the night. ACTH is positively related to the number of awakenings. Furthermore, ACTH is inversely related to the amount of slow wave sleep (SWS). Patients with PTSD exhibit a significantly decreased cortisol:ACTH ratio (CORT: ACTH) upon awakening compared to TCs. TCs demonstrate an increased CORT:ACTH during the night compared to both PTSD patients and HCs, suggesting an increased response of the adrenals upon ACTH stimulation under baseline conditions in veterans without lifetime psychiatric disorders.Chapter 5 shows that PTSD patients have lower GH levels during the night. Fragmented sleep is inversely related to GH secretion. Noticeably, overnight memory consolidation is inversely related to awakenings. A positive relationship between memory recall and GH secretion has been observed.1-antagonistic properties.Chapter 6 comprises a systematic review, showing that pharmacotherapeutic options for sleep disturbances in PTSD have not been extensively studied with RCTs. So far, best results have been described in small RCTs investigating drugs with αn=6) has no effect on the number of awakenings or other PSG parameters and sleep diary measurements compared with placebo (n=6) in a small RCT. Significantly, more side effects occur after prazosin treatment.Chapter 7 shows that treatment of sleep symptoms in PTSD patients with prazosin  receptor-mediated synaptic currents decreased in hippocampal neurons. Moreover, NMDA receptor loss was observed, as was a decline in long-term potentiation. These processes normalized when GH injections were administered during sleep deprivation. Reduced GH secretion may possibly be related to decreased hippocampal functioning in patients with PTSD. The relationship between treatment response to a selective serotonin reuptake inhibitor (SSRI) and neurogenesis in the hippocampus was reported in a preclinical study . Both cortisol and ACTH levels were correlated with SWS, while in a regression analysis only ACTH was an independent predictor for SWS. Interestingly, ACTH levels also correlated positively with the number of awakenings. ACTH secretion is stimulated by CRH activity. The correlation between ACTH and both SWS and awakenings may therefore be indicative for CRH being involved in waking and SWS regulation in PTSD. CRH is known to inhibit SWS and increase awakening during sleep  is innervated by the LC. Noradrenergic activity stimulates awakening by stimulating the ascending reticular arousal system (ARAS) and inhibiting sleep-promoting ventrolateral preoptic nucleus (VLPO) activity , with short treatment periods of 1 week, have been conducted  sleep in relation to a reduction in nightmare complaints.A meta-analysis including all RCTs on prazosin using polysomnography should be performed to further analyze the effect of prazosin on objective sleep quality in PTSD. However, polysomnography may not be a suitable method for detecting the underlying mechanism of nightmares in PTSD. Alternative methods may further elucidate the suggested effect of blocking α1-adrenoceptor antagonists doxazosin and alfuzosine, may be useful. However, RCT is warranted to assess the efficacy of doxazosin and alfuzosine in PTSD-related sleep disturbances. Also sleep-focused psychotherapy may not always be available to PTSD patients, as not all psychologists and psychiatrists are familiar with these interventions. The choice of treatment depends on the preference of the patient and availability of therapeutic options.In summary, prazosin and atypical antipsychotics are effective in the treatment of PTSD-related sleep complaints. However, prazosin does not increase the risk of a metabolic syndrome and has therefore a more favorable side effect profile. One RCT showed that sleep-focused behavioral therapy was as effective as prazosin on both insomnia and nightmares. Imaginary rehearsal therapy (IRT) is also effective for those suffering from nightmares, but cannot be applied in those without dream content recall. Prazosin treatment, IRT, and sleep-focused cognitive behavior therapy (CBT) are all effective for treating sleep disturbances  are hyperresponsive in PTSD patients, who demonstrate exaggerated responses to dexamethasone administration (de Kloet, Vermetten, Heijnen et al., Future research investigating stress and posttraumatic symptoms should focus on the dynamic characteristics of the HPA-axis, for instance, calculating CORT:ACTH ratios. In addition, sensitivity and upregulation of receptors involved in the HPA-axis should be further explored.Sleep has been studied with polysomnography in the early days of PTSD research. However, the lack of objective findings in PSG studies urged the need to develop alternatives for measuring sleep in patients with PTSD. This dissertation shows that sleep in patients with PTSD is characterized by frequent awakenings at night, according to polysomnographic registrations. The number of awakenings in patients with PTSD is associated with HPA-axis functioning, subjectively perceived sleep, and, interestingly, GH secretion and memory consolidation. Furthermore, this dissertation supports the idea that disturbed sleep exerts a negative effect on PTSD symptomatology. First, nightmares before military deployment predicted PTSD symptom development, independently early life trauma, mood, and anxiety symptoms. Second, a positive correlation was observed between PTSD severity and the number of sleep apneas, which may indicate an increase in PTSD symptoms when sleep quality is compromised by external factors. Our results suggest that disturbed sleep increases the risk for PTSD. PTSD, in turn, leads to increased sleep fragmentation, decreased GH secretion, and frequent nightmares, which may again compromise fear extinction, synaptic plasticity, and recovery. This suggests that disturbed sleep is a precipitating and perpetuating factor in PTSD symptomatology, possibly creating a perpetual circle.Longitudinal studies are warranted to investigate whether the differences in sleep fragmentation, GH secretion, and increased HR during sleep, found in our cross-sectional studies, are “trait or state” phenomena. In addition, more research is needed to further investigate the effects of sleep disruptions on fear extinction memory consolidation. New approaches are advised, such as combined functional MRI/EEG studies to elucidate brain activation patterns and functional connectivity during sleep. More studies investigating sleep-dependent neuroplasticity and growth factors during sleep are also needed to further explore whether sleep disturbances affect biological underpinnings of psychiatric disease and recovery through the effect of sleep on synaptic plasticity.


The unique ability of centrosomes to nucleate and organize microtubules makes them unrivaled conductors of important interphase processes, such as intracellular payload traffic, cell polarity, cell locomotion, and organization of the immunologic synapse. But it is in mitosis that centrosomes loom large, for they orchestrate, with clockmaker’s precision, the assembly and functioning of the mitotic spindle, ensuring the equal partitioning of the replicated genome into daughter cells. Centrosome dysfunction is inextricably linked to aneuploidy and chromosome instability, both hallmarks of cancer cells. Several aspects of centrosome function in normal and cancer cells have been molecularly characterized during the last two decades, greatly enhancing our mechanistic understanding of this tiny organelle. Whether centrosome defects alone can cause cancer, remains unanswered. Until recently, the aggregate of the evidence had suggested that centrosome dysfunction, by deregulating the fidelity of chromosome segregation, promotes and accelerates the characteristic Darwinian evolution of the cancer genome enabled by increased mutational load and/or decreased DNA repair. Very recent experimental work has shown that missegregated chromosomes resulting from centrosome dysfunction may experience extensive DNA damage, suggesting additional dimensions to the role of centrosomes in cancer. Centrosome dysfunction is particularly prevalent in tumors in which the genome has undergone extensive structural rearrangements and chromosome domain reshuffling. Ongoing gene reshuffling reprograms the genome for continuous growth, survival, and evasion of the immune system. Manipulation of molecular networks controlling centrosome function may soon become a viable target for specific therapeutic intervention in cancer, particularly since normal cells, which lack centrosome alterations, may be spared the toxicity of such therapies. Cancer is an evolutionary multistep process arising in single cells resulting from accumulation of non-lethal mutations that increase, decrease, deregulate, or interfere with the function of critical genes, leading to autonomous growth and loss of homeostasis. Cancer cells fail to execute programed cell death when required, fail to exit the cell cycle when prompted, or to differentiate in response to appropriate external or internal regulatory signals. This dynamic “renegade” behavior , which wAn abnormal complement of chromosomes, i.e., aneuploidy, is arguably the first identified hallmark of cancer cells. Beginning in 1890 Leo Hansemann, in a series of beautifully illustrated observations Figure , 5. ThouThe centrosome is a multifunctional structurally complex macromolecular machine composed of hundreds of proteins –16 Figu. It is tIn interphase, the centrosome establishes and controls the microtubule network that serves as the highway for fast intracellular payload traffic of protein and organelles . It contThe centrosome possesses microtubule-independent functions as well. The most important of these is its cell cycle regulatory activity. Several proteins that localize to centrosomes sequentially control a number of cell cycle processes. Centrosomes license post-mitotic G1 cells for entry into the next S phase . In addide facto “centrosome integrity checkpoint” that precludes normal cells from reentering the cell cycle once centrosome integrity has been compromised, thus avoiding chromosome instability (CIN) and genomic instability , non-transformed human cells , 50. CelA mature centrosome is comprised of two centrioles in orthogonal configuration, surrounded by an amorphous electron-dense protein-rich cloud, termed pericentriolar material (PCM) –53 Figu. Each ceDrosophila as an eight-subunit centrosome protein complex of 340 kDa that localizes γTuRC to the mitotic spindle where it is indispensable for nucleating microtubules in a centrosome-independent manner, increasing microtubule density within the spindle, and stabilizing kinetochore microtubules  and CDK5Rap2 in a functional complex in the inner layer of the PCM .These studies combined indicate that the PCM, in spite of its amorphous appearance under the regular fluorescence or electron microscope, is highly organized Figure . In cellde novo, which is followed by recruitment of PCM. One centriole component in particular, Sas-4 (human CPAP), which is a component of the proximal centriole and of the complex that initiates template-dependent procentriole growth , which is a multifunctional chaperone protein – a large fraction of which localizes to the nucleolus. NPM1 rapidly shuttles between nucleus and cytoplasm  and assoT468A, a non-phosphorylatable form of hMps1, accumulates in the cytoplasm but is continuously removed from centrosomes in a proteasome-dependent manner , readily cause centrosome reduplication, even in the absence of cyclin A-Cdk activity. Accordingly, failure of wild type hMps1 overexpression to cause centrosome re-duplication appears to be the consequence of its efficient proteasome-dependent removal from the centrosome (Mps1 (Esk) , 149 ovet manner , suggestntrosome . The exqntrosome . OAZ tarntrosome . It has ntrosome . Indeed ntrosome . It is pntrosome .limb E3 ubiquitination and proteasome directed proteolysis (D. melanogaster Asterless) through interactions with Cep192 (C. elegans Spd-2). The complex localizes to the outer surface of the proximal end of the mother centriole, precisely the site from which the procentriole will sprout , which to Boveri’s trained embryologist eye, immediately suggested the work of abnormal centrosomes. Boveri theorized that a peculiar “combination of genetic determinants” may give rise to cancer and the transmission of that peculiar combination of genetic determinants  may occasionally arise in daughter cells of abnormal multipolar mitoses. Boveri reasoned that the degree of centrosome abnormalities he inferred from Hansemann’s drawings, were probably detrimental as a whole, as he had directly observed in doubly fertilized sea-urchin zygotes .Centrosome phenotypes in cancer are heterogeneous with both numerical and structural abnormalities documented. Nevertheless, attempts at classification of centrosome abnormalities in cancer have met with limited success, primarily because of the difficulty inherent in carrying out comprehensive surveys at the ultrastructural level using EM, which until recently has been the only technology capable of visualizing centrioles and PCM with sufficient detail –283. Thee future  (vide suover-replication pathway), a phenotype that has been variably referred to as centrosome amplification (de novo formation during interphase (de novo pathway) (accumulation pathway)  , 290 (Fipathway) , 292 (Fipathway) , 294]. Wpathway) .It is likely that only one of these three centrosome amplification pathways operates in an individual tumor. Nevertheless, there is precedent for pathway cooperation. Using a marker for the mother centriole, Duensing et al. were able to determine that the papillomavirus oncoprotein HPV16-E7 leads to over-replication of centrosomes in G2, while HPV16-E6 leads to both increased centrosomes and increased ploidy , by a me−/− MEFs restored normal centrosome replication control. These experiments clearly demonstrated that p53 played a major role in centrosome homeostasis, and that prevention of centrosome over replication was clearly dependent on an intact p53-Waf1 axis  in culture frequently acquire supernumerary centrosomes . The supaf1 axis . These eaf1 axis , 297 , which lack a p53 dependent G1 checkpoint , has addfter all . Time-laormation . Furtherormation . These oormation –314. Payormation , 313–316A similar process has been reported by Kramer and collaborators using a lung cancer cell line carrying a centrin-2-Dendra2 transgene in which the fluorescent protein tag is photoconvertible from green to red, permitting to distinguish unambiguously between pre-existing centrioles (photoconverted red) from newly developed centrioles (green) . Using tde novo pathway is active in cancer cells despite the presence of resident centrosomes. Indeed, some observations suggest that not all centrosomes may be functional in cancer cells, as documented by free centrosomes not associated to spindle poles in some cancer cell lines  in transformed/cancer cells arrested in S or G2 phase, the above two studies suggest that the ll lines . Moreovell lines  are templl lines . Treatmell lines , which nll lines . Similarll lines .in vivo by multiplexed high-resolution fluorescence microscopy. Such studies will provide a wealth of new information, rapidly identifying the critical molecular events, which implicitly are targets for tumor specific targeted therapies.Although numerical abnormalities of centrosomes are the most common centrosome “cancer phenotype,” qualitative changes frequently co-occur. Qualitative changes are far less well characterized, and little is know about their impact on the fidelity of chromosome segregation during mitosis. They include abnormally shaped centrioles, excess or deficits in PCM, and acentriolar MTOCs , 321–325Regardless of the mechanism of origin, supernumerary centrosomes pose the same initial challenge to dividing cells: once two or more functionally mature centrosomes are present at the G2 phase of the cell cycle, the potential for multipolar spindles, and chromosome missegregation on the next mitosis is very real. However, the outcome of multipolar mitoses differs significantly depending on a number of additional factors Figure . One keyMitoses with multipolar spindles are inherently inefficient, exhibiting a high rate of intra-mitotic (mitotic catastrophe) , 331, poin vivo observations of mitoses with multipolar spindles have revealed important clues. It turns out that a large proportion of cells with multipolar spindles utilize a spindle correction mechanism active in normal cells  revealed three main classes of proteins: components of the mitotic spindle assembly checkpoint, regulators of cortical acto-myosin contractility, and microtubule associated proteins (MAPs) (The correction mechanism itself seems to be dependent on kinetochore microtubule dynamics and interaction of polar microtubule bundles. The minus-end-directed microtubule motors nuclear mitotic apparatus protein (NuMA) and dynein have been implicated in this process . Two recs (MAPs) . Also dis (MAPs) , but is s (MAPs) . A secons (MAPs) . The stuNevertheless, not all is well in cells that manage to convert multipolar to bipolar spindles. Multipolarity, even if transient , may leaTwo forms of cancer aneuploidy are readily distinguishable in clinical cancer karyotypes: stable aneuploidy and unstable or dynamic aneuploidy. In the former, all cells in a cancer growth share gains and/or losses of the same normal or structurally abnormal chromosome(s), whereas in the latter, cancer cells have more extensive gains and losses of chromosomes, only some of which are shared by most of the cells in the tumor, while others are shared only by subsets of cells. Whereas the former is thought to results from rare and transient mitotic chromosome missegregation events in a founder cancer cell, the latter is due to frequent and continuous mitotic chromosome missegregation and is a symptom of an intrinsically defective chromosome segregation machinery . Unstablvide infra), again implicating centrosome dysfunction in the cause of sCIN.In CIN, numerical (nCIN) and structural (sCIN) chromosome abnormalities nearly always co-exist [reviewed in Ref. –365]. nCA second class of distinct “genome level” structural abnormality in cancer gleaned from whole-genome sequences has been recently delineated in prostate cancer . Termed A significant body of evidence implicating centrosome dysfunction on CIN has accumulated in the past 20 years. Centrosome defects are ubiquitous in cancer and are associated with dynamic CIN due to chromosome missegregation during mitosis. Surprisingly, centrosome dysfunction also participates in promoting structural CIN by a number of mechanisms, principally by initiating micronucleus formation through merothelic chromosome attachments, chromosome breakage at centromeres, and DNA damage on miss attached chromosome. The combination of structural and numerical chromosome abnormalities triggered by centrosome dysfunction, ultimately leads to gene reshuffling and reprograming of the cancer genome. Reprograming results primarily from four related events associated with gene reshuffling: deregulation of gene expression resulting from gene repositioning, which changes both the regulatory element landscape and chromatin regulatory domains; gene dosage changes resulting from numerical changes of part or whole chromosomes; gene mutations  resulting from chromosome domain repositioning; and changes in the feasibility and probability of oncogene gain or tumor suppressor gene loss by dissociating genes from neighboring genes that normally exert opposite selection pressure. Importantly, cancer cells have developed mechanisms to cope with altered centrosome function, primarily by reconfiguring multipolar spindles into bipolar spindles prior to anaphase. The intricate molecular defects of centrosome dysfunction in cancer provide a unique opportunity for hyper-targeted therapies, which not only interfere with a specific molecule also present in normal cells, but also with a process specifically deranged in cancer, on principle avoiding harm to normal cells. Technical advances in microscopy, fluorescent protein technology and high throughput screening will permit a more rigorous examination of centrosome defects and their functional consequences in short-term cultures of human cancer samples and immortalized “non-transformed” human cells. Only through this exercise will we fully understand the magnitude and the critical differences in centrosome biology between normal and cancer tissue permitting us to develop smart therapies to combat “the emperor of all maladies.”The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Non-alcoholic fatty liver disease (NAFLD) is a growing health problem in both developed and developing countries. Metabolic abnormalities, specially insulin resistance and hyperglycemia are highly correlated with NAFLD. Lifestyle modifications including physical activity and promoting nutrient intakes are critical in prevention and treatment of NAFLD. Hence, in this article we aimed to review the evidence regarding the effects of various macronutrients on fat accumulation in hepatic cells as well as the level of liver enzymes.The relevant English and non-English published papers were searched using online databases of PubMed, ISI Web of Science, SCOPUS, Science Direct and EMBASE from January 2000 to January 2013. We summarized the findings of 40 relevant studies in this review.Although a hypocaloric diet could prevent the progression of fat accumulation in liver, the diet composition is another aspect which should be considered in diet therapy of patients with NAFLD.Several studies assessed the effects of dietary composition on fat storage in liver; however, their findings are inconsistent. Most studies focused on the quantity of carbohydrate and dietary fat; whilst there is very limited information regarding the role of protein intake. Non-alcoholic fatty liver disease (NAFLD) is identified as lipid accumulation in individuals who consume less than 20g ethanol/d and not affected by other known causes of fatty liver such as drugs consumption or toxins exposure . The fatThe primary treatment of NAFLD is life style modifications due to its important role, both in prevention and maintenance of overall health for patients with NAFLD . Among lSome papers believe that high carbohydrate intake is responsible in the development of this disease -20; whilThe relevant English and non-English published papers were searched using PubMed, ISI Web of Science, SCOPUS, Science Direct and EMBASE from January 2000 to January 2013. We used the following keywords in our search: non-alcoholic fatty liver, non-alcoholic steatosis fatty liver, macronutrients, carbohydrate, fat and protein. We found 1575803 English papers published between 2000- and 2013; however, most were excluded because some of them had molecular and biochemical view, and others investigated animal model without any practical and clinical approach or general point regarding the lifestyle and diet without any specific focus on macronutrients. Finally, we included 40 papers in this study. We also summarized the most important studies reviewed in the current paper in Previously, a low fat diet was considered as an optimal suggestion for NAFLD. However, recent studies revealed that low carbohydrate diets have more beneficial effects in these patients. High-carbohydrate diets contribute to the association between hepatic steatosis and insulin resistance through activation of the transcription factor ChREBP (Carbohydrate response element binding protein). Postprandial hyperglycaemia raises the hepatic concentrations of phosphorylated intermediates causing activation of ChREBP and induction of its target genes. Both enzymes of glycolysis and lipogenesis pathways and glucose 6-phosphatase (G6PC) are involved, which may result in insulin resistance. High-carbohydrate diets induce hepatic insulin resistance to protect the liver from substrate overload . AccordiA thirty-six months cohort study compared soft drink consumption between healthy and NAFLD patients without classic risk factors such as obesity, diabetes and insulin resistance . DiffereHowever, most of experimental studies tend to include high intake of fructose  which is not reflective of average human intake. Combining in vivo, in vitro and genetic researches would provide substantial mechanistic evidence into the role of fructose in NAFLD development and its complications . Some meCarbohydrate quantity and quality has a role in NFALD. A recent paper showed the beneficial effect of a low-fat/low-saturated fat/low-glycemic index diet to reduce liver fat in older subjects . A quasiSeveral studies in animal and human models have shown that a high-fat diet induces hepatic steatosis . A five-day trial showed that an isoenergetic high-fat, low-carbohydrate diet causes a 3.7-5.3-fold increment in the liver de novo lipogenesis in hyperinsulinemic obese patients compared to normoinsulinemic lean and obese subjects . HoweverAccording to the reports, different kinds of fat can act differently in non-alcoholic fatty liver. Saturated fat, monounsaturated fat, polyunsaturated fat, omega-3 fatty acids, and all-trans fat have different roles in NAFLD. Increased saturated fatty acid intake (SFA) is usually associated with high insulin resistance which can provoke NAFLD progression. Evidence shows that SFA accumulation in the liver can have detrimental effects on the liver function. An epidemiological study revealed that the ratio of polyunsaturated/saturated fatty acid intake in both the NASH and fatty liver patients was lower than the ratio in randomly selected controls . HoweverEssential fatty acid deficiency could be associated with liver steatosis in the rat model studies. Polyunsaturated fatty acids with omega-6 and omega-3 fatty acids have crucial role on cardiovascular risks. Omega-3 fatty acids intake is also related to reduce insulin sensitivity. It seems that n-3 fatty acids found in fish oils and walnuts may improve blood lipid profiles and reduce inflammation, steatosis, and liver damage in patients with NAFLD. A 8-week randomized cross-over clinical trial found that dietary supplementation with 4 g/d omega-3 fatty acids decreased liver fat content without any significant change in serum ALT concentration in women with polycystic ovary syndrome (PCOS) . In a cuBesides PUFAs, dietary MUFAs also have beneficial effects on NAFLD. MUFAs could decrease oxidized LDL, LDL cholesterol, total cholesterol (TC), and triacylglycerol concentrations; without decreasing HDL, which is usually provided by low-fat diets. It is shown that the replacement of carbohydrate and saturated fat with MUFAs results in glucose and blood pressure reduction and serum HDL increase. It is reported that a MUFA-rich diet (40% of energy as fat) is more acceptable than a high-carbohydrate diet (28% of energy as fat) for patients with diabetes . A recenNowadays we have a problem with all-trans fats produced by hydrogenation. There are some natural all-trans fats in dairy products and different kinds of meat; however, the detrimental effects of all-trans fats are mostly related to those all-trans fats that are the results of hydrogenation of liquid vegetable oils. Partially hydrogenated vegetable oils are the most prevalent source of all-trans fats due to the hydrogenation process. Trans fats had the most harmful effects on the lipid profiles and insulin resistance according to the recent publications .According to a recent paper, compared with PUFA- and SFA-fed mice, TRANS-fed mice had less adiposity, impaired glucose tolerance characterized by greater HOMA (IR) index, and NASH-like lesions due to greater hepatic lipogenesis . The mecCarbohydrate involves the major dietary components in the Middle East . White rThe effects of protein quality and quantity on NAFLD have been poorly assessed and these studies are mainly limited to animal models. An increment in dietary protein content has been shown to reduce the risk of hepatic fat accumulation during a high fat diet both in human and rodents , 70, 71.Dietary treatment of NAFLD and NASH should be highly individualized based on nutritional status, dietary habits, and personal goals and preferences. The replacement of macronutrients with each other should be resulted in acceptable diets by patients. It is important to choose an appropriate replacement for restricted macronutrients since they could affect the compliance of recommended diet. Due to the close associations between obesity, metabolic syndrome and various metabolic abnormalities, especially insulin resistance and NAFLD, it is probable that patients with NAFLD face metabolic abnormalities. Hence, nutrition therapy for liver diseases should be consistent with dietary recommendation which improves these abnormalities. Although, weight reduction and lifestyle changes such as exercise and dietary intakes are considered as the main treatment goals for NAFLD, there is very few evidence on macronutrients and NAFLD, especially in human models. Higher consumption of simple carbohydrate, sweetened drinks and saturated fatty acids may exacerbate NAFLD and cause more fat accumulation in the liver; whilst higher intake of fiber and low GI carbohydrate, MUFA and n-3 fatty acids, soy and whey protein tend to be favorable to ameliorate NAFLD. Moreover, it seems that low carbohydrate, low fat and high protein content of diets are helpful for patients with NAFLD. Fraser study  showed tTo the best of our knowledge, the present review was the first article; which reviewed and compared the effects of various macronutrients intake in NAFLD. Previous review articles , 60, 80 Due to the lack of evidences for proper dietary approach, there is no consensus on diet therapy in patients with NAFLD. For example, the favorable percentage of different macronutrients for patients with NAFLD has not been suggested; furthermore, the optimal dose of omega-3 fatty acids, proper candidate for n-3 PUFA (DHA or EPA), adequate time for supplementation and the safe proportion of different types of fatty acids have not been clarified. Another limitation regarding the fatty acids is their long-term effect on liver fat storage. On the other hand, few studies have assessed the effect of omega-3 fatty acids on prevention of fibrosis and cirrhosis. Moreover, the permissible amount of refined carbohydrate or soft drinks and fructose and the safety of artificial sweeteners for liver are questionable. Most of available studies are limited to assess the effects of replacing carbohydrate and fat with each other. Nevertheless, both high and low protein intakes are associated with liver damage. Hence, future studies should be conducted to assess the effects of dietary protein quality and quantity on NAFLDs, when consumed as the replacement of dietary fat or carbohydrate. Additionally, many studies conducted to assess the effects of n-3 PUFA on NAFLD, but only few studies assessed the effects of dietary n-6 PUFA and cholesterol intake on liver function. Furthermore, it is beneficial to assess health outcomes of various vegetable oils on liver because of their different antioxidants content and consequently their different metabolic outcomes. Another limitation in this field was related to the period of conducted studies. Most of researchers reported their clinical trials results after a short period. Well-designed randomized clinical trials and long-term longitudinal studies are needed for quantify the optimal proportion of various macronutrients in patients with NAFLD.


Over a third of the US population is obese and at high risk for developing type 2 diabetes, insulin resistance, and other metabolic disorders. Obesity is considered a chronic low-grade inflammatory condition that is primarily attributed to expansion and inflammation of adipose tissues. Indeed, adipocytes produce and secrete numerous proinflammatory and anti-inflammatory cytokines known as adipokines. When the balance of these adipokines is shifted toward higher production of proinflammatory factors, local inflammation within adipose tissues and subsequently systemic inflammation occur. These adipokines including leptin, visfatin, resistin, apelin, vaspin, and retinol binding protein-4 can regulate inflammatory responses and contribute to the pathogenesis of diabetes. These effects are mediated by key inflammatory signaling molecules including activated serine kinases such as c-Jun N-terminal kinase and serine kinases inhibitor κB kinase and insulin signaling molecules including insulin receptor substrates, protein kinase B , and nuclear factor kappa B. Bariatric surgery can decrease body weight and improve insulin resistance in morbidly obese subjects. However, despite reports suggesting reduced inflammation and weight-independent effects of bariatric surgery on glucose metabolism, mechanisms behind such improvements are not yet well understood. This review article focuses on some of these novel adipokines and discusses their changes after bariatric surgery and their relationship to insulin resistance, fat mass, inflammation, and glucose homeostasis. The binding of insulin to its receptor leads to tyrosine phosphorylation of the receptor. This phosphorylation is recognized by the IRS family that has 6 member proteins, IRS1 to IRS6. IRS1 plays an important role in transmitting signals from the insulin receptor on cell membrane to intracellular phosphatidiylinositol-3-kinase (PI3K)/Akt and extracellular signal-regulated kinases (Erk)/mitogen-activated protein kinase (MAPK) pathways -γ in adipocytes , an acute phase protein, is primarily synthesized in the liver and plays an important role in regulating the innate immune system  and gastric bypass (n = 15), plasma visfatin levels were significantly increased 7 months after the surgery, and they were positively correlated with the percentage of waist circumference reduction  is secreted predominantly by adipocytes and hepatocytes. In plasma, RBP-4 is the carrier protein of retinol and appears to relate to glucose metabolism and insulin sensitivity  and glucagon-like peptide 1 (GLP-1), which stimulate post-prandial insulin secretion Holst, . GIP is There are two hypotheses trying to explain the increase in incretins secretion; foregut; and hindgut hypotheses (Strader et al., Bariatric surgery alters gut microbiota dramatically (Zhang et al., Obesity is a chronic low-grade inflammatory disease. In adipose tissue, both adipocytes and macrophages secrete a large number of hormones, proteins, cytokines, and chemokines, collectively called adipokines. These adipokines contribute to the pathogenesis of metabolic syndrome, insulin resistance, type 2 diabetes, and cardiovascular disease, most likely via regulating the inflammatory pathway mediated by TNF-α, IL-6, NF-kB, JNK, and IKK and insulin signaling pathway mediated by IRSs, PI3k/Akt, and SOCSs. Weight loss via surgeries dramatically alters levels of these adipokines and overall increases insulin sensitivity. However, despite ample evidence supporting the role of these adipokines in obesity and insulin resistance, mechanisms mediating their effects are for the most part still unclear. It is also unclear whether or how these adipokines mediate the effect of weight loss surgeries such as bariatric surgery on inflammation and insulin response. Further studies are required to better understand the relationship between those adipokines and insulin resistance and how these are modulated by bariatric surgery. Alteration in the adipokine profile primarily reflects changes in adipose-tissue production and secretion of these cytokines. Thus, additional studies are needed to determine whether reduced adipose-tissue inflammation following bariatric surgery is responsible for reduced systemic inflammation and improved insulin sensitivity. Furthermore, the development of animal models which recapitulate the bariatric surgery model will lead to a better understanding of mechanisms by which this surgery improves metabolic outcomes related to diabetes and obesity. It is especially important to understand whether the beneficial effects of bariatric surgery are solely related to weight loss, improved adipose-tissue inflammation and/or changes in gut physiology and endocrinology. In addition, with an adequately powered sample sizes for cross-sectional or case-control studies, the various types of adipose tissues, including subcutaneous, omental, and mesenteric adipose tissues, along with plasma and other tissues, can be collected from severely obese patients who undergo bariatric surgery. Finally, long term studies are critical to assess whether weight loss surgery and associated metabolic improvements are sustained over a long period of time and whether these are primarily related to weight loss or other beneficial effects of the bariatric surgery.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Kounis syndrome, also named as “allergic angina syndrome,” is a diagnosis in which exposure to an allergen causes mostly coronary spasm and rarely plaque rupture, resulting in ischemic myocardial events. Myocardial bridging is defined as an intramural segment of a coronary artery and its systolic compression by overlying fibers. Myocardial bridging generally has a benign prognosis and mostly affects the mid portion of left anterior descending coronary artery. However, some cases with myocardial ischemia, infarction, and sudden death have also been reported. A 17-year-old boy presented to the clinic with acute anterolateral myocardial infarction after having first dose of clindamycin and diagnosed as Kounis syndrome. Further diagnostic workup of the patient showed myocardial bridging at the mid left anterior descending artery. In this report, we present the combination of Kounis syndrome and myocardial bridging leading to myocardial infarction at young age. Myocardial bridging (MB) is called when a segment of a major coronary artery courses intramurally. The intramural part is named as the “tunnelled segment,” and mostly the mid portion of the left anterior descending coronary artery (LAD) is affected , 2. TherMyocardial ischemia signs and symptoms accompanied by allergic or hypersensitivity and anaphylactic or anaphylactoid reactions are defined as Kounis syndrome (KS) . It is aIn this report, we have a case Type 1 KS together with myocardial bridging at the mid portion of the LAD leading to acute anterolateral myocardial infarction in a 17-year-old male patient.A 17-year-old boy presented to the emergency unit complaining of retrosternal chest pain radiating to his left shoulder and back for one hour. Four days ago, he has started to receive penicillin treatment due to acute tonsillitis, and, on the fourth dose of penicillin, he had an episode of severe itching, nausea, and vomiting. It was accepted as penicillin allergy, and the treatment was changed to clindamycin therapy. One hour after the first dose of clindamycin, the retrosternal chest pain has started. His electrocardiogram (ECG) on admission indicated acute anterolateral MI with ST segment elevations on leads DI, Avl, and V2 to V6 and also reciprocal ST depressions on leads DIII and aVF . He had He was taken to the invasive laboratory, and coronary angiography was performed. His angiogram resulted as totally normal coronary arteries except at about 15 mm in length myocardial bridging at the mid portion of the LAD . No furtIn 1991, regarding Kounis syndrome, the first case was reported by Kounis and Zarvas as “allergic angina syndrome.” Constantinides declared that even nonserious allergic reactions could provoke atherosclerotic plaque rupture, in 1995. In 1998, Braunwald pointed out that histamine and leukotriene-like mediators released during allergic reactions contracted the coronary blood vessels . MyocardMast cells, the key elements of allergic reactions, are located between cardiomyocytes and around coronary arteries in healthy people. Larger amounts are present at atherosclerotic vessels. They play major role in allergic and anaphylactoid reactions. After allergen exposure, antigen-anticor complexes or the allergen itself directly activates mast cells , 11. MedMyocardial bridging is usually an incidental finding at coronary angiography, but sometimes the patients may be admitted to the emergency units with typical or atypical angina pectoris, ST elevation, or non-ST elevation MI and very rarely with sudden cardiac death in the presence of myocardial bridging , 13. It Myocardial bridging is usually a clinically silent condition, and the clinical significance of the bridge is determined by the anatomy of the tunnelled segment, concomitant vaso-constrictive situations, and atheromatous changes. During systole, contraction of the overlying myocardium compresses the underlying coronary segment; this compression may persist into the diastole, in which the majority of coronary blood flow occurs normally. Increased heart rate, shortening of diastole, increased myocardial contraction and flow velocity, and all causes leading to coronary spasm like exercise, drugs, or allergic reactions can cause ischemia in patients with myocardial bridging , 21. TheIn symptomatic patients with myocardial bridging, the management is usually medical rarely surgical or invasive. Available medications include beta-blockers and calcium channel blockers. These drugs have the negative inotropic properties that slows the heart rate and elongates the diastolic phase to obtain adequate time for the coronary arteries to maintain the blood flow. Nitrates should generally be avoided because they can increase the angiographic narrowing due to the increased heart rate and can lead to worsening of the symptoms. Surgical treatment by dissecting the overlying myocardial fibers (myotomy) or coronary artery bypass should be limited to patients with severe symptoms or recurrent ischemia that persist despite optimal medical treatment. Coronary stenting may be another treatment option in retractable cases; however, the restenosis rates and complications during the procedures limit their frequent usage . Our patTo the best of our knowledge, it is the first case report in the literature that Type 1 Kounis syndrome overlapping with preexisting myocardial bridging and causing acute ST elevation MI in a 17-year-old male patient right after taking a clindamycin tablette. It should be kept in mind that, although the myocardial bridging is considered a safe and simple condition, with the additive vasoconstrictive effects of allergens, drugs, or the patients, it can cause ischemia and infarction.