For almost a century, therapeutic hypothermia - or as it was termed in the early days: hibernation - has been discussed as a potential neuroprotective measure, in particular in patients suffering from severe intracranial disease leading to impairment of consciousness, associated with fever -3.per se and side effects of rewarming or inconstant maintenance of temperature levels [In a wide range of diseases, secondary damage to the brain or other organs follows the initial impact and may be responsible for aggravation of disease condition or clinical state, in particular neurological morbidity and/or mortality -11. There levels -17.This abstract limits itself to potential pathophysiological mechanisms of actions, the risks of any such mechanism and side effects derived from them ,12,16-18decreased metabolism with less oxygen and energy consumption and carbon dioxide production may prevent secondary injury when oxygen supply is interrupted or, at least, impaired. However, it needs to be stressed that the reduction in metabolic rate, as seen in hypothermia, requires adjustment in ventilator setup, insulin infusion rate, correct interpretation of electrolytes, in particular low phosphate, magnesium and potassium levels. Of particular interest are the rebound phenomena during rewarming or when, involuntarily, the temperature cannot be maintained at the targeted low level.The protective effect of hypothermia may be explained by several pathways. A necrotic. In these earliest stages these pathways may be blocked by hypothermia. However, little is known about the time frame and best window of opportunity to use therapeutic hypothermia to prevent initiation of apoptotic/necrotic processes.Following ischemia, hypoxia or direct trauma apoptotic processes may be initiated in brain tissue and neuronal cells may even become neuro-excitatory cascade, starting off with excessive calcium influx, glutamate receptor activation, neuronal hyperexcitability, eventually leading to cell death even after reperfusion and normalization of glutamate levels. It has been suggested that therapeutic hypothermia may reduce cellular/neuronal damage following this neuro-excitatory cascade.Any type of neuronal injury may provoke the release of free radicals may be deleterious to both neuronal cells and the brain's defense mechanisms alike. Whether the direct impact or the ischemia reperfusion injury is overwhelmingly responsible for the release/increase of free radicals oxidizing and damaging neuronal cell components is both still a matter of discussion and of limited interest when therapeutic hypothermia comes into play.It has been accepted that the intercellular/extracellular acidosis.Hyperexcitability, cellular hyperactivity, mitochondrial dysfunction, ion-pump failure and reduction in cellular membrane integrity may lead to intracellular and, consequently, also Early initiation of hypothermia may improve this full spectrum of cellular failure, improve brain glucose and energy metabolism and reduce lactate accumulation; with this, intracellular and intercellular acidosis will improve and eventually metabolic recovery be enhanced ,19-21.disrupting the blood brain barrier leading to enhanced vascular permeability, brain edema, vascular permeability and perivascular hemorrhage. Brain edema, both after ischemia/hypoxia and traumatic injury peaks after 24 to 72 hours (sometimes reaching its highest peak even after this period of time) - thus opening widely the therapeutic window - allowing for therapeutic hypothermia to reduce brain edema via stabilizing the disrupted blood-brain barrier and vascular permeability. After brain injury proinflammatory mediators are released, leucocytes cross the - already impaired - blood-brain barrier leading to an accumulation of inflammatory cells in the brain. This inflammatory response starts within 1 hour after injury and may persist for up to 5 days, a fact which also suggests a widely open therapeutic window for intervention. Hypothermia has been shown to reduce ischemia induced inflammatory and immune reactions [Any type of brain injury is capable of eactions -22.hyperthermia-related neuronal cellular injury [In healthy persons, brain temperature is around 0.5 to 1°C higher than core body temperature. In any type of brain injury, in particular, in patients with fever or hyperpyrexia respectively, injured areas may be definitely hotter (up to 2°C post injury), most probably due to transitory cellular hyperactivity. Local brain edema might lead to cerebral thermopooling adding to r injury ,16,18-21Cooling below 35°C has been shown to affect coagulation, it depends on the initial type of brain injury whether a procoagulatory effect or an anticoagulatory effect is believed to be neuroprotective in an individual case.Targeted temperature management may influence the secretion of vasoconstricting substances  or vasodilating substances . Their balance is essential to maintain homeostasis. Ischemic or traumatic conditions may increase vasoconstricting substances thus leading to reduced cerebral blood flow. Whether hypothermia is capable of regulating/improving cerebral perfusion is still a matter of investigation, pending the influence of cerebral autoregulation and the quantity of secreted vasoactive mediators in brain-injured patients with cerebral ischemia or any other type of injury .per se - adding to neuronal destruction [Whether epileptic activity, in particular, subtle nonconvulsive status epilepticus, accepted to indicate severe brain damage, can be positively influenced by therapeutic hypothermia still needs further research. However, it is accepted that a subtle nonconvulsive status epilepticus occurring in the acute phase of brain injury is - truction ,16.While many pathophysiological processes and cascades may be influenced by targeted temperature management/therapeutic hypothermia and/or even prevention of fever through prophylactic normothermia, it is unclear whether in all types of severely brain-injured patients (for whatever reason) the benefits of this therapeutic hypothermia always outweigh its risks. It is now fully accepted and of a high level of evidenced medicine that in cerebral hypoxia (in a patient with cardiac arrest due to a shockable arrhythmia) as well as asphyxial encephalopathy a 24-hour therapeutic hypothermia (33 to 34°C), irrespective of the type of cooling, improves neurological outcome; that is, morbidity but also mortality ,10. WhetIt may be stated beyond doubt that the neuroprotective effect of moderate hypothermia (33 to 34°C) has been shown in cerebral hypoxia and asphyxial encephalopathy. However, different neurocritical care disease entities as discussed above have different mechanisms of primary insults as well as the mechanisms and cascades of secondary brain injury and therefore require a different therapeutic approach in respect of temperature management.Any type of therapeutic measure, still being the subject of research, must never harm the patient. Hypothermia-induced neurological signs and symptoms must never be misinterpreted and as a matter of course the diagnosis of brain death can never be confirmed under hypothermic conditions .


Stroke is one of the main causes of death and disability in the world. Cardioembolic etiology accounts for approximatelyone fifth of all ischemic strokes whereas 25-30% remains undetermined even after an advanced diagnosticworkup. Despite there is not any biomarker currently approved to distinguish cardioembolic stroke among other etiologiesin clinical practice the use of biomarkers represents a promising valuable complement to determine stroke etiology reducingthe number of cryptogenic strokes and aiding in the prescription of the most appropriated primary and secondarytreatments in order to minimize therapeutic risks and to avoid recurrences. In this review we present an update about specificcardioembolic stroke-related biomarkers at a protein, transcriptomic and genetic level. Finally, we also focused onreported biomarkers associated with atrial fibrillation (a cardiac illness strongly related with cardioembolic stroke subtype)thus with a potential to become biomarkers to detect cardioembolic stroke in the future. Stroke remains one of the most important neurological affection representing the second leading cause of preventable death and being one of the major causes of productivity impairment. In the US, on average, every 40 seconds, someone has a stroke and annually, 5.5 million people die worldwide, with 44 million disability-adjusted life-years lost , 2. FurtThere exist two principle acute stroke subtypes. The main one, representing over 80-85% of all strokes, is ischemic stroke caused by brain arterial occlusion. On the other hand, 15-20% are due to bleeding into the brain as a consequence of an arterial rupture [Since the Harvard Stroke Regisitry development in 1978 , severalIn contrast, new classifications such as SSS-TOAST, its automated version CCS (Causative Classification of Stroke System) , 8, the The latest classification system, CISS (Chinese Ischemic Stroke Subtype Subclassification), is a two step system which was conceived in 2011. CISS first step aims at the etiology, considering five TOAST-based categories but including more accurate subgroups, whereas the second step classifies stroke patients by the mechanism that underlies the ischemic event . Even thDepending on the causes of the artery occlusion patients might be differently managed in the stroke unit. If the thrombus has a cardiac or atherosclerotic origin, those affected individuals who fulfil the inclusion criteria receive r-tPA as a primary treatment. On the contrary there exists controversy about thrombolysis on patients with lacunar strokes. Some authors are against the administration of intravenous r-tPA in patients without demonstrated artery occlusion , whereasRegarding secondary prevention therapy, patients will receive different treatment depending on etiology: cardioembolic strokes are usually treated with anticoagulant drugs whereas atherosclerotic strokes follow an antiplatelet therapy or even surgery (e.g. carotid endarterectomy). Similarly antiplatelet agents are the treatment of choice for lacunar strokes, together with antihypertensive drugs. In spite of the importance of the accurate stroke subtype classification, the etiology of approximately 30% of all stroke cases remains unknown even after a precise and advanced diagnostic workup has been conducted . The useStroke caused by cardiac embolism accounts for approximately one fifth of ischemic strokes each year and 6-12% patients experience recurrences within 2 weeks after the first embolism . ThrombuOne of the purposes of the stroke etiological classification systems is to classify patients for the therapeutic decision-making but, in spite of their usefulness, these classification systems still have important limitations . Biomarkers of stroke etiology might have a great importance in the development of more precise and reliable classification schemes which may serve as a valuable research and diagnostic tool .cardioembolic stroke AND biomarker and selected data on different available biomarkers that may be measured in blood, such as proteins and circulating microRNAs, or analyzed at genetic level as gene expression profile or polymorphisms.This review presents an update of the research done in stroke biomarkers focusing on the possibility of identifying stroke of cardioembolic etiology since a more aggressive management will reduce dramatically stroke recurrence rates. For that we performed a search in Medline database introducing the terms 1).The most promising candidates to become biological markers for each stroke etiology are supposed to play a role in the pathophysiology of each stroke subtype  . Unfortu2) and classified by the pathophysiologic mechanism they are involved in. In the subsections below we will focus on protein biomarkers associated with cardioembolic stroke grouped by the underlying pathophysiological mechanism. The biomarkers discussed are represented in  -most common cardiac abnormality leading to stroke- but also has been found raised in CE stroke patients compared with other etiologies -24. A reRaised fibrinogen and D-dimer/fibrinogen ratio in patients with CE stroke  were also found in this study. D-dimer together with other hemostatic biomarkers, such as thrombin-antithrombin III complex (TAT), fibrinogen, fibrin/fibrinogen degradation products (FDPs), fibrin monomer complex (FMC) and soluble fibrin (SF), have been assayed lately among different subtypes of stroke . CE stroOther markers for CE stroke have been further investigated. B-type natriuretic peptide (BNP) has an antifibrotic role in the heart and acts as a cardiac hormone. BNP is the main product of the cleavage of propeptide (proBNP), which also equimolarly release N-terminal peptide (NT-proBNP). All three peptides are considered to have a similar potential to discern CE stroke subtype among other etiologies . MontaneNT-proBNP has also been proposed for discerning between CE and other stroke etiologies in 92 patients with AF . As authRegarding proBNP, Rodríguez-Yáñez and colleagues published a study including 262 patients from all TOAST etiologies and showed that plasma levels over 360 pg/mL of this peptide were independently associated with CE stroke  in a model that included basal NIHSS .Von Willebrand Factor (vWF), a well studied hemostatic marker, has been found to be related with CE stroke. Raised levels of vWF were determined in CE patients by Licata and collaborators but only showed a trend (10 (5-12) ng/ml; p=0.0053) compared to other stroke subtypes . Other sOther biological markers of cardiac damage such as proatrial natriuretic peptide (pro-ANP) together with creatine kinase MB (CK-MB) were analyzed and reported to be higher in patients with CE infarcts. Authors suggested a cutoff point of 2.6 ng/mL  and 2266.6 fmol/mL , for each marker respectively .Very recently Santamarina and collaborators determined plasma concentrations of some of these previously studied biomarkers  in a cohort of 89 selected patients with undetermined stroke. After cardiological work-up, 49 of these patients with cryptogenic stroke were diagnosed as embolic. The most common findings were AF, severe aortic atheromatosis, patent foramen ovale, aneurysm of atrial septum and dilated cardiomyopathy. Cardioembolic stroke patients had higher plasma concentrations of BNP , myoglobin  and CK-MB  than the ones that remained as cryptogenic. Finally, they constructed a predictive model adjusted by age, gender, risk factors, heart disease and stroke severity where BNP and CK-MB together with suffering of a previous stroke were independently associated to embolic abnormalities . These results evidence the fact that some biomarkers contain the potential to improve the diagnosis of a stroke from an embolic source optimizing the performance of early cardiac explorations in those patients with undetermined stroke .High serum levels of immuno-inflammatory mediators such as TNFα, IL-6, IL-1β, selectins and adhesion molecules have been associated with ischemic stroke suggesting that both molecular and cellular inflammation mediates the mechanisms of cerebral injury and repair. Several studies have tried to clarify the role played by inflammation in the pathogenesis of different stroke etiologies. Licata and collaborators evaluated the levels of different cytokines, selectins and adhesion molecules among ischemic stroke subtypes . In thisC reactive protein (CRP) is a well-known acute phase reactant protein whose concentration rises in response to inflammation or infection. In spite of being one of the most studied inflammatory markers in stroke, several controversial results have been reported regarding its use as etiologic biomarker. Terruzzi and collaborators showed higher plasma levels of CRP in CE stroke patients when compared with other TOAST subtypes within the first 6 hours after symptoms onset . HoweverMicro and macroangiopathy affect endothelial walls thickness and reduce blood flow through small and large vessels. These processes are strongly related with hypertension and diabetes.Reduced plasma levels of soluble advanced glycation end products receptor (sRAGE), a cell surface molecule member of the immunoglobulin superfamily, are considered to be related with the development of microangiopathy. Plasma levels of this protein were compared between stroke etiologies in a total of 482 enrolled patients by Yokota and collaborators. Distribution of sRAGE were significantly different among etiologies, being CE plasma concentrations the highest (1280 (271-4720) pg/mL, p=0.001) . In this1. Table 2 shows the CE stroke-related biomarkers with a highest sensitivity and specificity found in the literature.Biomarkers which have been assayed in ischemic stroke patients and related with CE subtype are summarized in Table Apart from stroke biomarkers strongly related with CE etiology, some other molecules are associated with high risk cardioembolic conditions and therefore remain as candidates to become markers for CE stroke. The most common of these cardiac conditions which may lead to a cardioembolic event are: atrial fibrillation, recent myocardial infarction, dilated myocardiopathy, and mitral rheumatic stenosis. Other major sources of cardioembolism are ineffective endocarditis, marantic endocarditis and atrial myxoma; and patent foramen ovale, atrial septal aneurysm, atrial or ventricular septal defects, calcific aortic stenosis, and mitral annular calcification as minor sources , 57. The3 shows those candidates which are associated to AF, the most common CE stroke related cardiac affection. Table Gene expression profile can also be used to discern between different stroke subtypes. In 2010, Jickling GC and colleagues reported the results of the complete CLEAR trial. The expression profile from a total number of 23 CE and 10 LAA patients were compared and, as a result, 40 genes whose expression was significantly different among both etiologies were identified . 11 of tENPP2 (Ectonucleotide pyrophoshpatase/phosphodiesterase family member 2) and GRM5 (Glutamate receptor metabotropic 5). ENPP2 protein is involved in angiogenesis and neurite growth, whereas GRM5 encodes the glutamate receptor metabotropic 5, which is involved in normal brain function. Other genes such as LHFP, TMEM19 and EBF1 are involved in cardiac proliferation, cardiovascular development and haematological system function [Especially interesting genes are function . The proOn the other hand, in the same study a different 37 genes expression profile was found to distinguish patients with CE stroke due to AF and non-AF causes with a probability higher than 90%. This 37 genes list may provide physicians an additional tool for the identification of patients more prone to suffer AF, as its detection strongly depends on cardiac monitoring, not always available for all patients. Moreover, paroxysmal AF detection requires a more prolonged follow-up period making more difficult the diagnosis of AF, thus this 37 gen expression profile analysis at baseline could be very helpful to identify these individuals.In a later study, the same authors followed a similar strategy in a cohort of patients with lacunar and non-lacunar stroke. The study reported 41 genes whose expression profile allowed to distinguish both groups and predict etiology in small deep infarcts of undetermined cause .Finally, these two gene profiles, the 40-genes list that distinguished CE and LAA strokes and the 41-genes list that distinguished lacunar and non-lacunar strokes, were integrated and combined with infarct location assessed by neuroimaging to predict the most probable cause of stroke in a cohort of 131 patients with cryptogenic strokes. Of these 131 undetermined strokes, 76 (58%) were predicted to be CE, 24  were LAA, 15  were lacunar and 16  remained unknown . As authors discussed, these studies have some limitations being the small population size the most important. However, they evidenced that gene expression profile could allow us to distinguish between different causes of stroke. With the development of point-of-care devices, based on fast analysis, cryptogenic stroke clarification and preventive stroke treatments could be further improved.microRNAs (miRNAs) are small (19-25 nt length) non-coding RNAs involved in the post-transcriptional regulation of genes by inhibition or degradation of mRNA. miRNAs are single stranded molecules of RNA whose high stability allows its detection in serum or plasma. Moreover, their expression patterns may reflect underlying pathophysiological processes. These important features make miRNAs very attractive biomarkers for human diseases . Unfortunately, just a few studies have attempted to find differential miRNA levels between patients and controls. The study conducted by Gan and colleagues is an example. They measured blood levels of miRNA-145 (a modulator of vascular smooth muscle cells phenotype) and showed an up-regulation in stroke . On the Among etiologies, until now only one study has focused on finding differences on miRNAs expression . This stIn contrast to the small number of published studies of miRNA focused on stroke etiologies, numerous studies have documented a relation between some specific miRNA and AF, strongly related with CE stroke . Very reThe results of these studies suggest, on one hand, the use of miRNA as plasma biomarkers for AF detection and consequently the identification of an embolic source in undetermined strokes; on the other hand, they open the door to potential therapeutic targets by direct miRNA silencing.PITX2 (Paired-like homeodomain 2) and ZFHX3 (Zinc finger homeobox 3) genes respectively, and both related with CE etiology; or the SNP rs2383207 located in the CDKN2A/CDKN2B (Cyclin-dependent kinase inhibitor 2) gene, related with LAA stroke. Interestingly, a previously unknown association between LAA stroke and the SNP rs11984041  gene) was firstly identified in this study. Finally, a third additional verification step was performed in 735 LAA cases and 28583 controls which further confirmed previous data. Taken together, the results from the discovery and two-steps verification phases provide strong evidence for association between the new SNP rs11984041 and LAA stroke (p=1.87x10-11) and further confirmed the association between CE stroke etiology and previously identified polymorphism in genes PITX2 and ZHF3. To date several studies have been performed to further understand the genetic basis of ischemic stroke. The most promising results have been obtained from projects that performed Genome Wide Analysis (GWA) approaches. The International Stroke Genetics Consortium (ISGC) and the Wellcome Trust Case Control Consortium 2 (WTCCC2) conducted a GWA study on three stroke subtypes: LAA, SVD and CE stroke . This waOther studies have been carried out with approaches different from GWA, identifying other SNPs related to stroke etiology subtypes, e.g. rs2020918 related with SVD , 88, or CCR5 (Chemokine C-C motif receptor 5) gene (Δ32 polymorphism) is considered to exert a protective effect against CE stroke as it has lower frequency in this subtype  than in LAA, SVD or cryptogenic strokes [Other polymorphisms different from single nucleotide ones have been analyzed and observed to be specifically associated with a stroke subtype. For instance, a 32 base-pair deletion in  strokes . 4 shows a compilation of CE stroke and AF related genes, miRNA and polymorphisms.Although blood proteins, nucleic acids and even gene expression profiles may aid in the diagnosis and decision-making during acute and subacute phases of stroke, genetic biomarkers specific for each etiology provide valuable evidence before stroke occurrence allowing physicians to prescribe the most suitable preventive treatment. Furthermore, the identification of genetic signatures of each etiology may be of main interest in guiding undetermined stroke diagnosis, especially during subacute phase when it becomes primordial an optimal secondary prevention to minimize recurrences. Table 5 shows the general strengths and shortcomings of the studies on stroke etiology biomarkers. During the last years, a great number of studies have been conducted aiming to find new biomarkers that could aid in the differentiation of ischemic stroke etiologies. Although some of these studies have shown markers with high sensitivity and specificity, in a large cohort of patients and proving to be independent predictors of ischemic stroke, there are still some hurdles to take over before implementing them to daily clinical routine. Table Recent advances achieved in proteomics in the last few years have brought new approaches for the identification of biomarkers. The use of quantitative proteomics has proven to be a promising strategy for identifying potential biomarkers for a number of diseases such as cancer, infectious diseases or autoimmunity. The stroke field can also take benefit from this fast development since recent studies have reported very promising results mainly directed at diagnosis. Dawson and collaborators explored the urinary proteome from ischemic stroke and transient ischemic attack patients versus controls. They developed two biomarker-based classifiers with identified proteins and validated them in independent blinded samples, showing a clear association of these biomarkers and stroke . Dayon aAt a genetic level, recent studies in transcriptomic and specially those performed through GWA approaches have provided new stroke and even etiology-related markers. These newly described genetic markers may not only aid in the diagnosis or patient etiologic classification, but also may serve as future therapeutic targets for each stroke etiologic subtype.Despite having found many encouraging candidates by all these approaches their clinical application requires several careful validation steps. Multi-centric studies, with greater cohorts of patients, supported by multiple replications and performed with tools for massive molecular and genetic analysis will be the base to increase the output of potential biomarkers that may be implemented in daily clinical practice.


Objectives: The goal of the present study was to evaluate the results of applying acupuncture or occlusal decompression splints in the treatment of patients diagnosed with the temporomandibular joint pain-dysfunction syndrome.Design of the study: We conducted a randomized clinical trial including 20 patients to whom the mentioned treatments were applied. Results were evaluated through an analogue pain scale, measurements of mouth opening and jaw lateral deviation in millimetres, and assessment of sensitivity to pressure on different points: preauricular, masseter muscle, temporal muscle and trapezius. Parameters were evaluated before and 30 days after the treatment. For standardized pressure, we used a pressure algometer. Results: Patients treated with decompression splints showed reductions in subjective pain and pain upon pressure on temporal, masseter and trapezius muscles, as well as increased mouth opening after the treatment. Patients treated with acupuncture showed pain reduction in the short term and improvements in all of the evaluated para-meters .Conclusion: Acupuncture was an effective complement and/or an acceptable alternative to decompression splints in the treatment of myofascial pain and temporomandibular joint pain-dysfunction syndrome. Key words:Temporomandibular joint, temporomandibular dysfunction, acupuncture, decompression splint, arthralgia, myofascial pain, joint palpation. The term “temporomandibular disorders” was suggested by the American Dental Association as a common label for different clinical conditions involving chronic orofacial pain  . DiffereMyofascial pain, also called myofascial pain-dysfunction syndrome (PDS) is the most frequent subtype of temporomandibular disorder, affecting subjects in every socioeconomic and ethnic level . The aetPain relief is the main goal of such treatments . UsuallyA number of physical techniques have been tried to treat PDS . Some of them have been accepted after exhaustive scientific discussion; others lack evidence enough to support their therapeutic effects .Acupuncture originated in China more than 3000 years ago. Beneficial effects of this technique in the management of PDS have been reported -8. AlthoResults of controlled clinical trials suggest that the effects of acupuncture therapy are similar to those of stabilization splints ,10-13.The goal of this study was to assess the results of applying acupuncture or occlusal decompression splints to treat patients with PDS; as well as to evaluate the efficacy of such treatments.This study included 20 patients, who had visited the Dental Care Services of different Primary Health Centres in the Canary Islands and had been referred to the Department of Stomatology and Oral and Maxillofacial Surgery of the Hospital Insular de Gran Canaria with symptoms compatible with a diagnosis of muscle-related PDS. This study was approved by the Hospital Commission for Research, Teaching and Training.Patients were selected according to the following inclusion criteria:• Three-month or longer history of at least two of the following signs or symptoms: pain upon palpation of the temporomandibular joint (TMJ) or associated muscles of mastication, restriction or deviation of jaw movement, headache plus joint noise. Headache and joint noise were not considered when they occurred separately.• Legal age.• Normal vertical dimension with complete or almost complete dentition.Exclusion criteria were.• Legal involvement such as traffic accidents, sick leave, etc.• Dental malocclusion with variations from normal vertical dimension.• Malignancies or other diseases, especially those involving other joints.• Bone and/or degenerative diseases.• Headache associated with general organic conditions.• Fibromyalgia.• Mental disorders.• Previous treatment with acupuncture and/or decompression splint.• Previous surgery of the TMJ.• Orthodontic treatment at the time of the study.• Wearing a complete removable prosthesis.• Allergy to metal.Patients were randomly allocated to either decompression splint or acupuncture therapy. The studied population consisted of 20 patients  between 18 and 58 years of age (average 39 years); 8 females and 2 males were treated with acupuncture; 9 females and 1 male were treated with decompression splints. All of the enrolled patients signed an informed consent form. All of them underwent.▪ detailed physical examination and preparation of complete clinical record.▪ mouth-dental examination to assess tooth-decay, periodontal disease and general mouth hygiene.▪ specific TMJ examination.▪ orthopantomography.Treatments were applied by two operators: a physician specialized in stomatology, who was in charge of patient examination before and after the treatments, as well as of designing the decompression splints; and an acupuncturist graduated in traditional Chinese medicine, who applied the acupuncture treatment to all patients in the acupuncture group.Patients with the acupuncture therapy were treated with local and distal acupuncture points (acupoints). Local acupoints were: EX-HN5, SJ 21, GB2, SJ17, ST6 .• Visual analogue pain scale, where 0 corresponded to absence of pain and 10 corresponded to the worst imaginable pain.Numerical variables were expressed as mean and standard deviation. Sample normality was evaluated with the non-parametric Kolmogorov-Smirnov test. The pre- and post-treatment mean values were compared by using the Student’s t-test for dependent samples. Hypotheses contrast was considered to be significant for p-values lower than 0.05. We used the SPSS 14.0.1 statistical package.Both groups of patients – treated during five weeks – showed reduction of myofascial pain in the short term.Patients treated with decompression splints showed reductions in subjective pain and pain on pressure points located on the temporal, masseter and trapezius muscles, although differences did not reach statistical significance (p>0.05) Fig. .Patients treated with acupuncture experienced significant improvements in all of the studied parameters . Pain reduction was statistically significant (p<0.05) for all the evaluated points except the one located on the masseter muscle (p=0.068) Fig. .Since we did not conduct long-term patient follow-up these results are restricted to immediate effects of both treatments. Patients who had received a decompression splint were recommended to keep on wearing it on a regular basis.Acupuncture is currently considered an effective therapeutic alternative for most clinical conditions involving chronic pain ,14,15. CThe two most frequent conditions treated with acupuncture are headache and low back pain, although this therapy has also been used to treat sore throat, post-surgical dental pain, oncologic pain, polyneuritis, rheumatoid arthritis, sciatica, bursitis, tendinitis, etc. .Acupuncture is currently considered to be effective to treat dental pain, as well as postoperative and post-chemotherapy nausea and vomiting. Positive results have been reported with migraine, low back pain and temporomandibular disorders. Some authors consider that results are positive, while others consider them difficult to interpret. In general, this therapy is considered a relatively safe procedure . PublishThe prevalence of PDS is equivalent among both men and women. Women however, demand treatment more often; 85% of our subjects were women.Coincidently with other authors ,8 we obsFew studies document long term results of acupuncture or interocclusal splints. List and Helkimo  concludeOcclusal splints are extensively used to treat PDS. Several hypotheses have been proposed to explain their effectiveness -25, all As mentioned, reliable measurement of pain upon palpation of TMJ and associated muscles entails major difficulties, derived from inter- and intra-observer variability, as well as from variations of subjective pain reported by patients at different times . In ordeRaustia et al. -12 studiFinally, we would like to consider a possible placebo effect of acupuncture. Goddar  presenteBecause of time restrictions, patients could not be followed during a longer period and a larger sample of subjects could not be recruited. Longer time and more subjects could have produced better and more conclusive results.The results of this study indicate that acupuncture has analgesic effects in the short-term and is therefore comparably effective to occlusal splints, in the treatment of TMJ-PDS.


Exosome secretion is a notable feature of malignancy owing to the roles of these nanoparticles in cancer growth, immune suppression, tumor angiogenesis and therapeutic resistance. Exosomes are 30–100 nm membrane vesicles released by many cells types during normal physiological processes. Tumors aberrantly secrete large quantities of exosomes that transport oncoproteins and immune suppressive molecules to support tumor growth and metastasis. The role of exosomes in intercellular signaling is exemplified by human epidermal growth factor receptor type 2 (HER2) over-expressing breast cancer, where exosomes with the HER2 oncoprotein stimulate tumor growth and interfere with the activity of the therapeutic antibody Herceptin®. Since numerous observations from experimental model systems point toward an important clinical impact of exosomes in cancer, several pharmacological strategies have been proposed for targeting their malignant activities. We also propose a novel device strategy involving extracorporeal hemofiltration of exosomes from the entire circulatory system using an affinity plasmapheresis platform known as the Aethlon ADAPT™  system, which would overcome the risks of toxicity and drug interactions posed by pharmacological approaches. This technology allows affinity agents, including exosome-binding lectins and antibodies, to be immobilized in the outer-capillary space of plasma filtration membranes that integrate into existing kidney dialysis systems. Device therapies that evolve from this platform allow rapid extracorporeal capture and selective retention of target particles < 200 nm from the entire circulatory system. This strategy is supported by clinical experience in hepatitis C virus-infected patients using an ADAPT™ device, the Hemopurifier®, to reduce the systemic load of virions having similar sizes and glycosylated surfaces as cancer exosomes. This review discusses the possible therapeutic approaches for targeting immune suppressive exosomes in cancer patients, and the anticipated significance of these strategies for reversing immune dysfunction and improving responses to standard of care treatments. A large body of literature has documented the relationship between suppressed immune status and cancer progression resulting from tumor-mediated mechanisms as well as from immune ablation caused by the therapeutic agents themselves . Althoug+-ATPase transmembrane pumps that maintain the low pH of the tumor microenvironment are essential for fusion of tumor-derived exosomes with target cells, which is believed to be related to higher rigidity of exosomal membranes at a lower pH , that harbors newly synthesized MHC class II molecules in transit to the plasma membrane . It was s in vivo. These vs in vivo. A pleths in vivo and indus in vivo-25. Mores in vivo-29.in vivo[in vitro could be considered artefactual, there are also many naturally occurring examples of exosomes as mediators of immune tolerance.The discovery that exosomal cargo mirrors that of their originating cell types has lead to the understanding that exosomes can be either immune stimulatory or tolerogenic depending on the originating cell’s activation state and the cellular cargo that is packaged into the vesicles. DC are key orchestrators in whether immune activation or immune tolerance occurs as a result of their interactions with T cells. It has been reported that immature DC promote induction of tolerance , and thain vivo. Given oin vivo,33, the in vivo. Similarin vivo. This grin vivo. Kim et in vivo. Althougin vivo example where exosomes promote immune tolerance to the “fetal allograft”. During pregnancy, local and systemic immune deviation occurs [Pregnancy represents an n occurs  and the n occurs ,40. Inten occurs . As discn occurs .Pregnancy-associated exosomes possess multiple means for modulating T cell responses. For example, the inhibitory molecule PD-1 ligand is found on pregnancy-derived exosomes in circulation, and can inhibit both CD4+ and CD8+ T cells . ExosomeAnother physiological example of exosome-mediated immune tolerance is the antigen-specific immune modulation that can be elicited in response to oral antigen administration. Induction of oral tolerance is associated with the generation of T regulatory (Treg)/Th3 cells with specificity for food-borne antigens . Clinicain vitro correlates with disease activity and lymph node metastasis in head and neck cancer patients [Many of the tolerogenic effects of exosomes secreted by healthy cells are also imparted by tumor-derived exosomes, as represented in Figure patients . FasL onpatients ,65. Low patients -71.in vitro[Tumor-derived exosomes also promote antigen non-specific immune suppression through their effects on myeloid-derived suppressor cells (MDSC), a population of immature myeloid cells that are among the major inhibitors of T cell activation in cancer . Accordiin vitro. Collectin vitro[in vitro[The effects of cancer exosomes on the myeloid lineage also extend to maintaining immaturity of DC, which is associated with cancer progression in tumor-bearing hosts . A studyin vitro. Similarin vitro. Aberranin vitro. Additio[in vitro. Whitesi[in vitro,83.NK cells play a critical role in tumor immune surveillance, as exemplified by a study that showed a higher incidence of spontaneous tumors in mice deficient in NKG2D , an actiExosomes have emerged as major players in transporting soluble proteins involved in cancer growth, including members of the human epidermal receptor (HER) family, which are constitutively active in many cancers as a result of gene amplification, protein over-expression, and/or mutations of their tyrosine kinase domains . The HERAn important pro-cancer effect of cancer exosomes is in mediating resistance to immunotherapeutic agents. The humanized monoclonal antibody Herceptin® , which binds to the extracellular domain of HER2, is the standard of care for breast cancers with HER2 amplification. Herceptin® binds to HER2 with high affinity and evokes a broad range of anti-tumor effects including direct inhibition of HER signaling, induction of antibody-dependent cell cytotoxicity (ADCC) by NK cells and possibly through downregulation  of HER proteins . HER2 diin vitro. These data suggest that a strategy for targeting exosomes could be beneficial for unmasking the efficacy of therapeutic antibodies.A second example of exosome-mediated resistance to monoclonal antibody therapy is observed in B cell lymphoma. CD20-bearing tumor exosomes have been demonstrated to bind to and intercept anti-CD20 antibodies (i.e. the therapeutic antibody rituximab) and also consume complement, thereby impairing ADCC and complement-dependent cytolysis against tumors . StrikinIn addition to interfering with the activity of immunotherapeutic agents, tumor-derived exosomes also participate in the resistance of tumors to certain chemotherapy drugs. A role of exosomes in drug export from tumor cells was suggested by observations that cisplatin-resistant ovarian cancer cells displayed reduced lysosomal content of platinum and increased secretion of exosomes containing platinum as compared to cisplatin-sensitive cells . Similar+-ATPase-driven efflux pumps using proton pump inhibitors (PPIs), which are widely prescribed for suppressing gastric acid [+-ATPases are overactive in tumors, pumping high concentrations of protons across the plasma membrane to generate highly acidic extracellular microenvironments [+/Na+ and Na+/Ca2+ channels, was effective for mitigating the immune suppressive effects of exosomes and restoring the responsiveness of cancer-bearing hosts to the chemotherapeutic agent cyclophosphamide [in vivo efficacy at unmasking immune function and therapeutic responses in cancer.A promising alternative for inhibiting exosome secretion involves targeting vacuolar Hric acid . Since tric acid . Vacuolaronments ,122. PPIronments . Signifironments . In one sphamide . The DMAsphamide . Anothersphamide . Hence, Staphylococcus aureus covalently linked to a silica matrix to capture circulating immunoglobulin G (IgG) and immune complexes containing IgG, which was FDA-approved for rheumatoid arthritis and idiopathic thrombocytopenic purpura as a complementary therapy for clearing pathogenic autoantibodies. In a study examining the efficacy of the Prosorba column in cancer, there was a measurable reduction in tumor burden in 22 of 104 patients and increased immune system activity reportedly occurred in the hours following treatment [Another promising cancer treatment strategy involves extracorporeal hemofiltration of immune suppressive factors including exosomes from the circulation. In a pioneering study by Dr. Rigdon Lentz, continuous whole blood ultrapheresis was used to remove low molecular weight proteins  from the blood of 16 cancer patients of which 6 patients presented with a minimal 50 % reduction in the sizes of their tumors . The prireatment ,127. Howreatment .Given the recent appreciation for the roles of exosomes as malignancy-associated factors, an extracorporeal strategy for specifically targeting exosomes is an attractive therapeutic option for cancer. Aethlon Medical has devised a therapeutic hemofiltration approach, termed the Aethlon ADAPT™ system. This technology consists of immobilized affinity agents in the outer-capillary space of hollow-fiber plasma separator cartridges that integrate into standard dialysis units or continuous renal replacement therapy (CRRT) machines. As the patient’s blood passes through device, plasma components < 200 nm in size travel through the porous fibers and interact with the immobilized affinity agent(s) to which target molecules are selectively adsorbed while blood cells and non-bound serum components pass through the device Figure . This deGalanthus nivalis agglutinin (GNA) is covalently coupled to capture viruses on the basis of the high mannose glycoproteins on viral envelopes [There is a clinical precedent that supports the safety and efficacy of affinity hemodialysis using ADAPT™ devices. The first ADAPT™ device, the Hemopurifier®, consists of a plasmapheresis cartridge to which the lectin nvelopes . Aethlonnvelopes  and dataTumor-derived exosomes are enriched for high mannose structures on their surface glycoproteins  and havein vitro and in experimental animals, the impact of diminishing exosomes therapeutically must still be studied in terms of the potential efficacy in promoting immune recovery and hindering tumor growth in a clinical setting.In a therapeutic context, the fact that the ADAPT™ system can access soluble factors in the circulation but not those within the tumor or regional lymph nodes makes this device strategy suitable for metastatic cancers. Indeed, tumor-derived exosomes have been demonstrated to transport molecular signals involved in angiogenesis and stroma remodeling for tumor cell adhesion and growth during priming of the pre-metastatic niche ,140. MorExosomes have emerged as being important vehicles for intercellular communication and for modulating immune responses, owing to their content of proteins and genetic material that mirror their cells of origin. Whereas exosomes from activated lymphocytes can possess immune stimulatory functions, there are many physiologic examples of exosomes exerting tolerogenic functions during dampening of immune responses, oral tolerance and pregnancy. In cancer, the tolerogenic activities of exosomes represent pathological responses whereby tumor cells secrete vast amounts of immune inhibitory exosomes that hinder anti-cancer immune responses. Tumor-derived exosomes are involved in the fundamental aspects of cancer pathogenesis including growth, metastasis, angiogenesis, and immune suppression. Therefore, to address the unmet need for a strategy to target tumor-secreted exosomes, one possible option involves a therapeutic hemofiltration approach, the Aethlon ADAPT™ system, which is designed to selectively capture and remove target particles such as exosomes from the entire circulatory system. This technology consists of hollow fiber plasma filtration cartridges constructed with affinity agents that are fitted for existing dialysis machines. The ADAPT™ system has the potential to address a variety of types and stages of cancer since it can incorporate diverse affinity agents for capturing cancer-specific exosomes on the basis of their display of surface proteins (using antibodies) and/or glycoproteins (using lectin affinity agents). The emerging evidence that tumor-secreted exosomes are involved in mediating resistance to therapies provides an impetus for exploration novel therapeutic options for addressing the immune inhibitory and tumor growth-promoting effects of cancer exosomes.ADAPT, ; ADCC, (antibody dependent cell cytotoxicity); CRRT, ; DC, (Dendritic cells); DMA, (Dimethyl amiloride); EGFR, ; GNA, ; HCV, (Hepatitis C virus); HER, ; ILV, ; MICA/B, (MHC class I chain-related proteins A and B); MIIC, (Major histocompatibility complex class II-enriched compartment); MDSC, (Myeloid-derived suppressor cells); MVB, (Multivesicular bodies); PPIs, (Proton pump inhibitors); Treg, (T regulatory); UL-BP, (UL-16 binding proteins).JAJ, RHT and AMM are employees and/or shareholders of Aethlon Medical. CSC has no competing interests.JAJ and RHT conceived of the ADAPT™ technology described in this manuscript. AMM drafted the manuscript with the participation of CSC, JAJ, and RHT. All authors read and approved the final manuscript.


EHP 121(1):105–110; Baker et al.]. They found, via in vitro and in vivo studies with male mice, that exposure rapidly and significantly disrupted several important biological indicators.Many factors are suspected in the global surge in type 2 diabetes, among them exposures to toxic chemicals including polychlorinated biphenyls (PCBs). To investigate the potential mechanisms of the type 2 diabetes/PCB connection, a team of investigators studied two coplanar PCBs, PCB-77 and PCB-126 [PCBs are long-lasting toxicants that accumulate in fatty tissues and remain prevalent in the bodies of people and wildlife around the world, despite a ban decades ago. Human exposure is primarily dietary or occupational.In mice fed a low-fat diet, PCB-77 was associated with significant impairment of glucose and insulin tolerance, and PCB-126 significantly impaired insulin tolerance, compared with untreated mice fed the same diet. Further investigation of PCB-77  showed the effects lasted two weeks following cessation of PCB exposure. The investigators also found that plasma of treated animals had significantly increased concentrations of tumor necrosis factor alpha (TNF-α) and interleukin 6 for two weeks after the last dose. These inflammatory cytokines are related to insulin resistance. Notably, mice exposed to PCB-77 exhibited a significant increase in TNF-α in adipose tissue (fat), a well-known site of insulin resistance.To explore a process that might be involved in these adverse effects, the team exposed the mice treated with PCB-77 to a known aryl hydrocarbon receptor antagonist and found that the alterations vanished, suggesting this receptor plays a key role in effects on glucose homeostasis. That finding is generally consistent with other studies that have found this pathway plays a role in various bodily responses to PCBs and other toxicants.In mice fed a high-fat diet, the team found no connection between PCB-77 exposure and effects like those seen in the low-fat group, despite the animals’ having double the concentration of the toxicant in fat tissue. Weight loss improved glucose and insulin tolerance and reduced fat levels of TNF-α in all the mice, but these effects were significantly weaker in exposed mice than in unexposed animals. Previous research has shown that lipid-soluble toxicants sequestered in fat are released into circulation during weight loss, which may reduce PCBs levels in fat but increase them elsewhere in the body.Before these findings can be translated to humans, larger studies using different exposure lengths and concentrations are needed. Studies should also investigate factors such as the roles of additional PCBs, differences between males and females, and additional possible mechanisms and pathways.


Liver cirrhosis is associated with a wide range of cardiovascular abnormalities including hyperdynamic circulation, cirrhotic cardiomyopathy, and pulmonary vascular abnormalities. The pathogenic mechanisms of these cardiovascular changes are multifactorial and include neurohumoral and vascular dysregulations. Accumulating evidence suggests that cirrhosis-related cardiovascular abnormalities play a major role in the pathogenesis of multiple life-threatening complications including hepatorenal syndrome, ascites, spontaneous bacterial peritonitis, gastroesophageal varices, and hepatopulmonary syndrome. Treatment targeting the circulatory dysfunction in these patients may improve the short-term prognosis while awaiting liver transplantation. Careful fluid management in the immediate post-transplant period is extremely important to avoid cardiac-related complications. Liver transplantation results in correction of portal hypertension and reversal of all the pathophysiological mechanisms that lead to the cardiovascular abnormalities, resulting in restoration of a normal circulation. The following is a review of the pathogenesis and clinical implications of the cardiovascular changes in cirrhosis. Patients with end-stage liver disease manifest a hyperdynamic circulation characterized by a decrease in the systemic vascular resistance and arterial pressure, and an increase in the heart rate and cardiac output. The clinical manifestations of hyperdynamic circulations include warm skin, spider angioma, palmer erythema, and bounding pulse. These cardiovascular changes were described over 50 years ago by Kowalski and Abelmann in a group of alcoholic cirrhotic patients. These fiDifferent pathophysiological mechanisms including neurogenic, humoral, and vascular dysregulations are implicated in the pathogenesis of these cardiovascular changes. The hyperdynamic circulation is most likely initiated by splanchnic and peripheral vasodilatation, leading to reduction in the effective arterial blood volume. This leads to a diminished renal blood flow in cirrhotic patients, which in turn stimulates the rennin-angiotensin-aldesterone system (RAAS), sympathetic nervous system, and antidiuretic hormone resulting in renal artery vasoconstriction, sodium retention, and volume expansion. WorseninThese circulatory changes lead to the development of multiple life-threatening complications including hepatorenal syndrome (HRS), ascites, spontaneous bacterial peritonitis (SBP), gastroesophageal varices, and hepatopulmonary syndrome.The following is a review of the pathogenesis and clinical implications of the cardiovascular changes in cirrhosis.Arterial vasodilatation is regulated by complex interactions of different vasodilator molecules. Cirrhosis leads to portal hypertension which induces portosystemic collaterals, allowing gut-derived humoral substances to directly enter the systemic circulation without detoxification by the liver. In recent years, nitric oxide (NO) has been recognized as the most important vasodilator molecule in the splanchnic and systemic circulation. NO is overproduced in cirrhosis; measured serum levels are significantly elevated in both cirrhotic patients and in animal models.–10 NO is1114et al demonstrated that the selective inhibition of iNOS causes peripheral vasoconstriction in patients with cirrhosis but not in healthy-matched controls, suggesting the contribution of NOS in the regulation of peripheral vascular tone and the hyperdynamic circulation of end stage liver disease.[Three isoforms of NO synthase (NOS) have been described: endothelial (eNOS), inducible (iNOS), and neuronal (nNOS). However, the leading isoform contributing to these vascular changes remains obscure. Multiple studies using nonspecific NOS inhibitors revealed that diminishing NO production resulted in normalization of the peripheral vascular vasodilatation. Ferguson disease. Other st disease.–19Other agents that are thought to play a role in the peripheral vasodilatation of cirrhosis include endocannabinoids. They areet al, demonstrated that primary afferent denervation by capsaicin, reversed the hyperdynamic circulation in cirrhotic rats. These findings suugest that primary afferent nerves may be the signaling pathway from the periphery to the CNS. Detection of a marker protein (Fos) in the brainstem and hypothalamic cardiovascular-regulatory nuclei of rats, immediately following portal vien ligation, indicates CNS activation. This is followed by hyperdynamic circulation, suggesting that the CNS activation plays a role in the pathogenesis of the hyperdynamic circulation. Additionally, blocking CNS Fos expression in cirrhotic rats resulted in eliminating the development of the hyperdynamic circulation.[More recently, multiple studies have shown a potentially important role of the central nervous system in the pathogenesis of the portal hypertension-induced hyperdynamic circulation.–25 Liu eIn addition to the hyperdynamic circulation, impaired ventricular contractility in response to stimuli was also described in cirrhotic patients.–27 Initi283In the absence of specific diagnostic criteria, the exact prevalence of cirrhotic cardiomyopathy remains unclear. The characteristic features of cirrhotic cardiomyopathy include (a) an attenuated systolic or diastolic response to stress stimuli, (b) structural or histological changes in cardiac chambers, (c) electrophysiological abnormalities, and (d) serum markers suggestive of cardiac stress.The impaired cardiovascular responsiveness in cirrhosis is likely related to a combination of factors that include cardiomyocyte plasma membrane physicochemical changes, attenuated stimulatory pathways, and enhanced activity of inhibitory systems which includes the following:et al. found that β-adrenoceptors signaling pathway is also impaired at different levels, starting with decreased membrane content and function of the stimulatory Gs-protein and ending up with impaired activity of the adenylate cyclase enzyme itself.[β -adrenergic receptor function: The role of β-adrenergic receptors was examined in multiple studies. Heart cell contractility is mainly determined by the stimulatory β-adrenergic receptor system. This syse itself.–34Muscarinic receptor activity: Muscarinic responsiveness was found to be blunted in cirrhotic hearts. MuscarinMembrane fluidity: Membrane fluidity is a term used to describe the degree of motional freedom for lipid moieties in the lipid bilayer of the plasma membrane. It has b34et al. have shown altered control of vascular tone by Ca++ and K+ channels. In their study, potassium channel blockers resulted in a significant increase in the vascular tone in cirrhotic rats compared to normal rats.[+ channels in ventricular myocytes from cirrhotic rats, which could potentially explain the prolongation of the QT interval.[Altered membrane fluidity also affects the function of membrane-bound ion channels. Moreau mal rats.38 Anotheinterval. AdditionNitric oxide: NO plays an important role in regulating the systemic and coronary vascular tone and its effect has been implicated in the pathogenesis of different cardiac dysfunctions including ischemic heart disease.41 Non-seet al. investigated its role in the pathogenesis of cirrhotic cardiomyopathy. They showed that HO-1 mRNA transcription and protein expression are significantly augmented in ventricles of cirrhotic animals compared to controls. They also showed that the hemeoxygenase inhibition significantly decreased the elevated cGMP content and reversed the decreased contractility of isolated BDL papillary muscles with no affect on control muscles.[Carbon monoxide (CO): CO is a known vasodilator that also exerts a negative effect on cardiac contractility through cGMP. CO stimu muscles. Based onet al. showed that the blunted contractile response of isolated left ventricular papillary muscle from cirrhotic rats is restored after preincubation with a CB1 antagonist.[Endocannabinoids: Upregulation of the cannabinoid signaling pathway has been described in chronic liver disease. Endogeno46tagonist.This circulatory dysfunction characterized by arterial vasodilatation and an increase in cardiac output is the proposed pathophysiological mechanism leading to sodium and water retention in patients with liver cirrhosis. Initiall50et al. revealed that octerotide and midodrine therapy significantly improved renal function and 30 day survival in patients with type 1 hepatorenal syndrome.[Several indicators of poor prognosis in liver cirrhosis are those which occur in association with extreme peripheral arterial vasodilatation, including a low mean arterial blood pressure, portal hypertension, and the elevation of different neuroendocrinal substances. Thus, treatment targeting the circulatory dysfunction in these patients may improve the short-term prognosis while awaiting liver transplantation.–57 A recsyndrome.P=0.035).[Transjugular intrahepatic portosystemic shunt (TIPS) insertion in cirrhotic patients leads to significant hemodynamic changes. TIPS causes a sudden increase in the preload in patients who are manifesting a hyperdynamic circulation at the time of the shunt insertion.–62 Multi60P=0.035). These fiP=0.035). These stThe consequences of cirrhosis-related cardiovascular alterations can also be manifested at the time of transplantation. During orthotopic liver transplantation (OLT), the hyperdynamic circulation is further compromised by the effect of anesthesia, mechanical ventilation, and surgical clamping. This results in significant reduction in the preload and subsequently a reduction in the cardiac output.67 RipollPostoperatively, inappropriate fluid management could lead to either hypovolemia or fluid overload, which can also be a strain on the heart. Metabolic derangements in the immediate postoperative period can also impair the cardiac contractility and hence result in significant swings in the systemic hemodynamic parameters.2.[Hemodynamic depression caused by hypocalcemia-induced citrate intoxication from massive transfusion was reversed after the administration of CaCl2. On the oet al. reviewed one hundred and ninety-seven patients to clarify the factors that may be able to predict cardiac complications following OLT, of whom 40% suffered one or more cardiac complications within 6 months of the surgery. Pulmonary edema was the most common complication occurring in 30% of patients; other complications included overt heart failure, arrhythmia, pulmonary hypertension, pericardial effusion, and cardiac thrombus formation. In this study, adverse intraoperative cardiovascular events, previous cardiac disease, and advanced liver disease as quantified by MELD score, predicted post-operative cardiac complications. Other variables including age, sex, OLT indication, body mass index, blood pressure and smoking, had a poor predictive value. Additionally, none of the pre-OLT investigations including chest X-ray, electrocardiogram, echocardiography, coronary angiopgraphy, pulmonary arterial pressure and 2-methoxy isobutyl isonitrile scan, predicted post-operative cardiac complications.[Cardiac complications following liver transplantation are common involving up to 70% of patients; fortunately most of these complications are subclinical. Pulmonar6766Intrapulmonary vascular abnormalities consisting of pulmonary vascular dilatation, intrapulmonary shunting and a low pulmonary vascular resistance, have been described in patients with liver cirrhosis78 This i818386et al. demonstrated in a CBDL model that not only does the macrophage production of of NO increase, but it also has an up-regulating effect on the CO production, contributing further to the pulmonary hemodynamic changes.[Endotoxin, TNF-α, endothelin-1 (ET-1), and CO are among other factors that may contribute to the pulmonary vascular changes. More rec changes. Circulat changes.89 Intrap changes.91Portopulmonary hypertension is another syndrome that has been associated with end-stage liver disease. Portopulmonary hypertension is less prevalent than hepatopulmonary syndrome, with an estimated prevalence of around 5%.93 The pa9498et al, following which multiple imaging studies using various molecules confirmed these findings.[The pulmonary vascular dilatation and the intrapulmonary shunts in patients with liver cirrhosis are the leading contributors to hypoxemia in advanced liver disease. The low pulmonary vascular resistance leads to a reduction in the intrapulmonary transit time. This leads to a decrease in the oxygen diffusion across the dilated pulmonary vessels, and has been labeled as the alveolar-capillary disequilibrium hypothesis. Based on101findings.–105 Despfindings.Liver transplantation is the only definitive treatment for hepatopulmonary syndrome with at least 85% of patients experiencing significant improvement or complete resolution of hypoxemia following surgery. However,et al. compared survival in patients with potopulmonary hypertension versus idiopathic pulmonary hypertension and showed that patients with portopulmonary hypertension have a higher risk of death when compared to patients with idiopathic pulmonary hypertension.[Portopulmonary hypertension is associated with high mortality, ranging between 50-90% in 5 years. Kawut rtension. Postoperrtension.113 Patiertension.et al. examined the hemodynamics of 12 patients at 2 weeks and 2 months following liver transplantation and suggested that most of the hemodynamic changes reverse.[et al. studied the cardiac output in 21 patients before and at 1 or 2 years following transplantation. They showed that the high cardiac output persist at both time periods.[Liver transplantation results in correction of portal hypertension and reversal of all the pathophysiological mechanisms that lead to hyperdynamic circulation. The effect of liver transplantation on the systemic hemodynamics has been studied by different groups. We studied the hemodynamic changes of 66 patients in the immediate postoperative period, comparing patients with viral and alcoholic cirrhosis. We found reverse. On the o reverse.119 Hende periods. Another


The criteria for choosing relevant cell lines among a vast panel of available intestinal-derived lines exhibiting a wide range of functional properties are still ill-defined. The objective of this study was, therefore, to establish objective criteria for choosing relevant cell lines to assess their appropriateness as tumor models as well as for drug absorption studies.We made use of publicly available expression signatures and cell based functional assays to delineate differences between various intestinal colon carcinoma cell lines and normal intestinal epithelium. We have compared a panel of intestinal cell lines with patient-derived normal and tumor epithelium and classified them according to traits relating to oncogenic pathway activity, epithelial-mesenchymal transition (EMT) and stemness, migratory properties, proliferative activity, transporter expression profiles and chemosensitivity. For example, SW480 represent an EMT-high, migratory phenotype and scored highest in terms of signatures associated to worse overall survival and higher risk of recurrence based on patient derived databases. On the other hand, differentiated HT29 and T84 cells showed gene expression patterns closest to tumor bulk derived cells. Regarding drug absorption, we confirmed that differentiated Caco-2 cells are the model of choice for active uptake studies in the small intestine. Regarding chemosensitivity we were unable to confirm a recently proposed association of chemo-resistance with EMT traits. However, a novel signature was identified through mining of NCI60 GI50 values that allowed to rank the panel of intestinal cell lines according to their drug responsiveness to commonly used chemotherapeutics.This study presents a straightforward strategy to exploit publicly available gene expression data to guide the choice of cell-based models. While this approach does not overcome the major limitations of such models, introducing a rank order of selected features may allow selecting model cell lines that are more adapted and pertinent to the addressed biological question. A wide panel of intestinal cell lines is being used to study the biology of the intestine. All of these cell lines are either directly derived from primary colo-rectal cancers (CRCs) of different clinical stages and differentiation grades or from metastatic sites originated from a colon tumor. The major oncogenic pathways in colon cancer include loss of function mutations in APC, TP53 and SMAD4 (approximately 80–85% of sporadic tumors), or DNA mismatch repair genes, and activating mutations in beta-catenin . As a coWhile cancer drug discovery has mainly focused on targeting tumor cell proliferation, the outcome of a cancer depends largely on tumor invasion and dissemination . Recent The variety of available human cancer cell lines reflects the genomic heterogeneity across the human cancer population at least in part and has therefore regained attention notably to predict responsiveness of anticancer drugs ,16. StarIn this study we compare for the first time gene expression signatures relating to a wide panel of commonly known intestinal cell lines, primary cell cultures of human cancer-associated fibroblasts and laser-dissected human colonocytes, small intestinal enterocytes and tumor cells. We delineate selection criteria for CRC derived cell lines based on genomic expression patterns related to clinical parameters, migratory capacities and proliferative activities. While some cell lines are mainly being used to study mechanisms associated with tumor biology others serve as models for normal enterocytes studying drug absorption. Thus, we used the same strategy to assess the validity of models for oral drug absorption.Most dominant gene expression differences as revealed by principal component analysis (PCA) were observed between normal epithelium and all tumor-derived cell lines, and cells with epithelial versus mesenchymal properties.PCA was performed to assess the major gene expression differences between microdissected normal and tumor epithelium, primary cancer-associated fibroblast (CAF) cultures and the various CRC cell lines. PCA involves a mathematical procedure that transforms a number of possibly correlated variables into a smaller number of uncorrelated variables called principal components. Hence, the first principal component accounts for as much of the variability in the data as possible and each succeeding component accounts for as much of the remaining variability as possible. Two breast cancer cell lines with known pronounced MB231) or weak (MCF7) EMT traits  were inc or weak Next, the suitability of the various cell lines for tumor biology related studies was assessed. There are no standard models and selection criteria are not well defined. The activation of the Wnt pathway is a hallmark in colon carcinogenesis. Recent findings indicate that the Wnt activity defines CRC stem cells and is regulated by the microenvironment . Thus, tInvasive tumor cells acquire higher motility through EMT . Thus, wThe model of choice to evaluate drug absorption are Caco-2 cells as they undergo in vitro spontaneous enterocytic differentiation by developing an apical brush border membrane endowed with hydrolases such as sucrase-isomaltase and aminopeptidase N ,32-36. OConsequently, we made use of our objective approach to assess the suitability of the Caco-2 cells as model for oral drug absorption as compared to other CRC derived cell lines, taking inter-laboratory differences into account. As described above, PCA suggested that T84, HT29 and Caco-2 cells grown to confluency for 3 weeks were most similar to small intestinal enterocytes. Yet, when performing PCA filtering on solute carriers, transporters mostly responsible for active uptake, differentiated Caco-2 cells emerged as most akin to small intestinal enterocytes Figure . HoweverRecent reports suggest that chemotherapy may lead to a selection of tumor cells with EMT and stem cell properties and increased chemo-resistance . For exahttp://dtp.nci.nih.gov/docs/cancer/cancer_data.html).To extend this analysis we addressed more comprehensively to what extent EMT, HuISC and WNT signatures correlated with GI50 values of 50 commonly used chemotherapeutics in the NCI60 cell line panel . Clustering of the correlation coefficients revealed two distinct gene sets .In view of the heterogeneity of solid tumors ,43 and tScreening the literature with key words such as “absorption” and “transporters” revealed that, within the CRC cell line panel assessed herein, Caco-2 is the most widely used intestinal cell line for absorption-related studies -47. Comphttp://dtp.nci.nih.gov/docs/cancer/cancer_data.html). We therefore probed these data sets for a correlation between EMT and CSC signatures and chemoresistance. Using the EMT signature defined herein, we could indeed confirm such a correlation in the breast cancer data set of Gupta et al. l results,41,55-58Click here for fileFigure S4. Enrichment of small intestinal signature in Caco-2 cells upon differentiation. Heatmap representing enrichment scores obtained by gene set enrichment analysis of the selected panel of gene sets. Genes in the various cell lines were ranked according to their relative average expression (n = 2-3) in the given cell line compared to a panel of healthy epithelial tissues. Details see Additional file Click here for file


Although several studies did not demonstrate that daptomycin may cause significantly higher rates of pulmonary adverse effects when compared with vancomycin or penicillinase-resistant penicillins, there have been a few case reports of severe pulmonary complications associated with daptomycin administration.A rare case of eosinophilic pneumonia occurring 10 days after daptomycin administration in a 78-year-old Caucasian man with possible infectious endocarditis is described. He developed new onset fever, up to 38.5°C, with bilateral pulmonary crackles on physical examination and with no signs of severe respiratory failure. A chest computed tomography-scan showed bilateral nodular consolidations with air bronchograms and pleural effusions. Immediate discontinuation of daptomycin was followed by vigorous improvement of clinical signs and symptoms with progressive resolution of pulmonary consolidations a month later.Physicians should be aware of this rare but serious complication during daptomycin treatment, and prompt discontinuation of the offending agent, with or without additional supportive treatment, must occur immediately. Acute EStaphylococcus aureus [enterococci [Daptomycin, an antimicrobial agent of the cyclic lipopeptide group of antibiotics, has an outstanding coverage for Gram-positive bacteria and is licensed for the treatment of bacteraemia and right-sided endocarditis due to methicillin-susceptible and methicillin-resistant s aureus . It is aerococci . Althougerococci -7, recenerococci -11.We present a case of pulmonary infiltrates and broncho-alveolar lavage eosinophilia occurring during treatment with daptomycin in a patient with possible infectious endocarditis (IE). In this particular case, and in contrast to previously published reports, our patient did not develop severe respiratory failure, and direct discontinuation of daptomycin without the systemic administration of corticosteroids was associated with the progressive and complete resolution of clinical manifestations and laboratory disturbances.A 78-year-old Caucasian man, with a history of coronary artery disease, presented with symptoms of acute congestive heart failure (CHF) including dyspnea at rest, orthopnea and paroxysmal nocturnal dyspnea.The patient had a history of a transurethral prostatectomy (TURP) one month before admission. A week after the TURP, he developed a fever of 38.5°C that was considered a manifestation of a post-operative urinary tract infection and was treated empirically with oral ciprofloxacin 500 mg twice daily. The fever did not respond and treatment changed to oral amoxicillin/clavulanic 1 g twice daily and intramuscular netilmicin, 300 mg once daily. The fever resolved and no other clinical manifestations developed until the day of admission to our hospital. Regarding his past medical history, he was a non-smoker, he had no known allergies and he did not mention any recent travels.2 was 92% on ambient air. The remaining physical examination revealed decreased breath sounds at both lung bases and inspiratory crackles at the lower pulmonary fields bilaterally, a 4/6 diastolic heart murmur at the lower left parasternal area and a 4/6 systolic heart murmur at the right upper parasternal area. Laboratory studies revealed a leukocyte count 8350/μL, hematocrit 36.8%, platelet count 270,000/μL and C-reactive protein (CRP) 1.0 mg/dL . A chest radiogram showed bilateral perihilar alveolar edema with a "butterfly" appearance and bilateral pleural effusions  as well. Despite the treatment, there was no clinical improvement. A thoracocentesis with a collection of pleuritic fluid for analysis was performed and the latter revealed a transudate with 6700 nucleated cells . In addition, cultures for acid fast-bacilli and adenosine deaminase activity test of the pleuritic fluid were negative. To further investigate the nature of the aforementioned clinical syndrome a bronchoscopy with BAL was carried out, which disclosed 480 nucleated cells/μL . Additional cultures for acid fast-bacilli, fungal and parasitic infections were also negative. Given the above findings the diagnosis of EP was made, daptomycin (as a probable cause of EP) was replaced by linezolid and moxifloxacin with meropenem were discontinued. Twenty-four hours after the daptomycin withdrawal the fever resolved completely. During the following seven days a significant improvement of the clinical and radiographic findings occurred, whereas CRP was within the normal range. One month later, a follow up chest-HRCT was normal  or acute respiratory distress syndrome (PaO2/FiO2 <200 mmHg). It typically appears as areas of consolidation and ground-glass opacity on CT imaging, usually involving the peripheral pulmonary parenchyma. In addition, it may or may not be associated with peripheral blood eosinophilia, however pulmonary eosinophilic infiltrates or BAL eosinophilia are the corner stone for the diagnosis of EP [2/FiO2 ratio being 276. Moreover, in imaging studies with chest-HCRT he developed the characteristic pattern of bilateral peripheral consolidations and ground-glass opacities that we usually find in cases with eosinophilic pneumonia. Finally, BAL fluid examination revealed significant eosinophilia, a condition that is fundamental for the diagnosis of EP, whereas parasitic and fungal infections were excluded. However, before the accomplishment of the bronchoscopy procedure, we considered it essential to carry out a serological screening for autoimmune markers and a thoracocentesis, in order to examine the pleuritic fluid. Indeed, pleuritic fluid analysis revealed a transudate while cultures for acid fast bacilli and ADA test were negative; findings that were inconsistent with the possibility of tuberculosis as a cause of the clinical syndrome in our case. In addition, serological screening for autoimmune markers was also performed with the intention of excluding diseases of autoimmune origin, such as small vessel vasculitis, or systemic lupus erythematosus, conditions that may both provoke significant pulmonary lesions and non-infectious endocarditis [Drug-induced EP can appear either as an acute or as a chronic syndrome that may occur within days or weeks after starting the offending agent. Diagnosis usually requires synthesis of information including clinical history, laboratory data and radiologic findings . Patientis of EP . A lung carditis ,15.Patients with idiopathic EP often require systemic corticosteroids treatment whereas those with drug induced EP demonstrate significant improvement, only with offending agent withdrawal. However, cases with persistent symptoms may need treatment with systemic corticosteroids and additional respiratory support with supplemental oxygen and assisted ventilation.The EP described in our case is most likely attributable to an adverse drug reaction due to daptomycin administration. The patient had no history of chronic primary lung disease and he developed significant pulmonary abnormalities early after daptomycin initiation and had a remarkable improvement soon after daptomycin discontinuation. To the best of our knowledge, only five cases of EP associated with daptomycin have been reported thus far, but they should be considered in individuals who receive the drug and develop new pulmonary infiltrates -11. In tin vitro and in vivo studies are necessary in order to elucidate its toxicity biochemical pathways. The primary mechanism of action involves calcium-dependent transitions, which are responsible for conformational changes of the daptomycin molecule that allow interactions with cytoplasmic membrane, enhancing daptomycin-cytoplasmic membrane binding capacity and cytoplasmic membrane permeability. The latter may induce significant leakage of intracellular ions, such as potassium. It has been recently demonstrated that synthetic surfactant binds to daptomycin and diminishes its antibacterial activity [Daptomycin's toxicity mechanism remains uncertain and further activity . Therefoactivity .Daptomycin is a relatively new drug extensively used in tertiary health care units and in intensive care practice with excellent results regarding its antimicrobial activity. Although extremely rare, daptomycin-induced EP must be considered for patients who receive the drug and develop new unexplained pulmonary infiltrates. Significant morbidity and mortality may occur if this condition remains unrecognized and not properly treated in a timely fashion. Finally, further investigation through experimental and clinical studies needs to be completed in order to elucidate the exact mechanism behind this rare yet grave adverse drug reaction.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All authors are aware of and approved the manuscript being submitted to this journal. AK has made substantial contributions in drafting and revising the manuscript. ST, DL, PF and AS have been involved in revising the manuscript critically for important intellectual content. AS has given final approval of the version to be published.


Glutamatergic hilar mossy cells of the dentate gyrus can either excite or inhibit distant granule cells, depending on whether their direct excitatory projections to granule cells or their projections to local inhibitory interneurons dominate. However, it remains controversial whether the net effect of mossy cell loss is granule cell excitation or inhibition. Clarifying this controversy has particular relevance to temporal lobe epilepsy, which is marked by dentate granule cell hyperexcitability and extensive loss of dentate hilar mossy cells. Two diametrically opposed hypotheses have been advanced to explain this granule cell hyperexcitability—the “dormant basket cell” and the “irritable mossy cell” hypotheses. The “dormant basket cell” hypothesis proposes that mossy cells normally exert a net inhibitory effect on granule cells and therefore their loss causes dentate granule cell hyperexcitability. The “irritable mossy cell” hypothesis takes the opposite view that mossy cells normally excite granule cells and that the surviving mossy cells in epilepsy increase their activity, causing granule cell excitation. The inability to eliminate mossy cells selectively has made it difficult to test these two opposing hypotheses. To this end, we developed a transgenic toxin-mediated, mossy cell-ablation mouse line. Using these mutants, we demonstrated that the extensive elimination of hilar mossy cells causes granule cell hyperexcitability, although the mossy cell loss observed appeared insufficient to cause clinical epilepsy. In this review, we focus on this topic and also suggest that different interneuron populations may mediate mossy cell-induced translamellar lateral inhibition and intralamellar recurrent inhibition. These unique local circuits in the dentate hilar region may be centrally involved in the functional organization of the dentate gyrus. The hippocampal formation is critically involved in various brain functions such as spatial memory and navigation  axis , while dentate granule cells appear to be relatively resistant  “mossy cell loss-induced sprouting” hypothesis, (2) “dormant basket cell” hypothesis, and (3) “irritable mossy cell” hypothesis. The first theory, “mossy cell loss-induced sprouting” hypothesis, proposes that the epilepsy-induced loss of mossy cells triggers mossy fiber sprouting, which generates epileptogenesis Nadler, . HoweverA receptor-mediated inhibition of granule cells. In his model, physiological abnormality in dentate granule cell was seen only in animals that exhibited a loss of adjacent dentate hilar mossy cells and hilar somatostatin/neuropeptide Y-inimunoreactive neurons. GABA-immunoreactive dentate basket cells survived despite the extensive loss of adjacent hilar neurons. However, parvalbumin (PV) immunoreactivity, present normally in a subpopulation of GABA-immunoreactive dentate basket cells, was absent on the stimulated side. According to these results, he proposed the following hypothesis. After mossy cell loss, the excitatory synapses on interneurons  in the distant lamella are removed, making these translamellar interneurons hypoactive (“dormant”) and thereby creating a seizure-prone dentate network. On the other hand, mossy cell-driven translamellar interneurons inhibit granule cells under normal condition, thereby dentate information flows only in a particular lamella to CA3  granule cell excitability to perforant-path stimulation  line , immunostaining of GluA2/3 and calretinin (mossy cell markers) and Fluoro-Jade B staining for labeling neurodegeneration revealed that this mossy cell-restricted diphtheria toxin receptor expression line  showed an extensive mossy cell degeneration. The degree of degeneration was up to nearly 80% within a week and eventually 90% after 1 month, throughout the longitudinal axis of both dorsal and ventral hippocampus (Figure Recently we have generated a transgenic toxin-mediated, mossy cell-degeneration mouse line, by crossing the mossy cell/CA3-restricted Cre line with forebrain-restricted s Figure . WhereasOur findings have several implications for the existing theories regarding the role of mossy cell loss in epileptogenesis. First, our results revealed that acute granule cell hyperexcitability follows the selective and extensive degeneration of mossy cells, which provides the first direct evidence for a net inhibitory role of mossy cells in the dentate gyrus. Thus, these results support the central tenet of the “dormant basket cell” hypothesis, which states that mossy cell loss reduces the excitatory drive onto the inhibitory basket cells, hence they become “dormant” and as a result, dentate granule cells become hyperexcitable (Sloviter, Second, despite of strong support for dormant basket cell hypothesis, our findings also indicate that the granule cell hyperexcitability caused by mossy cell loss in this mouse model is apparently not enough to cause spontaneous granule cell epileptiform discharges or spontaneous behavioral seizures. Granule cells are possibly powerful amplifiers of excitation, but the disinhibited granule cells alone may not generate spontaneous epileptiform discharges unless abnormal excitatory inputs elicit spontaneous epileptiform discharges in granule cells. One plausible explanation is the involvement of the entorhinal cortex and other related structures in temporal lobe epileptogenesis. Schwarcz and colleagues (Du et al., Third, we did not see any signature for “irritable” mossy cells, even if 10–20% of mossy cells survived in the mutants, because sEPSC frequency of granule cells in mutant mice was robustly reduced upon mossy cell degeneration. Accordingly, granule cell hyperexcitability in the mutants is unlikely due to the hyperexcitability of surviving mossy cells after DT treatment. However, we do not exclude a possibility that surviving mossy cells play a role in spreading excitability through their long-range direct connections to granule cells.Fourth, our findings suggest that mossy cell loss alone is insufficient to trigger mossy fiber sprouting. As one of potential mechanisms of reverberating excitation in the dentate gyrus of epileptic brains, mossy fiber sprouting has been extensively studied since the original findings of Nadler and colleagues (Tauck and Nadler, Finally, instead of mossy fiber sprouting, we observed compensatory GABAergic sprouting onto IML which began as early as 2 weeks after DT treatment and gradually progressed until 6–8 weeks after mossy cell degeneration. Concomitantly, the sIPSC frequency from the mutant granule cells, which was transiently decreased during the acute phase, returned back to the normal level by the chronic phase. This suggests that this slow process of synaptic reorganization may reverse the acute granule cell hyperexcitability.Our findings may also shed light on the mechanisms of dentate pattern separation. There are several possibilities that may explain the context discrimination deficits observed following mossy cell loss in the mutant mice. First, electrophysiological recordings from dentate gyrus of awake behaving rats demonstrated decorrelated firing patterns of the dentate granule cells in response to subtle changes in input as evidence for pattern separation (Leutgeb et al., Alternatively, mossy cell loss may disturb the feed-back regulation by CA3 cells of the pattern separation function, since mossy cells appear to be under direct modulation by CA3 axons, that back-project to the dentate gyrus (Scharfman, Finally, considering a likely role of newborn granule cells in the mnemonic processes (Aimone et al., There are a few limitations of the mossy cell deletion mouse model (Jinde et al., Our study using mossy cell degeneration mutant mice revealed that mossy cell-driven GABAergic interneurons play a crucial role in granule cell inhibition. Since mossy cells presumably project to virtually all types of interneurons across lamellae, except interneuron-selective cells (Zappone and Sloviter, Furthermore, analysis of granule cell-rise time separated in these preparation raises a possibility that two distinct types of interneurons that provide IPSCs of, project to the same granule cells, in relation to the location of mossy cells activating them Figure . One groA receptor subunits inserted at the synapse also depend on the types of presynaptic interneurons. Kinetics of GABAergic transmission depends on the subunit composition of the GABAA receptors, and α subunits are particularly important among others. For example, GABAergic transmission involves α1 subunit at fast-spiking basket cell to CA1 pyramidal cell synapses (Thomson et al., A receptors usually demonstrate fast-rise time kinetics, while α5 GABAA receptor subunits which are utilized for example, at the bitufted cell to pyramidal cell synapses in the somatosensory cortex display slower rise time kinetics (Ali and Thomson, It is widely accepted that properties of the presynaptic cells as well as the target cells determine the synaptic properties (Klausberger and Somogyi, According to anatomical studies, we know that most interneuron types in the dentate gyrus receive inputs from mossy cells and that mossy cells are involved in translamellar lateral inhibition (Buckmaster et al., in vitro slice recording using the mutant mice, we hypothesize that there are two distinct populations of mossy cell-driven interneurons which inhibit dentate granule cells. One is a type of interneurons with slow-rise time kinetics of sIPSCs at the granule cell synapse which receive inputs from mossy cells in an intra-lamellar manner. Another one is a basket cell-like interneuron-type with fast-rise time kinetics which receives excitatory input from mossy cells in a translamellar manner. Since our study as well as previous literature (Zappone and Sloviter, Here we presented an overview the characteristics of mossy cells, including connectivity, physiology and function. We described the involvement of mossy cells in temporal lobe epilepsy and mnemonic processes, reviewing several hypotheses addressing the effect of mossy cell loss. We further summarized the recent results from our transgenic mouse that exerts toxin-mediated mossy cell degeneration. The toxin-induced selective mossy cell degeneration resulted in acute granule cell hyperexcitability, which suggests a net inhibitory effect of mossy cells. Despite this, no epileptic seizure or mossy fiber sprouting was observed after mossy cell degeneration. Based on our 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.