Migraine: imaging the aura

We currently conceive of a migraine attack as originating in the brain. Triggers of an attack initiate a depolarizing neuroelectric and metabolic event likened to the spreading depression of Leao. This event activates the headache and associated features of the attack by mechanisms that remain to be determined, but appear to involve either peripheral trigeminovascular or brainstem pathways, or both. The excitability of cell membranes, perhaps partly genetically determined, is the brain's susceptibility to attacks. Factors that increase or decrease neuronal excitability constitute the threshold for triggering attacks. Using a model of visual stress-induced migraine or by studying spontaneous attacks and applying advanced imaging and neurophysiological methods, results have been obtained that support spreading neuronal inhibition as the basis of aura. This neuroelectric event is accompanied by hyperoxia of the brain, possibly associated with vasodilation. Evidence has also been obtained that the spreading cortical event can activate the subcortical centers possibly involved in nociception and associated symptoms of the migraine attack. Susceptibility to migraine attacks appears to be related to brain hyperexcitability. These newer techniques of functional neuroimaging have confirmed the primary neural basis of the migraine attack with secondary vascular changes, reconciling previous theories into a neurovascular mechanism.     

Adjuvant therapy for resectable liver metastases: Can metastatic colorectal cancer be cured?

Surgery remains the only curative therapy for patients with liver metastases from colorectal cancer. Unfortunately, only a minority of patients are candidates. The use of clinical prognostic indicators and computer programs, such as OncoSurge, may help to identify optimal candidates. Neoadjuvant chemotherapy may render previously ineligible patient candidates for curative surgery after downsizing. Neoadjuvant chemotherapy is associated with histopathologic changes of the liver, and the effect of such changes on survival is unclear. Promising results have been seen with chemotherapy infused through the hepatic artery in conjunction with systemic chemotherapy in the neoadjuvant and adjuvant settings. Adjuvant therapy with oxaliplatin-or irinotecan-based regimens after resection of liver metastases is generally recommended. Individuals should be encouraged to participate in clinical trials to help clarify the role and optimal sequencing of systemic chemotherapy, targeted agents, local therapies, and surgery for patients with hepatic metastases from colorectal cancer.     

Definition of a saxitoxin (STX) binding code enables discovery and characterization of the anuran saxiphilin family

American bullfrog (Rana castesbeiana) saxiphilin (RcSxph) is a high-affinity “toxin sponge” protein thought to prevent intoxication by saxitoxin (STX), a lethal bis-guanidinium neurotoxin that causes paralytic shellfish poisoning (PSP) by blocking voltage-gated sodium channels (Na_Vs). How specific RcSxph interactions contribute to STX binding has not been defined and whether other organisms have similar proteins is unclear. Here, we use mutagenesis, ligand binding, and structural studies to define the energetic basis of Sxph:STX recognition. The resultant STX “recognition code” enabled engineering of RcSxph to improve its ability to rescue Na_Vs from STX and facilitated discovery of 10 new frog and toad Sxphs. Definition of the STX binding code and Sxph family expansion among diverse anurans separated by ∼140 My of evolution provides a molecular basis for understanding the roles of toxin sponge proteins in toxin resistance and for developing novel proteins to sense or neutralize STX and related PSP toxins.

Saxitoxin (STX), one of the most potent nonpeptidyl neurotoxins, blocks the bioelectrical signals in nerve and muscle required for life by inhibiting select voltage-gated sodium channel (Na_V) isoforms (1–3). Cyanobacteria and dinoflagellate species associated with oceanic red tides produce this bis-guanidinium small molecule and its congeners, whose accumulation in seafood can cause paralytic shellfish poisoning (PSP), a commercial fishing and public health hazard of growing importance due to climate change (1, 3–5). Its lethality has also earned STX the unusual distinction of being the only marine toxin declared a chemical weapon (1, 3). Select vertebrates, particularly frogs, resist STX poisoning (6–9), a property that is thought to rely on the ability of the soluble “toxin sponge” protein saxiphilin (Sxph) to sequester STX (8, 9). Recent structural studies (10) defined the molecular architecture of the American bullfrog [Rana (Lithobates) castesbeiana] Sxph (RcSxph) (8, 11–14) showing that this 91-kDa soluble, transferrin-related protein from frog heart and plasma has a single, high-affinity STX binding site on its C lobe. Remarkably, even though RcSxph and Na_Vs are unrelated, both engage STX through similar types of interactions (10). This structural convergence raises the possibility that determination of the factors that underlie the high-affinity Sxph:STX interaction could provide a generalizable molecular recognition code for STX that would enable the identification or engineering of STX binding sites in natural and designed proteins.To characterize RcSxph:STX interactions in detail, we developed a suite of assays comprising thermofluor (TF) measurements of ligand-induced changes in RcSxph stability, fluorescence polarization (FP) binding to a fluorescein-labeled STX, and isothermal titration calorimetry (ITC). We paired these assays with a scanning mutagenesis strategy (15, 16) to dissect the energetic contributions of RcSxph STX binding pocket residues. These studies show that the core RcSxph STX recognition code comprises two “hot spot” triads. One engages the STX tricyclic bis-guanidinium core through a pair of carboxylate groups and a cation–π interaction (17) in a manner that underscores the convergent STX recognition strategies shared by RcSxph and Na_Vs (17–22). The second triad largely interacts with the C13 carbamate group of STX and is the site of interactions that can enhance STX binding affinity and the ability of RcSxph to act as a “toxin sponge” that can reverse the effects of STX inhibition of Na_Vs (8, 9).Although Sxph-like STX binding activity has been reported in extracts from diverse organisms including arthropods (13), amphibians (11, 13, 23), fish (13), and reptiles (13), the molecular origins of this activity have remained obscure. Definition of the RcSxph STX recognition code enabled identification of 10 new Sxphs from diverse frogs and toads. This substantial enlargement of the Sxph family beyond RcSxph and the previously identified High Himalaya frog (Nanorana parkeri) Sxph (NpSxph) (10) reveals a varied STX binding pocket that surrounds a conserved core of “hot spot” positions. Comparison of the new Sxph family members further identifies dramatic differences in the number of thyroglobulin (Thy1) domains inserted into the modified transferrin fold upon which the Sxph family is built. Biochemical characterization of NpSxph, Oophaga sylvatica Sxph (OsSxph) (24), Mantella aurantiaca Sxph (MaSxph), and Ranitomeya imitator Sxph (RiSxph), together with structural determination of NpSxph, alone and as STX complexes, shows that the different Sxphs share the capacity to form high-affinity STX complexes and that binding site preorganization (10) is a critical factor for tight STX association. Together, these studies establish an STX molecular recognition code that provides a template for understanding how diverse STX binding proteins engage the toxin and its congeners and uncover that Sxph family members are abundantly found in the most varied and widespread group of amphibians, the anurans. This knowledge and suite of diverse Sxphs, conserved among anuran families separated by at least 140 My of evolution (25), provide a starting point for defining the physiological roles of Sxph in toxin resistance (9, 24, 26), should facilitate identification or design of other STX binding proteins, and may enable the development of new biologics to detect or neutralize STX and related PSPs.     

Development and validation in Ecuador of the EPD Questionnaire,a diabetes‐specific patient‐reported experience and outcome measure: A mixed‐methods study

IntroductionThe global prevalence of diabetes in 2019 in adults was estimated to be 9.3%. This study developed in Ecuador, for the first time, instruments to assess patient‐reported outcomes and experiences.MethodsThe Experiences of the Person with Diabetes (EPD) Questionnaire is a diabetes‐specific instrument. A mixed‐methods study was conducted. First, a qualitative item development phase that included four focus groups and six semi‐structured interviews with patients was conducted in different rural and urban areas of Ecuador to obtain information on culture, beliefs, demographics, diet and social perspectives. A second quantitative phase for psychometric validation was carried out in primary care settings of rural and urban areas of Ecuador.ResultsForty‐two and four hundred and eighty‐nine participants were included in each phase, respectively. The item development phase resulted in a questionnaire of 44 items (23 for perceived outcomes and 21 for experiences). In the validation study, most participants were women (58%) and from urban areas (57%). Exploratory factor analysis revealed three dimensions for each instrument. Outcomes instrument dimensions were symptoms and burnout, worries and fears and social limitations. Experiences instrument dimensions were information, patient‐centred care and care delivery. Cronbach''s α values of the total score and dimensions were high, ranging between .81 and .93 in both instruments. Confirmatory factor analysis showed an acceptable fit of the data.ConclusionThe EPD Questionnaire is probably the first instrument developed to assess patient‐reported experiences and perceived outcomes in a middle‐income country that included patients to capture all dimensions relevant for the intended population. Its psychometric properties are robust and could provide valuable information for clinicians and policymakers in the region.Patient or Public ContributionThe development of these instruments has taken into consideration patients and the public since their conception. A qualitative approach gathered relevant information related to the cultural, social and economic burden of different populations in Ecuador. Before validation, a pilot test was carried out with users of the National Health Services to obtain their perspectives and insights of the developed instrument. Finally, during the data analysis, we have given special consideration to social variables such as rural and urban populations.     

Atomic force microscopy for biomechanical and structural analysis of human dermis: A complementary tool for medical diagnosis and therapy monitoring

Skin mechanical properties are usually measured considering the entire skin thickness and very little is known about the mechanical behaviour of individual skin layers. We propose atomic force microscopy (AFM) as a tool to quantify nanoscale changes in the biomechanical properties and ultrastructure of human papillary dermis exposed to different mechanical and physical stimuli. Samples from 3 human skin biopsies were studied: one stretched by obesity, one subjected to a high level of sun exposure and normal skin as control. Slices of the papillary dermis layer were harvested at controlled depths from each skin biopsy and 25 μm² areas of each slice were imaged and D‐periodicity of collagen fibres measured by AFM, together with their stiffness. Standard histological analysis was also carried out to correlate biochemical properties and their distribution with stiffness and topography. We obtained similar stiffness values between the sample affected by obesity and the control sample at any depth level into the dermis, while the sun‐exposed sample presented a significantly lower stiffness. Additionally, all samples presented an increase in the stiffness at higher depths into the papillary dermis layer. Collagen fibres close to the epidermis of sample affected either by obesity and sun exposure—the former even more than the latter—are thicker and present a larger D‐period than those in the control sample. Our results open the possibility to use structural and mechanical analysis based on AFM as a complementary tool for medical diagnosis and therapy monitoring.     

Medicalización de la vida en la consulta: ¿hacia dónde caminamos?

The power of medicine has lately enhanced the idea of medicalizing any aspects of life that can be perceived as medical problems. Medicine sometimes creates false needs and there is nowadays an increasing number of situations are medicalized with the pretext of treating fake diseases such as spring fatigue, shyness o natural biological processes like menopause.Despite the better life conditions, we now attend more people that complain about discomfort that may have more to do with «feeling sick» than with authentic disease. There is an endless list: sadness, hyperactive children, anorexia, bulimia, vigorexia or problematic teenagers, amongst others. In this article we revise some interventions that, contribute to promote these situations also from the own doctor's office. Everyday adversity acquires today the status of disease, hence the remarkable increase in these consultations in the diverse sanitary services.