Phenylalanine as an effective stabilizer and aggregation inhibitor of Bacillus amyloliquefaciens alpha-amylase.

Aromatic compounds are known anti-amyloid aggregates. Their effect on amorphous aggregates of proteins is, however, less studied. We chose aromatic amino acids Trp, Tyr, and Phe, as well as another known stabilizer (i.e. Arg), as potential compatible solvents to be tested on Bacillus amyloliquefaciens alpha-amylase (BAA). Among these additives, Phe was the only one to be effective on the thermal inactivation and amorphous aggregation of BAA, while preserving its intrinsic activity. A concentration of 50 mM Phe was used to test its potential in counteracting the deleterious effect of BAA amorphous aggregates in vivo. After 21 days of daily subcutaneous injections of the native enzyme to mice, amorphous aggregates of BAA, as well as aggregates produced in presence of 50 mM Phe, the tissues located at the site of injection were studied histologically. Amorphous aggregates caused an increase in macrophages and lipid droplets. Serum levels of IL6 and TNF-α were also accordingly elevated and indicative of an inflammation state. Aggregates also resulted into increased levels of glucose, triglycerides and cholesterol, as well as liver enzymes SGOT and SGPT. On the other hand, the presence of Phe prevented this exacerbated inflammatory state and the subsequent impairment of biochemical parameters. In conclusion, Phe is an interesting compound for both stabilizing proteins and counteracting the pathological effect of amorphous aggregates.

Decoding the Structure-Function Relationship of the Muramidase Domain in E. coli O157.H7 Bacteriophage Endolysin: A Potential Building Block for Chimeric Enzybiotics.

Bacteriophage endolysins are potential alternatives to conventional antibiotics for treating multidrug-resistant gram-negative bacterial infections. However, their structure-function relationships are poorly understood, hindering their optimization and application. In this study, we focused on the individual functionality of the C-terminal muramidase domain of Gp127, a modular endolysin from E. coli O157:H7 bacteriophage PhaxI. This domain is responsible for the enzymatic activity, whereas the N-terminal domain binds to the bacterial cell wall. Through protein modeling, docking experiments, and molecular dynamics simulations, we investigated the activity, stability, and interactions of the isolated C-terminal domain with its ligand. We also assessed its expression, solubility, toxicity, and lytic activity using the experimental data. Our results revealed that the C-terminal domain exhibits high activity and toxicity when tested individually, and its expression is regulated in different hosts to prevent self-destruction. Furthermore, we validated the muralytic activity of the purified refolded protein by zymography and standardized assays. These findings challenge the need for the N-terminal binding domain to arrange the active site and adjust the gap between crucial residues for peptidoglycan cleavage. Our study shed light on the three-dimensional structure and functionality of muramidase endolysins, thereby enriching the existing knowledge pool and laying a foundation for accurate in silico modeling and the informed design of next-generation enzybiotic treatments.

Structural insights into the pathogenicity of point mutations in human acyl-CoA dehydrogenase homotetramers.

Acyl-CoA dehydrogenase deficiency (ACAD) is an inherited and potentially fatal disorder with variable clinical symptoms. The relationship between pathogenicity and deleterious point mutations is investigated here in ACAD structures of short (SCAD) and medium-chain (MCAD) types. Structures and dynamic features of native and mutant forms of enzymes models were compared. A total of 2.88 µs molecular dynamics simulations were performed at four different temperatures. Total energy, RMSD, protein ligand interactions and affinity, RMSF measures, secondary structure changes, and important interactions were studied. Mutations in the three main domains of ACADs are pathogenic, while those located at linker turns are not. Mutations affect mostly tetramer formations, secondary structures, and many contacts and interactions. In R206H (MCAD mutant) which is experimentally known to cause a huge turnover decrease, the lack of a single H-bond between substrate and FAD was observed. Secondary structures showed temperature-dependent changes, and SCAD activity was found to be highly correlated to the enzyme helix 3-10 content. Finally, RMSF patterns pointed to one important loop that maintains the substrate close to the active site and is a cause of substrate wobbling upon mutation. Despite similar structure, function, and cellular location, SCAD and MCAD may have different optimum temperatures that are related to the structure taken at that specific temperature. In conclusion, new insight has been provided on the effect of various SCAD and MCAD pathogenic mutations on the structure and dynamical features of the enzymes.

Correction to: Drug repurposing using computational methods to identify therapeutic options for COVID-19.

[This corrects the article DOI: 10.1007/s40200-020-00546-9.].

General Anesthesia in Schwartz-Jampel Syndrome: A Case Report.

Introduction: Schwartz-Jampel syndrome (SJS) is a rare autosomal recessive disease characterized by muscle weakness and stiffness, abnormal bone development, short stature, joint contractures, and facial dysmorphisms. Myopathy, anatomical deformities, and malignant hyperthermia are challenging for anesthesiologists. Case Presentation: This case report describes one case of SJS. The female patient was scheduled for Blepharoplasty in Rasuol Akram General Hospital. Conclusions: These patients may have difficult intubation and be prone to malignant hyperthermia. We managed this patient by applying Rocuronium, propofol, and C-MAC video laryngoscopy.

Chemical Modification of the Amino Groups of Human Insulin: Investigating Structural Properties and Amorphous Aggregation of Acetylated Species.

The efficacy of human recombinant insulin can be affected by its aggregation. Effects of acetylation were observed on insulin structure, stability, and aggregation at 37 and 50 °C and pH of 5.0 and 7.4 with the use of spectroscopy, circular dichroism (CD), dynamic light scattering (DLS), and atomic force microscopy (AFM). Raman and FTIR results were indicative of structural changes in AC-INS, and CD analyses showed a slight increase in ß-sheet content in AC-INS. Melting temperature (Tm) measurements indicated an overall more stable structure and spectroscopic assessment showed a more compact one. Formation of amorphous aggregates was followed over time and kinetics parameters showed a longer nucleation phase (higher t* amount) and lower aggregates amount (lower Alim) for acetylated insulin (AC-INS) compared to native (N-INS) in all tested conditions. The results of amyloid-specific probes approved the formation of amorphous aggregates. Size particle and microscopic analysis suggested that AC-INS was less prone to form aggregates, which were smaller if formed. In conclusion, this study has demonstrated that controlled acetylation of insulin may lead to its higher stability and lower propensity toward amorphous aggregation and has provided insight into the result of this type of post-translational protein modification.

Comparison of Effects of Stress and Midazolam on Retrograde and Anterograde Amnesia in Patients Undergoing General Anesthesia.

Background: The identification of different factors affecting anesthesia and physiological changes during anesthesia can be effective in improving the quality of anesthesia. Midazolam is a benzodiazepine that has been used for many years for sedation under anesthesia. Stress is also an important factor affecting memory and other physiological changes, such as blood pressure and heart rate. Objectives: his study aimed to investigate the effects of stress on retrograde and anterograde amnesia among patients undergoing general anesthesia. Methods: This multi-center, parallel, stratified, randomized controlled trial was performed on patients undergoing non-emergency abdominal laparotomy. The patients were divided into high- and low-stress groups according to the Amsterdam Preoperative Anxiety and Information Scale. Then, both groups were randomly divided into three subgroups receiving 0, 0.02, or 0.04 mg/kg of midazolam. Recall cards were shown to patients at 4 minutes, 2 minutes, and immediately before injection to determine retrograde amnesia and at 2 minutes, 4 minutes, and 6 minutes after injection to determine anterograde amnesia. Hemodynamic changes were recorded during intubation. The chi-square and multiple regression tests were used to analyze the data. Results: Midazolam injection was associated with the development of anterograde amnesia in all groups (P < 0.05); however, it had no effect on the development of retrograde amnesia (P < 0.05). Midazolam could decrease the systolic and diastolic blood pressure and heart rate during intubation (P < 0.05). Stress also caused retrograde amnesia in patients (P < 0.05); nevertheless, it had no effect on anterograde amnesia (P > 0.05). Stress and midazolam injection could not affect the oxygen levels during intubation. Conclusions: The results showed that midazolam injection could induce anterograde amnesia, hypotension, and heart rate; nonetheless, it had no effect on retrograde amnesia. Stress was associated with retrograde amnesia and increased heart rate; however, it was not associated with anterograde amnesia.

Local Insulin-Derived Amyloidosis Model Confronted with Silymarin: Histological Insights and Gene Expression of MMP, TNF-α, and IL-6.

Amyloidosis is a heterogeneous group of protein deposition diseases associated with the presence of amyloid fibrils in tissues. Analogs of insulin that are used for treating diabetic patients (including regular insulin) can form amyloid fibrils, both in vitro and in vivo as reported in patients. The main purpose of this study was the induction of localized insulin-generated amyloidosis and the observation of silymarin effects on this process. In order to obtain amyloid structures, regular insulin was incubated at 37 °C for 24 h. Congo red absorbance and transmission electron microscopy images validated the formation of amyloid fibrils. Those fibrils were then injected subcutaneously into rats once per day for 6, 12 or 18 consecutive days in the presence or absence of silymarin, and caused development of firm waxy masses. These masses were excised and stained with Hematoxylin and Eosin, Congo red and Thioflavin S. Histological examination showed adipose cells and connective tissue in which amyloid deposition was visible. Amyloids decreased in the presence of silymarin, and the same effect was observed when silymarin was added to normal insulin and injected subsequently. Furthermore, plasma concentrations of MMP2, TNF-α, and IL-6 inflammatory factors were measured, and their gene expression was locally assessed in the masses by immunohistochemistry. All three factors increased in the amyloidosis state, while silymarin had an attenuating effect on their plasma levels and gene expression. In conclusion, we believe that silymarin could be effective in counteracting insulin-generated local amyloidosis.

Phenylalanine and indole effects on the pathogenicity of human lysozyme amorphous aggregates.

Protein aggregation can affect the stability and function of proteins, and may lead to developing diseases, but reports on the in vivo effect of aggregates are scarce. In the current study, the effect of phenylalanine (Phe) and indole presence was first investigated on the structure and stability of human lysozyme (HLZ) and its aggregation under in vitro condition. Tm measurements, circular dichroism and spectrofluorimetric spectra, as well as and transmission electron microscopy (TEM) were performed in this stage. In the next step, pathogenicity of HLZ amorphous aggregates formed in presence or absence of the additives was investigated in vivo, by subcutaneous injection to adult male Wistar rats. Resulting inflamed tissues were studied by hematoxylin and eosin (HE), Congo red and Sudan black staining. Serum levels of liver enzymes (Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST)), specific inflammatory cytokines (Tumor Necrosis Factor Alpha (TNF-α) and Interleukin 6 (IL-6)) as well as glucose, cholesterol, and triglyceride levels were measured. Amorphous aggregates of HLZ caused inflammation and affected the number of fat cells, macrophages, cytokines, liver enzymes and glucose. Indole, that increases amorphous aggregates amount as shown with CD, fluorescence, and TEM experiments, leads into more severe inflammation. In presence of Phe, (which stabilizes HLZ structure) a markedly milder inflammatory state is observed in histological results and no increase could be detected in the inflammation-related parameters. In conclusion, amorphous aggregates of HLZ may be pathogenic in vivo, and presence of anti-aggregation compounds (such as Phe) can be effective in diminishing their deleterious manifestations.

Phylogenetic Analysis of Phaeosphaeria Species Using Mating Type Genes and Distribution of Mating Types in Iran.

Phaeosphaeria species are pathogenic on wheat, barley and a wide range of wild grasses. To analyze mating type loci of the Phaeosphaeria species and investigate mating type distribution in Iran, we sequenced mating type loci of 273 Phaeosphaeria isolates including 67 isolates obtained from symptomatic leaves and ears of wheat, barley, and wild grasses from two wheat-growing region in Iran as well as 206 isolates from our collection from other regions in Iran which were isolated in our previous studies. Mating type genes phylogeny was successfully used to determine the species identity and relationships among isolates within the Phaeosphaeria spp. complex. In this study, we reported seven new host records for Phaeosphaeria species and the Phaeosphaeria avenaria f. sp. tritici 3 group was first reported from Iran in this study. Mating type distribution among Phaeosphaeria species was determined. Both mating types were present in all sampling regions from Iran. We observed skewed distribution of mating types in one region (Kohgiluyeh va Boyer-Ahmad) and equal distribution in the other region (Bushehr). However, when considering our entire dataset of 273 Iranian Phaeosphaeria isolates, the ratio of mating types was not deviated significantly from 1:1 suggesting possibilities for isolates of opposite mating type to interact and reproduce sexually, although the sexual cycle may infrequently occur in some regions especially when the climatic conditions are unfavorable for teleomorph development.

Structural modeling of human AKAP3 protein and in silico analysis of single nucleotide polymorphisms associated with sperm motility.

AKAP3 is a member of the A-kinase anchoring proteins and it is a constituent of the sperm fibrous sheath. AKAP3 is needed for the formation of sperm flagellum structure, sperm motility, and male fertility. This study aims to model the AKAP3 tertiary structure and identify the probable impact of four mutations characterized in infertile men on the AKAP3 structure. The T464S, I500T, E525K, and I661T substitutions were analyzed using in silico methods. The secondary structure and three-dimensional model of AKAP3 were determined using PSI-BLAST based secondary structure prediction and Robetta servers. The TM-score was used to quantitatively measure the structural similarities between native and mutated models. All of the desired substitutions were classified as benign. I-Mutant results showed all of the substitutions decreased AKAP3 stability; however, the I500T and I661T were more effective. Superposition and secondary structure comparisons between native and mutants showed no dramatic deviations. Our study provided an appropriate model for AKAP3. Destabilization of AKAP3 caused by these substitutions did not appear to induce structural disturbances. As AKAP3 is involved in male infertility, providing more structural insights and the impact of mutations that cause protein functional diversity could elucidate the etiology of male fertility problems at molecular level.

A study on alpha-terpineol in Alzheimer's disease with the use of rodent in vivo model, restraint stress effect and in vitro Amyloid beta fibrils

Abstract Alzheimer's disease (AD) is a neurological disorder in which the neuronal degeneration is associated with inflammatory processes and oxidative stress. Since alpha-terpineol was shown to possess antioxidant and anti-inflammatory effects, the administration of this compound was studied on a rat model of AD. To create this model, Aβ1-42 was injected into the hippocampus of male Wistar rats. Generated AD models were divided into simple AD models and AD models in which short-term immobilization stress was added. Preventive and therapeutic (post-AD induction) effects of alpha-terpineol consumption (100 mg/Kg) were subsequently investigated in AD models, which were compared with control groups. Biochemical factors (superoxide dismutase and malondialdehyde), histological manifestations (amyloid plaques and neuron counts) and possible memory impairment (shuttle-box experiment) were investigated in all groups. For the in vitro experiment, alpha-terpineol effect was checked on Aβ1-42 fibril formation. In preventive and therapeutic modes, alpha-terpineol consumption could improve neurogenesis and long-term memory while reducing amyloid plaque counts and ameliorating biochemical factors (higher levels of superoxide dismutase and malondialdehyde and reduced levels of MDA). In vitro, shorter fibrillar structures were formed in the presence of alpha-terpineol, which indicates an anti-amyloid effect for this compound. In conclusion, alpha-terpineol significantly counteracted AD consequences.

PAMAM and polyester dendrimers as favipiravir nanocarriers: a comparative study using DFT method.

The electronic sensitivity and reactivity of polyamidoamine (PAMAM) and polyester dendrimers toward favipiravir (T705) were inspected using density functional theory method. The T705 drug is adsorbed on the surface of PAMAM and polyester dendrimers with the binding energy of -27.26 and -26.80 kcal mol-1, respectively, in the solvent phase. The energy gap of PAMAM and polyester dendrimers reduced by about 32% and 27%, indicating that the electrical conductance of carriers become 8.16 × 1023 and 4.41 × 1022 times higher, upon T705 adsorption. The work function (Φ) value of PAMAM and polyester is changed about 1.53 and 0.71 eV, respectively. Thus, PAMAM dendrimer is about 2.5 times stronger Φ-type sensor than polyester dendrimer. The recovery time for T705 desorption from the PAMAM and polyester surface is predicted to be 9.2 × 103 and 4.2 × 103 s, respectively, at physiological environment.

Aspergillus Section Flavi from Four Agricultural Products and Association of Mycotoxin and Sclerotia Production with Isolation Source.

Many agricultural products are susceptible to contamination by aflatoxin-producing species from Aspergillus section Flavi. The objectives of this study were to determine the occurrence of Aspergillus section Flavi in four agricultural products, such as pistachio, walnut, hazelnut, and dried fruits, collected from market and retail shops in various areas of Kerman County and obtain information on the relationships between isolation source and ability to produce sclerotia and potential for aflatoxin production. Aspergillus species were identified based on morphological characteristics as well as subsequent sequencing of the parts of the ß-tubulin and calmodulin genes. From 207 isolated strains, the following species were identified: A. flavus, A. tamarii A. nomius, A. parasiticus, A. arachidicola, A. caelatus, A. pseudotamarii, and A. leporis. To the best of our knowledge, this is the first report of A. pseudotamarii and A. arachidicola with the potential to produce aflatoxins from dried apricots and hazelnuts, respectively. Sclerotial type was significantly different between isolates from different isolation sources. From 192 tested isolates, 38% were aflatoxin producer from which 5% were scored as strong aflatoxin producers and 33% as average aflatoxin producers. A significant difference in the population of aflatoxin-producing strains across the isolation sources was observed which may reflect host adaptation and thereby different vulnerabilities to aflatoxin-producing species among the examined products.

Hydro alcoholic green tea extract effect on high fat diet treated NMRI mice and 3T3L1 cells.

PURPOSE: In order to counteract the obesity has epidemics, since current anti-obesity drugs effects remain limited, there is a need to provide new options. As a project aiming to assess potential anti obesity natural compounds, the effects of consumption of a minimal dose of green tea hydro alcoholic extract (GT) on adipocyte differentiation of 3T3L1 cell line were investigated. METHODS: Obesity was induced in female NMRI mice (which are less used overall) by the use of a high fat diet. Mice were divided into four groups of control (C), treated control (TC), obese (O) and treated obese (TO). TC and TO groups received 8 mg/Kg/day of GT for 8 weeks, and weighted weekly, after what biochemical and histological parameters were measured. GT was used at doses of 100,150 and 200 µg/ml on 3T3L1, and staining with Oil-red-O was done for estimation of fat droplet accumulation. RESULTS: Body weight was found to be affected significantly by GT. Blood glucose levels did not show significant changes between groups, while triglycerides levels of the O group was significantly higher than the C group, but the TO group showed no significant difference with the C group upon GT treatment. Liver and visceral fat tissues showed more normalized tissue and less fat accumulation in the TO group. TO and TC groups showed an ameliorated morphologic state of liver tissues. GT was also able to decrease fat droplet formation in a dose-dependent manner. CONCLUSIONS: Adding a minimal amount of GT to the daily consumption may have preventive effects on fat accumulation in healthy subjects, while in obese cases, GT shows significant therapeutic effect.

The therapeutic effects of berberine plus sitagliptin in a rat model of fatty liver disease.

OBJECTIVES: Fatty liver disease (FLD) is a disorder related to accumulation of excess fat within the hepatocytes. In this study, the effects of Berberine, a natural compound, and Sitagliptin as a DPP-4 inhibitor, were observed in a rat model of FLD. MATERIALS AND METHODS: Forty male rats were divided into five groups (n=6) including the control group (normal food and water), high-fat group (high-fat diet (HF) for 6 weeks), Berberine group (HF with oral administration of Berberine at 150 mg/kg for 6 weeks), Sitagliptin group (HF with oral administration of Sitagliptin at 10 mg/kg for 6 weeks), and Berberine/ Sitagliptin group (HF diet within combination with oral administration of Berberine 75 mg/kg and Sitagliptin 5 mg/kg for 6 weeks). Animals were examined for weight gain, serum and hepatic biochemical parameters, tissue histology, expression of glucose transporter type 4 (GLUT4) mRNA, and protein expression of Adiponectin receptor2 (AdipoR2) and extracellular signal-regulated kinase (ERK) and phoERK. RESULTS: The results showed that ALT, AST, lipid profile, insulin, glucose, MDA, and TNF-α were significantly improved in high-fat rats treated with Berberine/ Sitagliptin compared with HF and Sitagliptin, and Berberine alone groups. SOD and adiponectin levels in Berberine/ Sitagliptin group were also significantly increased compared with the other groups. Immunoblot analysis showed that the expression of pho-ERK/ERK was significantly decreased and expression of AdipoR2 significantly increased in the Berberine/ Sitagliptin group compared with other groups. CONCLUSION: Co-administration of Berberine and Sitagliptin is an effective therapeutic regimen for conditions associated with hyperlipidemia.

Modeling and simulation in medical sciences: an overview of specific applications based on research experience in EMRI (Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences).

The concomitant use of various types of models (in silico, in vitro, and in vivo) has been exemplified here within the context of biomedical researches performed in the Endocrinology and Metabolism Research Institute (EMRI) of Tehran University of Medical Sciences. Two main research aeras have been discussed: the search for new small molecules as therapeutics for diabetes and related metabolic conditions, and diseases related to protein aggregation. Due to their multidisciplinary nature, the majority of these studies have needed the collaboration of different specialties. In both cases, a brief overview of the subject is provided through literature examples, and sequential use of these methods is described.

5-[Aryloxypyridyl (or nitrophenyl)]-4H-1,2,4-triazoles as novel flexible benzodiazepine analogues: Synthesis, receptor binding affinity and lipophilicity-dependent anti-seizure onset of action.

A new series of 5-(2-aryloxy-4-nitrophenyl)-4H-1,2,4-triazoles and 5-(2-aryloxy-3-pyridyl)-4H-1,2,4-triazoles, possessing C-3 thio or alkylthio substituents, was synthesized and evaluated for their benzodiazepine receptor affinity and anti-seizure activity. These analogues revealed similar to significantly superior affinity to GABAA/benzodiazepine receptor complex (IC50 values of 0.04-4.1 nM), relative to diazepam as the reference drug (IC50 value of 2.4 nM). To determine the onset of anti-seizure activity, the time-dependent effectiveness of i.p. administration of compounds on pentylenetetrazole induced seizure threshold was studied and a very good relationship was observed between the lipophilicity (cLogP) and onset of action of studied analogues (r2 = 0.964). The minimum effective dose of the compounds, determined at the time the analogues showed their highest activity, was demonstrated to be 0.025-0.1 mg/kg, relative to diazepam (0.025 mg/kg).

Emergency Tracheostomy in Two Airway Trauma Patients Suspected of COVID-19: A Case Report.

Coronavirus disease 2019, known as COVID-19, was first identified in Wuhan, China, in December 2019 and became a pandemic on Mar 11, according to the World Health Organization report. In the epidemic of COVID-19, many patients admitted to hospitals for other reasons may be silent carriers of COVID-19 and have the risk of infecting medical personnel. Thus, meticulous personal protection measures should be considered in suspicious patients, especially when close contact with the patient's airway is anticipated. We introduce two airway trauma patients suspected of COVID-19 who required emergency tracheostomy. Patient one was a 29-year-old man who suffered facial trauma following a car accident. A chest CT scan showed peripheral ground-glass opacities suggestive for COVID-19. The second patient was a young elevator mechanic who experienced maxillofacial trauma after an elevator crash. The methods of anesthesia and airway protection and safety precautions are described.

Drug repurposing using computational methods to identify therapeutic options for COVID-19.

PURPOSE: Recently, the world has been dealing with a new type of coronavirus called COVID-19 that in terms of symptoms is similar to the SARS coronavirus. Unfortunately, researchers could not find a registered therapy to treat the infection related to the virus yet. Regarding the fact that drug repurposing is a good strategy for epidemic viral infection, we applied the drug repurposing strategy using virtual screening to identify therapeutic options for COVID-19. For this purpose, five proteins of COVID-19 (3-chymotrypsin-like protease (3CLpro), Papain-Like protease (PLpro), cleavage site, HR1 and RBD in Spike protein) were selected as target proteins for drug repositioning. METHODS: First, five proteins of COVID-19 were built by homology modeling. Then FDA-approved drugs (2471 drugs) were screened against cleavage site and RBD in Spike protein via virtual screening. One hundred and twenty-eight FDA-approved drugs with the most favorable free-binding energy were attached to the cleavage site and RBD in Spike protein. Of these 128 drugs, 18 drugs have either been used currently as antiviral or have been reported to possess antiviral effects. Virtual screening was then performed for the 18 selected drugs with ACE2, 3CLpro and PLpro and HR1 and TMPRSS2. RESULTS: According to the results, glecaprevir, paritaprevir, simeprevir, ledipasvir, glycyrrhizic acid, TMC-310911, and hesperidin showed highly favorably free binding energies with all tested target proteins. CONCLUSION: The above-mentioned drugs can be regarded as candidates to treat COVID-19 infections, but further study on the efficiency of these drugs is also necessary.