Category Archives: Nevada Stem Cells

Chris Bumstead is pulling out all the stops to ensure he leaves Las Vegas, Nevada with a sixth Classic Physique Olympia title. In a recent Instagram post, Bumstead underwent a longevity-inspired stem cell treatment to decrease inflammation and slow aging in the body.

Chris Bumstead is back again this time for a longevity treatment, says Dr. Khan.

Despite suffering from an autoimmune disease, Chris Bumstead has reached remarkable heights as an IFBB Pro bodybuilder. Since 2018, he has reigned over the Classic Physique division, having acquired five consecutive victories at the Olympia show.

To compete at the highest level, Bumstead has taken significant measures to preserve his health, including stem cell therapy for kidney regeneration. Now, with his sights set on another prestigious title, he walked his fans through his latest experience with Dr. Khan.

Mainly, I have an autoimmune disease and stem cells are really good at decreasing inflammation and really good for the immune system and keeping that at bay.

So, when I saw Dr. Khan last year, it was the healthiest Ive ever been afterward. I just want to keep up with all that, make sure Im staying ahead of everything. Also, as a bodybuilder, I put my body through a lot of stress with a lot of inflammation, a lot of joint pain, a lot of this and a lot of that.

According to Bumstead, he switched to regenerative medicines like stem cells after prescription drugs were unable to fix his health problems. With fewer risks associated with the treatment, Bumstead felt more confident in proceeding in this direction.

I turned to regenerative medicine, biohacking the more natural side of things anything other than the traditional medicine a while ago when I was in Canada, I was given a few prescription drugs that were kind of like a bandaid not helping any of my issues.

After a wide variety of more natural ways and after finding Dr. Khan and learning about stem cells, I realize that theres a lot more benefits I can get from that with seemingly less risk as well, shared Chris Bumstead.

Dr. Khan explained that the procedure would help Bumstead during his prep but highlighted how beneficial it would be for him in retirement.

Not only for prep but just for general longevity, meaning after he retires from bodybuilding, which he inevitably will, he wants to continue living a healthy strong life and this is one of the best ways to do it, intravenous stem cells and exosomes, are engineered now to enhance our ability to survive.

Specifically, Dr. Khan revealed that Bumstead received follistatin gene therapy to decrease inflammation and slow down aging in the body.

Were also using follistatin gene therapy which can inhibit myostatin, but more importantly decrease inflammation and slow down aging in the body.

Bumstead hasnt been the only top-tier bodybuilder to experiment with stem cell treatments. After losing his title at the 2022 Mr. Olympia, Mamdouh Big Ramy Elssbiay underwent a stem cell procedure to regenerate nerve damage that has negatively impacted his physique.

As the most hunted man in the Classic Physique division, time will tell if the operation will aid Bumstead in his quest to earn his sixth Olympia title later this year when the show celebrates its 60th anniversary in Las Vegas, Nevada.

RELATED:Chris Bumstead Shares Intense High-Volume Workout for Bigger Arms in the 2024 Off-Season

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Chris Bumstead Receives Stem Cell 'Longevity Treatment' to Decrease Inflammation and 'Slow Down Aging in the ... - Fitness Volt

Across the country, mass teacher shortages have been felt in seemingly every district, and the capital city is not immune.

There are currently 46 unfilled positions throughout the district, broken down as:

Teacher positions by study of currently unfilled include: elementary school, middle school science, middle school culinary arts, middle school math, middle school English, and middle school social studies.

To assist with the current teaching shortage, CCSD has re-hired some of our recently retired educators and increased the pay for substitute teachers, said Dan Sadler, associate superintendent of Human Resources for the district.

Additionally, some school sites have shuffled class schedules around to absorb the vacancies and provide support in creative ways, such as by buying teacher preps, which essentially means paying teachers to cover another classroom during their prep-time, which is generally spent grading, attendance, and lesson planning.

CCSD has a tiered system of substitute teachers currently assigned in our schools (emergency subs, daily subs, super subs, long term subs), said Sadler. CCSD is always looking for additional people who may be interested in supporting our schools.

In neighboring Washoe County, it was announced only days before the beginning of school that the district was short by more than 200 for classified teachers, and the district had to reassign multiple administrative positions and TOSAs (Teacher on Special Assignment) to cover classrooms.

There are a lot of issues contributing to why there are teacher shortages throughout the country, including burnout, low pay, behavior issues from both students, parents and the public alike, and more.

A Look at the Issues

There are currently over half a million fewer educators in Americas public schools today than there were prior to the pandemic.

Over 90 percent of teachers have reported that burnout is a serious problem within the teaching profession, and 55 percent have stated they are ready to leave their profession earlier than previously planned.

This is a five-alarm crisis, said National Education Association President Becky Pringle. We are facing an exodus as more than half of our nations teachers and other school staff are now indicating they will be leaving education sooner than planned. If were serious about getting every child the support they need to thrive, our elected leaders across the nation need to address this crisis now.

Behavior Issues: Student, Parent, Public

76 percent of teachers stated that student behavioral issues as well as a lack of respect from parents and the public are serious issues.

When it comes to the behavior of students, 87 percent of public schools agreed that these issues stem directly from the pandemic, and include classroom disruptions, acts of disrespect toward teachers and staff, rowdiness outside of the classroom, and the prohibited use of electronic devices.

Public schools reported needing more support for student and/or staff mental health (79 percent), training on supporting students socio-emotional development (70 percent), hiring of more staff (60 percent), and training on classroom management strategies (51 percent).

Across the country, and locally, school board meetings and public schools have been over run by a tiny but extremely vocal minority of individuals who spouted unsubstantiated claims that teachers were indoctrinating students into hating America, forcing vaccines upon them, and general abuses.

Carson City board members and educators faced these issues as well, with public commenters, the vast majority of whom did not have school-aged children, attending board meetings for months at a time stating that the schools were killing children by requiring them to wear masks, pushing Marxism on students, and asking for school board members to be fired because the COVID-19 vaccine contains aborted fetal cells, monkey kidney cells, E-Coli, animal parts, spermicide, and more.

While issues surrounding masks and vaccines have seemingly fallen away in recent months, school boards across the country are facing a new push from these vocal minorities: banning books.

Book banning is at an all time historic high, with a record-breaking 1,145 books being banned by school districts across the country between July 1, 2021 and March 31, 2022.

The books currently being banned throughout the country almost exclusively focus on LGBTQ+ issues, followed by the history of racism and oppression felt by certain groups within the U.S., such as Native and Black Americans.

Low Pay, Less Teaching Degrees

Currently, 78 percent of teachers have stated that low pay is a serious issue, and when it comes to pay, U.S. teachers now are making less than their counterparts 50 years ago.

In 1972, the average teacher in America was making $10,174 per year, which, in todays dollars, is the equivalent of over $72,000.

Today, however, that number has lowered to $65,000 with a huge range between states. For example, the average teacher salary in New York is almost $90,000 per year, while Mississippi teachers make an average of only $47,000.

Nevada teachers fall somewhere in between with an average salary of $56,676, and a typical range of between $47,000 to $69,000. By comparison, in the 70s, Nevada teachers made the equivalent of $65,315 in todays dollars.

In addition, the number of college students engaging in education teaching programs has simply, and drastically, decreased.

Between 2008 and 2019, the number of students graduating from teaching programs decreased by over a third. Up until the early 2010s, the number of these degrees were relatively stable, but began dropping quickly after.

Reasons attributed to this decrease in interest are linked to poor pay, heavy workloads, as well as political demonization.

Regardless of the reason behind the teacher shortages, one thing is clear: with more teachers leaving the profession than on boarding, those who will suffer the most are the students left in the gap.

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Carson City School District experiencing teacher shortage; nationwide data points to burnout, low pay and behavior issues as culprits - Carson Now

By Holland Chambers Womens, Infants, and Children Specialist

Wednesday, August 3, 2022

Breastfeeding is the natural way to nourish a baby, but that does not mean it comes easy. Most women have challenges with breastfeeding and wonder if they are making enough breast milk. This can be difficult because women do not visually see how much milk the baby is drinking, thus, it is difficult to figure out if enough milk is being produced.It is estimated that 5% of women are physically unable to produce enough breastmilk to feed their babies and less than 5% of women experience lactation failure. With this said, most new mothers do make enough milk for their baby and this should not be a major concern with breastfeeding.Breastfeeding is best for the baby and the mother, it is a great source of nutrition, with the perfect combination of protein, fat, and carbohydrates the baby needs to grow. Yes, breastmilk has the perfect macronutrients for the baby to grow, but it also has millions of live cells that include immune boosting white blood cells, stem cells, and bacteria to help aid in organ development. Breastmilk also includes growth factors, vitamins and minerals, antibodies, long chain fatty acids, oligosaccharides, and amino acid, which are all important factors in your babys development.All mothers want to make sure their babies are the healthiest they can be, but most mothers do not realize that a crucial decision, such as breastfeeding can affect their baby both now and the rest of their lives. Breast-fed babies usually live a healthier life with less incidence of chronic illnesses, food allergies, asthma, eczema, Type I and Type II diabetes, and much more that could lead to hospitalization and other health complications. Breastfed babies have a higher level of beneficial gut bacteria and healthier growth patterns than babies who are not breastfed. Breastfed babies have a lower rate of wheezing, which is one of the most common reasons infants are hospitalized or receive medical care. Breastfed babies have a lower risk of developing asthma, because of their strong gut microbiota. Formula-fed babies have a weaker gut, which can cause gut dysbacteriosis that results in a chronic inflammatory respiratory disorder, such as asthma. Breastmilk is unique to each mom and baby to benefit their individual needs Breastmilk is concentrated with bacteria that colonize the infants gut help setting the course for the babys growing immune system and metabolism Babies who are exclusively breastfed for the first 6 months have fewer ear infection and respiratory illnesses.For information on breastfeeding, contact your local WIC agency:Carson City Health and Human Services WIC900 E. Long St., Carson City775-887-2190Monday-Friday 8 a.m. to noon and 1-5 p.m.Douglas County WIC clinic1524 Highway 395 North775-283-4772Monday- Friday 8 a.m. to noon and 1-5 p.m.For additional resources and information about Carson City Health and Human Services programs and services, check out our website at http://www.gethealthycarsoncity.org, Like us on Facebook at http://www.facebook.com/cchhs, follow us on Twitter @CCHealthEd, call us at (775) 887-2190, or visit us at 900 E. Long St. in Carson City.

Originally posted here:
Get Healthy Carson City: Breastfeeding benefits a baby's health - Nevada Appeal

Affecting one in 5,000 male births worldwide, Duchenne Muscular Dystrophy (DMD) is a fatal genetic disorder that currently doesnt have a cure, but published research conducted at the University of Nevada, Reno School of Medicine shows promise and may lead to the eventual development of a new molecular therapeutic.

The latest, significant research finding, published in Human Molecular Genetics, February 2022, involves the small-molecule sunitinib which has been shown to mitigate DMD-related skeletal muscle disease in a number of ways.

As patients with DMD grow older, muscular dystrophy worsens, causing respiratory and cardiac muscle failure resulting in premature death. There are no effective treatments to prevent DMD-related cardiac failure, however continued research in the lab of UNR Med Professor of Pharmacology Dean Burkin is pointing to protein and molecular-based solutions, including sunitinib which is already FDA approved and used in cancer treatments.

Burkin conducted the latest research with Ph.D. student Ariany Oliveira-Santos. Based on a mouse model, they found that sunitinib improved major negative symptoms that stem from DMD, such as cardiac muscle damage, without depressing the immune system completely. Oliveira-Santos was lead author on the published results. The study was supported by a grant from the Muscular Dystrophy Association and the National Institutes of Health.

Burkins lab focuses mainly on studying two key proteins 71 integrinand laminin and understanding the role they play in muscle development and disease. The lab primarily studies two muscle-damaging diseases: DMD and Laminin-2 related congenital muscular dystrophy (LAMA2-CMD).

Were interested in the biology of the 71 integrin, that's really the central focus of [our research], Burkin said. But we also have other big interests in these muscle diseases where the integrin [protein] is normally found.

Burkin explains that through this translational research, which he also calls the lab bench to bedside approach, researchers attempt to understand the biology of a system as much as possible, and then continue through the development steps that lead to therapeutic treatments.

Patients with DMD lack dystrophin which causes progressive muscle degeneration and weakness. This means the more these muscles are used, the more damage occurs. While there are repair cells in muscles, these cells eventually tire out. Burkin and Oliveira-Santos noted that the heart, an organ being used all the time, does not have this repair system, making the damage severe in cardiac muscles as well. Currently some therapeutic approaches have been beneficial for skeletal muscles but not for the heart; therefore, its important to have a drug or treatment that can target and be beneficial to skeletal and cardiac muscle at the same time, Oliveira-Santos explained.

We looked to the electrical and mechanical function of the heart and both were improved, Oliveira-Santos said. Sunitinib helped the cardiac function [and reduced] cardiac damage, and inflammation. I don't think theres really many drugs out there that do that right now.

Oliveira-Santos remembers wanting to be a scientist as early as eight years old. She went on to earn degrees in Brazil, including a bachelors in biomedicine and a masters in the scientific fields of immunology and pharmacology as they relate to transplant rejection. While earning her masters degree, Burkin was invited to Brazil by Oliveira-Santoss supervisor to give a talk, and the two met in-person and discussed her masters project. At the time, they were studying the same molecule, but in different models, so Oliveira-Santos had read some of Burkins papers.

Oliveira-Santos had always been interested in the physiology and pathology of disease and thought it would be a great area to study for a doctoral degree. She knew Burkin was working in this field, so about five years after their in-person meeting, Oliveira-Santos reached out to Burkin. He told her about an open position in his lab for a Ph.D. student, and their project of understanding the role of an FDA-approved small molecule for the treatment of DMD cardiomyopathy. She felt this project was a good match for what she was looking for and joined the lab in January 2019.

Oliveira-Santos said the mentorship and support shes received from Burkin and the rest of the lab has been invaluable.

Dean is always available to discuss and very happy to help [the lab members] with everything we need, Oliveira-Santos said. Everyone had an important opinion about the project and that was essential for the projects success.

While working in science oftentimes can come with struggles, Oliveira-Santos expressed how much these experiences have taught her.

Being in science is a big challenge, because you have to learn how to deal with problems all the time, she said. There are more failures than success [so] it teaches you how to deal with failure. Failure is normal. You just need to try to find a way around to get a solution.

Oliveira-Santos is set to finish her Ph.D. in Cellular and Molecular Pharmacology & Physiology in the fall 2022.

When I bring a student to the lab, I say I can supply everything but enthusiasm. And that's one thing that Ariany brings in abundance, Burkin said. I'm putting my students in contact with other principal investigators that I know to try and make sure that the next level on their career is achieved. She can go anywhere right now and move forward. The world is her oyster.

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Promising solution to fatal genetic-disorder complications discovered by University professor and Ph.D. candidate - Nevada Today

Neuroscientist. 2020 Sep 11 : 1073858420956905.

1Department of Molecular Cell Genetics, L. Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland

2Department of Anatomy, L. Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland

3Center of Biomedical Research Excellence in Cell Biology, Reno School of Medicine, University of Nevada, Reno, NV, USA

4Department of Physiology and Cell Biology, Reno School of Medicine, University of Nevada, Reno, NV, USA

1Department of Molecular Cell Genetics, L. Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland

2Department of Anatomy, L. Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland

3Center of Biomedical Research Excellence in Cell Biology, Reno School of Medicine, University of Nevada, Reno, NV, USA

4Department of Physiology and Cell Biology, Reno School of Medicine, University of Nevada, Reno, NV, USA

In recent months it has emerged that the novel coronavirusresponsible for the COVID-19 pandemiccauses reduction of smell and taste in a large fraction of patients. The chemosensory deficits are often the earliest, and sometimes the only signs in otherwise asymptomatic carriers of the SARS-CoV-2 virus. The reasons for the surprisingly early and specific chemosensory dysfunction in COVID-19 are now beginning to be elucidated. In this hypothesis review, we discuss implications of the recent finding that the prevalence of smell and taste dysfunction in COVID-19 patients differs between populations, possibly because of differences in the spike protein of different virus strains or because of differences in the host proteins that enable virus entry, thus modifying infectivity. We review recent progress in defining underlying cellular and molecular mechanisms of the virus-induced anosmia, with a focus on the emerging crucial role of sustentacular cells in the olfactory epithelium. We critically examine the current evidence whether and how the SARS-CoV-2 virus can follow a route from the olfactory epithelium in the nose to the brain to achieve brain infection, and we discuss the prospects for using the smell and taste dysfunctions seen in COVID-19 as an early and rapid diagnostic screening tool.

Keywords: anosmia, COVID-19, olfactory epithelium, SARS-CoV-2, ACE2, prevalence, diagnosis, hyposmia, smell loss, taste, brain infection

Reduction of smell and taste is now recognized as one of the cardinal symptoms of COVID-19. The deficit appears to be most often transient, with a regaining of smell and taste after several days to weeks, but the anosmia differs from other virus-associated deficits in its sudden onset and its rapid recovery. Multiple reviews have covered this topicso why is the current review needed? We have come to realize that to understand COVID-19, it is necessary to consider multiple dimensions, from the cellular-molecular level to psychophysical and clinical features, as well as genetics and epidemiology. Relating different aspects of the disease in a holistic approach has been lacking in previous reviews; we will show that taking into account and integrating multiple disciplines provides a more complete insight and synthesis.

Anosmia and hypogeusia were not initially recognized to be linked to COVID-19; they were mentioned to affect only about 5% of COVID-19 patients in one of the first studies from China (Mao and others 2020), but a much higher prevalence was reported in subsequent studies from Europe, the Middle East, and North America (Agyeman and others 2020; Hannum and others 2020; Passarelli and others 2020; Printza and Constantinidis 2020; Sedaghat and others 2020; Tong and others 2020; von Bartheld and others 2020). Why is the reduction in smell and taste one of the first symptoms of COVID-19, and why were these deficits recognized to be a cardinal symptom of COVID-19 only when the pandemic had moved beyond East Asia? We discuss possible explanations for early symptoms and for the population differences and their implications. Key to understanding such differences in infectivity of SARS-CoV-2 may lie in the frequency of variants in the virus entry proteins, ACE2 and TMPRSS2, which may depend on cell type and population, with implications for infectivity, virus spread, and therefore managing the COVID-19 pandemic.

It has been a major mystery how the virus affects the senses of smell and taste. Significant progress has now been made to begin to elucidate the cellular and molecular mechanisms of coronavirus-induced anosmia. Recent work has provided new insights into the cell types in the olfactory epithelium that express the relevant virus entry proteins (Bilinska and others 2020) and that accumulate the virus after infection (Bryche and others 2020). Much less is known about the underlying mechanisms that may explain taste reduction in COVID-19. ACE2 is expressed in epithelial cells of the tongue (Sato and others 2020; Vaira and others 2020c; Xu and others 2020; Cooper and others 2020), but probably not in taste buds (Wang and others 2020e), yet ACE2 inhibitor drugs are known to induce taste (and smell) disorders (Irvin and Viau 1986; Naik and others 2010; Bertlich and others 2020). In the olfactory epithelium, the evidence suggests a distinct cascade of cellular events that can explain the transient anosmia in COVID-19. Whether and how the SARS-CoV-2 virus may utilize a route from the nose to infect the brain has been and still is a question of major interest and concern. We review a series of relevant studies that provide deeper insights on this topic, and we propose new hypotheses of how SARS-CoV-2 may gain access to the brain without relying on transport within olfactory neurons. In this context, we explain the importance of developing and investigating new transgenic mouse models for future research in this field. We also review the prospects for making use of the anosmia seen in COVID-19 as an early, rapid, and surprisingly effective diagnostic screening tool.

The literature on the prevalence of chemosensory dysfunctions in COVID-19 initially appeared to be confusing: wide ranges of prevalence were reported by different studies. In the first two months of the COVID-19 pandemic, clinicians considered such deficits to be a rare occurrence (Chen and others 2020a; Guan and others 2020; Mao and others 2020; Wang and others 2020d; reviewed by da Costa and others 2020). The first report that recognized smell and taste reduction to be a much more prevalent symptom came out of Germany (Streeck 2020), and subsequent studies have confirmed that a high prevalence of approximately 60% is the norm, especially outside of East Asia (von Bartheld and others 2020). Several reviews have summarized findings of the early studies on this topic (Agyeman and others 2020; Hannum and others 2020; Passarelli and others 2020; Printza and Constantinidis 2020; Sedaghat and others 2020; Tong and others 2020), which were followed by a more comprehensive review and meta-analysis (von Bartheld and others 2020). Worldwide, the prevalence of olfactory deficits in COVID-19 patients was calculated to be 44.1%, the prevalence of taste deficits was 43.3%, and the prevalence for any chemosensory deficits was 49.0% (). The prevalence of anosmia/ageusia in COVID-19 is generally thought to be an underestimate (Vaira and others 2020b; Tong and others 2020; von Bartheld and others 2020), because most studies rely on the patient telling the researcher about their subjective impressions, although some studies report that the results of subjective and objective measures are roughly equivalent (Parma and others 2020). Several researchers have noticed a possible difference in the prevalence of chemosensory deficits between populations in East Asia and in Western countries (DellEra and others 2020; Lovato and others 2020; Lechien and others 2020a; Meng and others 2020; Qiu and others 2020). Intriguingly, the most recent and comprehensive systematic review, of 30,264 patients, demonstrated a significant, nearly 3-fold higher prevalence in olfaction and/or taste impairment in populations in Western countries than in populations in East Asia, and the difference appears to be independent of age or disease severity (von Bartheld and others 2020, and ). There are no data yet specifically on populations in Africa, South America, or South Asia in this respect. The nasal epithelium has been shown to have a larger viral load than the epithelium in the lower respiratory tract (Hou and others 2020; Meinhardt and others 2020; Rockx and others 2020; Wang and others 2020c; Zou and others 2020). Therefore, population differences in viral load could have far-reaching implications for infectivity and virus spreading, and ultimately for successful management of the pandemic.

Prevalence of Dysfunctions in Smell, Taste, and Any Chemosensory Perception in COVID-19 Patients According to Our Recent Review and Meta-Analysis (von Bartheld and others 2020).

Prevalence of chemosensory deficits in COVID-19 patients. (A) World map based on 68 studies with a total of 30,264 patients (updated version, original from: von Bartheld and others 2020). (B) Prevalence of chemosensory dysfunction in COVID-19 patients in Western countries and East Asia according to a recent meta-analysis (von Bartheld and others 2020). Error bars are 95% confidence intervals. Data are based on a total of 22,011 Caucasian and 8253 East Asian patients with COVID-19 from n = 61 cohorts and n = 12 cohorts, respectively.

One trivial explanation that needs to be considered is that the smell and taste dysfunctions in East Asia were underreported, possibly because these symptoms were overlooked in China, when early in the pandemic anosmia did not yet receive much publicity. However, more recent studies, including those from Korea, Singapore, and Japan, also report much lower prevalence than studies from Western countries (von Bartheld and others 2020; and B), so underreporting alone is unlikely to explain the difference between populations. Two other reasons may account for the different rates of smell dysfunction among COVID-19 patients in different populations: genetic variation at the level of the virus, or genetic variation at the level of the host. Variants of SARS-CoV-2 may differ in geography, for example, due to mutations in the spike protein (Grubaugh and others 2020; Korber and others 2020; Li and others 2020a; Phelan and others 2020; Zhang and others 2020); Type C is predominant in East Asia, while both Type C and Type A occur outside of East Asia (Forster and others 2020). Alternatively, or in addition, there may be genetic polymorphism in the ACE2 or TMPRSS2 host receptors.

The receptor binding domain (RBD) of the virus spike protein (subunit S1) binds with high affinity to the peptidase domain of the entry protein ACE2 and thereby determines viral tropism and infectivity (Shang and others 2020). Therefore, genetic variability and the mutation rate within the RBD domain is of particular interest in the context of population differences in the prevalence of anosmia and ageusia. Recent studies indicate that SARS-CoV-2 has a significantly lower mutation rate as compared to SARS-CoV-1 virus and that the critical RBD domain of the spike glycoprotein is particularly well conserved (Jia and others 2020). Even though some genetic variability and mutation hot spots were identified in the RBD, which may affect its binding to the ACE2 receptor (Jia and others 2020; Ou and others 2020), these mutations were not restricted to one specific geographic area, but were present in Europe, Asia, and America (Ou and others 2020; van Dorp and others 2020). However, one particular mutation or rather SNP variant, G614, that is located outside the RBD, has become the dominant SARS-CoV-2 strain in the pandemic, while the D614 strain was initially dominant in East Asia (Korber and others 2020). In vitro, the G614 mutation increases viral load, and it is likely but not yet entirely clear whether it is clinically more infectious than D614 (Grubaugh and others 2020); it does not increase disease severity which correlates with older age (Korber and others 2020). The lack of correlation with disease severity/older age is similar but not exactly what one would expect if G614 caused increased prevalence of anosmia, since COVID-19-related anosmia is associated with younger age (von Bartheld and others 2020). Taken together, at present it is unclear whether mutations or genetic variability within or near the RBD of the virus spike glycoprotein can increase the likelihood of infection of the olfactory epithelium and thereby influence susceptibility to olfactory deficits; however, this question requires further attention (Forster and others 2020; Grubaugh and others 2020; Zhang and others 2020), and we expect that future studies will soon determine whether the G614 mutation may contribute to the differences in anosmia prevalence.

The second factor that may contribute to different susceptibility among populations is genetic variation of the host proteins which allow virus binding and entry. Anosmia in COVID-19 is known to have a considerable heritable component (48%, Williams and others 2020), possibly due to polymorphism and alternative splice variants of the ACE2 entry protein. Indeed, there is evidence for genetic differences in ACE2 between Asians (especially East Asians) versus Europeans (Benetti and others 2020; Cao and others 2020; Strafella and others 2020). So far, these studies have focused on expression of ACE2 variants in lung tissue and compared them with respiratory disease severity, and there are no studies yet that have compared expression of ACE2 variants in the olfactory epithelium with the prevalence of anosmia. In addition to ACE2, the TMPRSS2 protease, which facilitates virus entry, also contains variants which differ in frequency between populations, with Europeans having much higher levels of pulmonary expression than populations from East Asia (Dos Santos and others 2020). The polymorphism rs2285666 in ACE2 may be of particular interest, because its minor allele frequency is relatively high, it has a distinct geographical distribution, and it was predicted to affect ACE2 expression levels (Asselta and others 2020). The virus binding affinity, viral load in the nose, virus spreading, and thus infectivity may differ between populations, based on the frequency of variants in both ACE2 and TMPRSS2 proteins.

The possibility of splice variants of ACE2 is consistent with recent data showing that electrophoretic mobility of ACE2 expressed in (murine) olfactory epithelium differs from ACE2 expressed in brain, suggesting some tissue-specific differences in posttranslational modifications or cell-type specific ACE2 variant expression (Bilinska and others 2020). Although requiring further investigation, this suggests that subtle differences exist between ACE2 expressed in the olfactory epithelium and ACE2 expressed in other respiratory epithelial cells. Possible genetic differences in ACE2 variants or posttranslational modifications such as glycosylation may contribute to varying susceptibility to anosmia caused by SARS-CoV-2 (Li and others 2005; Li and others 2020a). Such variations should be considered among the reasons why some COVID-19 patients experience anosmia as the only sign, without any significant respiratory symptoms, because in these patients the ACE2 variant present in the olfactory epithelium may bind the virus with higher affinity than the ACE2 that is present in the epithelial cells of the lower respiratory tract.

Populations with a higher binding affinity of the ACE2 receptor or with more abundant TMPRSS2 for virus entry will have higher viral loads in the nasal epithelium and therefore are more likely to become super-spreaders, making it more difficult to control the pandemic, than populations that have ACE2 receptors with lower virus binding capability and lower viral loads in the nasal epithelium. Similar to the effects of blood type on the risks of COVID-19 disease severity (Ellinghaus and others 2020), genetically determined variants of ACE2 and/or TMPRSS2 may, in part, explain the more rapid spread of the virus in Western countries, as compared with East Asia. Thus, genetic differences of the host receptors may contribute to the varying success in managing the COVID-19 pandemic, besides the well-known cultural, social and political differences in strategies of containment and attitudes about social distancing and use of protective measures such as face masks.

The anosmia induced by SARS-CoV-2 has several unique features. Its high prevalence (in Western countries) is remarkable, as is its sudden onset, its rather short duration, and in most cases, a rapid recovery, as well as the fact that the anosmia (and taste dysfunction) can be the only symptoms in a significant fraction of patients, and that the anosmia often presents without nasal congestion or rhinorrhea. The chemosensory deficits are typically transient and last from several days to about 2 weeks (most resolve or significantly improve within 710 days, Lechien and others 2020a; Lee and others 2020; Printza and Constantinidis 2020; von Bartheld and others 2020). One study reported that smell is lost slightly earlier (peak on day 3) than taste (peak on days 57, as illustrated in ; Vaira and others 2020a). The timing and duration of the sensory deficits are so unique in COVID-19, they may give important clues about the potential underlying mechanism, as discussed below.

The time course and frequency of chemosensory dysfunctions in COVID-19 patients according to a study from Italy (Vaira and others 2020a). Note that dysfunction of smell peaked slightly earlier than dysfunction of taste, and most deficits resolved within 8 to 10 days after the peak.

The rather distinct clinical features of the anosmia differ dramatically from the SARS pandemic in which only one single case of anosmia was reported (Hwang 2006), versuss literally millions of cases in COVID-19 (von Bartheld and others 2020). This is surprising, because the two viruses have considerable genomic identity of 79% to 82% (Wu and others 2020a). So what is it at the cellular and molecular level in COVID-19 that enables such a potent effect on the senses of smell and taste?

Four different principal scenarios have been considered to explain the smell dysfunction in COVID-19 patients, as illustrated in : (1) nasal obstruction/congestion and rhinorrhea, (2) loss of olfactory receptor neurons, (3) brain infiltration affecting olfactory centers, and (4) damage of support cells in the olfactory epithelium. We will evaluate for each scenario to what extent the proposed mechanism is consistent with, or supported by, the available data.

Schematic of the olfactory pathway to the brain with four different scenarios how the SARS-CoV-2 virus may cause anosmia or hyposmia. (A) Normal pathway: odorant molecules bind to the olfactory receptor neuron (ORN), the ORN transmits the smell sensation through the cribriform plate (bone) to the mitral cell (MC) in the olfactory bulb of the brain. Olfactory epithelium also contains support cells (sustentacular cells, SuC) and stem cells (SC) that can regenerate SuCs and ORNs. (B) Odors may not reach the ORNs, because of nasal obstruction/congestion by increased mucus. (C) The transmission of odor sensation may be blocked because of damage and/or death of ORNs. (D) The sensation of smell may be compromised because the virus affects neurons in the brain. (E) The transmission of odor sensation may be compromised, because the SuC (which assists the ORN with odor processing) is damaged by the virus.

Many viral infections cause nasal obstruction, congestion and rhinorrhea, thereby impeding odorant access to the sensory epithelium and preventing the binding of the odorants to olfactory receptors (Doty and Mishra 2001; Hummel and others 2017). This possibility of physical obstruction (conductive olfactory loss) was initially considered a likely explanation of the anosmia in COVID-19 (Eliezer and others 2020; Gane and others 2020; Qiu and others 2020), but has now been all but ruled out by several studies, primarily because a large fraction (nearly 60%, von Bartheld and others 2020) of patients with anosmia do not have nasal congestion, obstruction or rhinorrhea (Kaye and others 2020; Lechien and others 2020b; Printza and Constantinidis 2020; Tong and others 2020; Vaira and others 2020b; von Bartheld and others 2020; Xydakis and others 2020), and because these patients lack any significant mucosal swelling of the nasal cleft or sinuses on radiographic imaging (Naeini and others 2020).

Does the virus infect olfactory receptor neurons, leading to their death? Such a sensorineural olfactory loss has been considered a plausible explanation of the anosmia (Baig and others 2020; Meinhardt and others 2020; Sia and others 2020; Ueha and others 2020; Wang and others 2020b). However, at closer look, there are three major inconsistencies with this scenario: the time course of cellular regeneration versus clinical recovery, the lack of expression of viral entry proteins, and the absence of the virus within olfactory neurons. When olfactory receptor neurons die, their replacement requires 8 to 10 days (Brann and Firestein 2014; Schwob 2002; Schwob and others 1995), plus about 5 days for cilia maturation (Liang 2020), but the time course of smell recovery in COVID-19 often is less than one week (DellEra and others 2020; Kaye and others 2020; Lee and others 2020; Printza and Constantinidis 2020; Sayin and Yazici 2020; Sedaghat and others 2020; Vaira and others 2020a; von Bartheld and others 2020). Thus, functional recovery after anosmia often is faster than the time it takes for neuron replacement, cilia maturation, and the growth of the new axons from the olfactory epithelium through the cribriform plate to form synapses in the olfactory bulb (Bryche and others 2020; Liang 2020; Schwob 2002; Soler and others 2020; ). Regarding expression of the virus entry proteins, Butowt and Bilinska (2020) were the first who predicted, based on in-silico data, that mature olfactory receptor neurons do not express ACE2, and therefore are not likely to be infected by SARS-CoV-2. They were also the first to localize the virus entry proteins to distinct cell types in the olfactory epithelium (Bilinska et al. 2020; ). There is now an emerging consensus that mature olfactory neurons do not express the virus entry proteins, ACE2 and TMPRSS2, at least not at significant levels, and not in the large majority of the mature olfactory neurons in mouse and human (Baxter and others 2020; Bilinska and others 2020; Brann and others 2020; Chen and others 2020b; Fodoulian and others 2020; Gupta and others 2020; Klingenstein and others 2020; Ziegler and others 2020see ). A recent study that localized the SARS-CoV-2 virus in the hamster olfactory epithelium confirmed this notion by showing that sustentacular cells contained the virus, but not olfactory neurons (Bryche and others 2020). This means that the olfactory neurons are not the initial and primary target of the virus. Taken together, these facts seem to rule out that many cases of anosmia in COVID-19 can be explained by direct virus-induced damage and death of olfactory receptor neurons, although death of the olfactory neurons is likely involved in prolonged cases of anosmia.

Chronology and Specifics of the Evidence for Expression of SARS-CoV-2 Entry Proteins ACE2 and TMPRSS2 in Identified Cell Types of the Olfactory Epithelium.

Entry of the SARS-CoV-2 virus in the olfactory epithelium and the virus predicted effects that may explain the anosmia in COVID-19 patients. Coronavirus enters (pink arrows) and accumulates in the sustentacular cells (SuC) which abundantly express ACE2 and TMPRSS2 proteins, the entry proteins of the virus. SuCs normally partake in the processing of the odorants by endocytosing the odorant-binding protein complex (green-black symbol), by detoxifying, by maintaining the cilia of mature olfactory receptor neurons (mORN), and by maintaining epithelial integrity. Olfactory sensation is impaired when these essential SuC functions are disrupted. It is unknown whether the virus may transfer from SuC to mature olfactory receptor neurons (mORN) which lack ACE2 and TMPRSS2 proteins (), but have axons extending to the brain. Both the SuC and mORN can be replaced by stem cells (SCblue arrows), although SuC replacement is much faster than replacement of mORN where SC first generates immature ORN (iORN) whose axons have to grow through the bone to the brain.

Does the virus infiltrate the brain, possibly from the nose, and affect olfactory centers (olfactory bulb and cortex), thereby reducing smell sensations? This scenario has been considered by several investigators (Arago and others 2020; Baig and others 2020; Briguglio and others 2020; DosSantos and others 2020; Gilani and others 2020; Karimi-Galougahi and others 2020; Lechien and others 2020a; Li and others 2020b; Meinhardt and others 2020; Politi and others 2020; Sia and others 2020). The sudden loss of smell (and taste), followed by a rapid recovery, is a strong argument against this possibility, as is the fact that the olfactory neurons, which constitute one direct route to the brain by anterograde axonal transport, do not express the obligatory entry proteins for the virus (as detailed above). No study to date has shown that the olfactory receptor neurons or olfactory bulb neurons accumulate the virus acutely in normal (non-genetically modified) animals, at least not within the first 2 weeks after infection (Bryche and others 2020). Accordingly, the third scenario is highly unlikely to explain the often rapid and transient anosmia in COVID-19. There is currently no evidence that the SARS-CoV-2 virus itself can reach the brain through the olfactory route in the acute phase of anosmia; alterations of brain tissues by magnetic resonance imaging were not a consistent finding and may have been caused by virus-induced inflammation or by vascular/systemic routes (Arago and others 2020; Cooper and others 2020; Politi and others 2020; Sedaghat and others 2020; Wang and others 2020b). The data from genetically modified mouse models, as discussed below, are inconsistent regarding brain infiltration (Bao and others 2020; Sun and others 2020a; Sun and others 2020b).

Could the virus produce damage to the support cells in the olfactory epithelium and thereby diminish rapidly, but transiently, the sense of smell? This mechanism is supported by the abundant expression of the two entry proteins, ACE2 and TMPRSS2, in sustentacular cells in the olfactory epithelium ( and ; Bilinska and others 2020; Brann and others 2020; Chen and others 2020b; Klingenstein and others 2020), and by the presence of the virus primarily, if not exclusively, in the sustentacular cells (Bryche and others 2020; Meinhardt and others 2020). The initial reports of ACE2 expression in sustentacular cells based on RNAseq reported that only between 1% and 3% of these cells expressed ACE2 (Brann and others 2020; Ziegler and others 2020), while immunocytochemistry indicated that the large majority, if not all sustentacular cells contain ACE2 protein (). The most likely explanation for this discrepancy is that RNAseq is an inadequate technique for quantification and estimation of the extent of protein expression (Brann and others 2020). Interestingly, death of sustentacular cells does not seem to necessarily cause death of olfactory receptor neurons; the study by Bryche and others (2020) has shown that the neurons cilia (the dendritic extensions of the olfactory receptor neurons that bind the odorant molecules) can transiently retract or lose protein expression, implying temporary neuronal dysfunction despite persistence of olfactory nerve axons. Death and regeneration of sustentacular cells occurs much faster than death and regeneration of olfactory neurons (Bryche and others 2020; Jia and others 2010; Schwob 2002), which have to mature their dendrites and grow new axons through the cribriform plate into the olfactory bulb (). Therefore, rapid replenishment of sustentacular cells is consistent with the rapid recovery of the sense of smell that is clinically observed in most cases (). Is damage or inactivation of sustentacular cells in the olfactory epithelium sufficient to cause functional deficits of smell sensation and is it consistent with the time course and the peculiarities of the impairment reported by COVID-19 patients? The answer to these questions requires some background knowledge about the multitude of functions that sustentacular cells may perform in the olfactory epithelium.

Time course of cellular events that may cause loss of smell and its recovery in COVID-19 patients. Day 0 = day of infection. Symbols and abbreviations are the same as explained in and . SuC, sustentacular cell; ORN, olfactory receptor neuron; SC, stem cell.

Sustentacular cells have been proposed to be involved in peripheral processing of odorants in multiple ways. They appear to endocytose (clear) the odorant-binding proteins after signal transduction at the neurons cilia to allow the next round of odorant receptor binding, thereby increasing sensitivity (Heydel and others 2013; Strotmann and Breer 2011). Sustentacular cells express multiple CYP450-family monooxygenases, which hydroxylate and help to remove toxic volatiles (Heydel and others 2013). Sustentacular cells may supply neuronal cilia with some of the glucose required to meet the high energy demands of the olfactory transduction cascade (Cooper and others 2020; Villar and others 2017). Sustentacular cells also maintain the structural integrity of the olfactory epithelium (Bryche and others 2020; Jia and others 2010). Hence, these support cells are closely associated, both metabolically and functionally, with olfactory neurons and with odorant signal transduction ().

Recently, the SARS-CoV-2 virus was localized after nasal infection, and the time course of its effects on the olfactory system was determined (Bryche and others 2020). The virus localized exclusively to sustentacular cells and caused a massive degeneration of the olfactory epithelium and a widespread loss of the sustentacular cells, along with the olfactory cilia. The rapid loss of the sustentacular cells was reminiscent to that seen when the olfactory epithelium was treated with nickel sulfate in neurotoxic concentrationsmost of the olfactory axons remained intact, implying that many olfactory receptor neurons survived (Bryche and others 2020; Jia and others 2010). The cilia began to recover within 7 to 10 days after infection (Bryche and others 2020). This suggests that the odorants would fail to bind to their cognate odorant receptors until cilia are structurally and functionally restored (Liang 2020). Sustentacular cells appear to be essential for the maintenance and normal function of the cilia extending from the knobs ().

Accordingly, the coronavirus-induced anosmia or hyposmia may be a direct effect of the virus on the function of sustentacular cells, by reducing the odorant clearing function, or they may be indirect, by causing secondary metabolic or other dysfunction of the olfactory receptor neurons, since the sustentacular cells also serve to protect these neurons. Sustentacular cells regenerate after damage with a faster rate than olfactory receptor neurons (Schwob 2002; Schwob and others 1995; ), which may explain why the COVID-19 anosmia is usually short lasting ().

It is tempting to speculate that a similar function of support cells exists in the taste buds, since the taste defects occur with a very similar time course as the olfactory defects (Lee and others 2020; Vaira and others 2020a; ), but there are no studies yet available to support this hypothesis, and a recent study using RNAseq did not find significant ACE2 or TMPRSS2 expression in mouse taste buds (Wang and others 2020e). As an alternative or supplement to the virus-induced destruction of sustentacular cells, there may be consequences of immune cell infiltration from the basal lamina into the olfactory epithelium. Immune cell infiltration by macrophages and lymphocytes has been shown for mammalian and human olfactory epithelium infected by SARS-CoV-2 (Bryche and others 2020; Meinhardt and others 2020), and this appears to be accompanied by a significant increase in the levels of the proinflammatory cytokine, tumor necrosis factor alpha (Torabi and others 2020). It has been suggested that inflammation-mediated loss of odorant receptor expression may contribute to the anosmia in COVID-19 (Rodriguez and others 2020; Torabi and others 2020; Yan and others 2020). The potential roles of inflammation in olfactory dysfunction was recently reviewed (Oliviero and others 2020; Rodriguez and others 2020).

It is curious that three recent studies reported contradictory findings about virus accumulation. Two studies claimed that the virus was present in some olfactory receptor neurons, in human and hamster (Meinhardt and others 2020; Sia and others 2020), while another study reported that, in hamster, the virus was present exclusively in sustentacular cells (Bryche and others 2020). How can this be reconciled? The former studies did not identify cell types in the olfactory epithelium, they only visualized the virus, and their interpretation of virus being located in olfactory neurons is questionable: in the Meinhardt study, the authors apparently mis-identified obliquely sectioned sustentacular cells for olfactory neuron processes in their (knobs are much too large), as also noted by Cooper and others (2020). Accordingly, the data presented by Meinhardt and others (2020) and Sia and others (2020) may be consistent with those of Bryche and others (2020), who employed double labeling with cell-type specific markers to unambiguously identify the virus-containing cell types in the olfactory epithelium.

Why do some COVID-19 patients have longer-lasting anosmia? While the large majority regain their sense of smell within 1 to 3 weeks, there are reports of some patients remaining anosmic or hyposmic for months or more. The most likely explanation is that in those cases, a larger area of the sensory epithelium was affected, possibly with a more profound destruction of the epithelium that included death of a larger number of olfactory receptor neurons. The extent of epithelial destruction varied in both the human and animal studies (Bryche and others 2020; Meinhardt and others 2020).

Taken together, it is most likely that the anosmia and hyposmia observed in COVID-19 patients is caused by viral entry, infection, and death of sustentacular cells, which does not necessarily lead to infection, damage, death, and the need for regeneration of olfactory receptor neurons. Therefore, the scenario (4), specific elimination of the function of sustentacular cells, is the most likely mechanism for the transient smell dysfunction in COVID-19. What would be needed for definitive proof of this hypothesis? Histological examination (biopsies) of human olfactory epithelium during progressive stages of COVID-19 infection, ideally by comparing biopsies from cases with anosmia and biopsies from cases without anosmia.

Several studies have reported that the nasal epithelium, and in particular the olfactory epithelium, expresses large amounts of the novel coronavirus entry proteins, ACE2 and TMPRSS2 (Bilinska and others 2020; Brann and others 2020, ). The abundance and the localization of the expression of the entry proteins may be responsible for the higher viral loads in nasal epithelium than in oral mucosa or throat respiratory epithelium (Hou and others 2020; Meinhardt and others 2020; Rockx and others 2020; Wang and others 2020c; Zou and others 2020), and this may explain why dysfunctions of smell and taste are rapid, immediate, and often the only symptoms in otherwise asymptomatic carriers of COVID-19. These studies further indicate that the sustentacular cells are the first to be infected by SARS-CoV-2, and apparently are responsible for the large viral load (Bryche and others 2020; Hou and others 2020; Meinhardt and others 2020; Rockx and others 2020). The abundant expression of entry proteins in the olfactory epithelium, together with the predicted high viral load in this tissue, has implications for the preferred location to obtain swabs for viral testing: Taking swabs from the pharynx may yield less virus than taking swabs from the nasal epithelium, thereby increasing sensitivity of the test and decreasing the number of false negatives (Butowt and Bilinska 2020). The extraordinarily high viral load in the nasal epithelium also explains why many of the otherwise asymptomatic COVID-19 carriers may be the super-spreaders responsible for much of the COVID-19 transmission (Oran and Topol 2020). Loss of smell is a symptom, which is particularly relevant for the infected young and working population who is likely to spread the disease faster. Rapid identification of these individuals, for example, by using smell monitoring mobile apps, could be very relevant to reducing pandemic spread (Menni and others 2020a).

Since many otherwise asymptomatic carriers of COVID-19 have reductions in smell and/or taste, and since such an impairment is one of the earliest symptoms, it has been suggested that olfactory/gustatory deficits could be used as a valuable screening tool and for a preliminary diagnosis (Bnzit and others 2020; Hopkins and others 2020; Parma and others 2020; Sedaghat and others 2020; Tong and others 2020; Tudrej and others 2020; Yan and others 2020). Such a screening is relatively cheap, and very fast, and could be implemented together with a subsequent gene- or protein-based test for viral particles. This approach may be more sensitive than temperature checks, given the relatively large percentage of COVID-19 patients in Western countries who do not present with a fever (Grant and others 2020). Quantitative analysis of more than 76,000 users of COVID-19 Symptom Study app revealed that the predictive ability of loss of smell and taste to be higher than fever or persistent cough (Menni and others 2020a). Certainly, olfactory deficits will not be entirely specific for COVID-19, as they may be associated with other viral and nonviral insults, but when rapid screening is needed, it may prove useful to distinguish between potentially infected and non-infected individuals. Above predictions were already tested by olfactory researchers. Population screening by Menni and others (2020b) based on developed smarthphone app suggested that loss of sense of smell and taste could be included as part of routine screening for COVID-19 and should be added to the symptom list currently developed by the World Health Organization. Additionally, few other online platforms such as SmellTracker (developed in Noam Sobels laboratory) are currently used for self-monitoring of smell for detecting early signs of COVID-19.

There are several reports which indicate that a support-cell induced olfactory impairment may differ from an impairment caused by simple nasal congestion, or by damage to the olfactory receptor neurons. This may be because the sustentacular cells are likely involved in termination of the odor binding (clearance of odorant-binding proteins, Heydel and others 2013, as discussed above), and therefore may predominantly alter the threshold of sensation (intensity of odors, DellEra and others 2020; Rodriguez and others 2020; Vaira and others 2020a; Walsh-Messinger and others 2020). Another aspect that needs to be considered is that the expression of ACE2 is not uniform throughout the nasal epithelium, but it shows a gradient with greater expression in the dorsal region, and less in the ventral region (Brann and others 2020). Since there is some topography in the location of different classes of odorant receptors in the olfactory epithelium (Sakano 2010; Vedin and others 2004), and some aspects of odorant perception such as hedonics are topography dependent (Kermen and others 2016), it can be speculated that the SARS-CoV-2 induced destruction of sustentacular cells may affect some aspects of odor processing and perception (e.g., intensity, aversiveness, attractiveness) more than others. In fact, altered odor hedonics was recently demonstrated in asymptomatic students in pandemic hot spot (Walsh-Messinger and others 2020). This could possibly lead to a characteristic profile of hyposmia that may be detectable by careful testing. If this atypical profile can be clinically differentiated from the garden variety anosmia or hyposmia, then this approach may provide useful diagnostic information. Although the current state of knowledge about the combinatorial odor coding in mammalian olfactory system has no bearing on this hypothesis, it is worth exploring this direction because we still do not know all the key mechanisms achieving odor detection at the molecular level.

The SARS-CoV-2 virus has been shown to be present in the brain parenchyma and cerebrospinal fluid in humans (Meinhardt and others 2020; Moriguchi and others 2020; Paniz-Mondolfi and others 2020; Wu and others 2020b) and in some of the animal models (Jiang and others 2020; Sia and others 2020; Sun and others 2020b, ), but it is still unclear how the virus manages to get there. The possible routes include three main pathways: Neuronal, by moving along cranial nerves (nervus terminalis, olfactory, trigeminal, facial, glossopharyngeal, vagal); vascular/systemic, mediated via endothelial cells or leukocytes that cross the blood-brain barrier; and gaining access to cerebrospinal fluid-containing spaces; or a combination of some of these three pathways (Briguglio and others 2020; Dub and others 2018; Li and others 2020b; Plakhov and others 1995; Zou and others 2020; Zubair and others 2020). We will focus in this section on the potential routes through the cribriform plate. Many investigators have discussed the possibility that SARS-CoV viruses infect the brain through an olfactory route (Baig and others 2020; Butowt and Bilinska 2020; Gilani and others 2020; Li and others 2020b; McCray and others 2007; Meinhardt and others 2020; Netland and others 2008; Sia and others 2020; Ueha and others 2020; Zhou and others 2020; Zubair and others 2020). Less often, it is remembered that a second cranial nerve enters the brain through the cribriform plate: the nervus terminalis. Intuitively, the olfactory and terminal nerves are a plausible pathway to the brain, because these neurons are the only cranial nerve neurons that have a peripheral dendritic process with direct access to the virus in the nasal cavity, and a central axon that reaches the brain, without any synaptic transfer through a pseudounipolar ganglion cell as in the other sensory systems. The four possible routes from the nose to the brain, through the cribriform plate, are illustrated in .

Genetically Modified Mouse Models Expressing Human ACE2.

Four potential routes of SARS-CoV-2 virus from the nose to the brain through the cribriform plate. (A) Olfactory circuits. (B) Nervus terminalis. (C) Cerebrospinal fluid. (D) Vasculature. BS, brainstem; CVOs, circumventricular organs; HY, hypothalamus; OB, olfactory bulb; OE, olfactory epithelium.

It is now well established that most of the olfactory receptor neurons do not express the virus entry proteins, ACE2 and TMPRSS2 (Baxter and others 2020; Bilinska and others 2020; Brann and others 2020; Chen and others 2020b; Fodoulian and others 2020; Gupta and others 2020; Klingenstein and others 2020; ), and consistent with the absence of the entry proteins, there is no convincing evidence that olfactory receptor neurons accumulate SARS-CoV-2, neither in animal models (Bryche and others 2020; Sia and others 2020) nor in humans (Meinhardt and others 2020). But just because the olfactory receptor neurons do not express the two entry proteins for the virus, or only at very low levels (TMPRSS2), is it safe to assume that SARS-CoV viruses cannot utilize the olfactory route to the brain? Unfortunately, the answer is no. There is circumstantial evidence that SARS viruses can move beyond sustentacular cells and can reach the brain. One can consider several potential mechanisms that may allow such a transfer to happen. We know that the virus can and does readily enter sustentacular cells (Bryche and others 2020). A key question is: how can the virus possibly transfer from sustentacular cells to either the olfactory neurons or to other cells or structures that allow it to gain access to the cerebrospinal fluid? Is close vicinity between cell types sufficient to transfer SARS-CoV-2 to a neighboring cell that is not synaptically connected ()? If this indeed happens, the virus may utilize an organelle exchange system (exosome pathway) between support cells and neurons, as has been shown to exist between donor and host cells in other systems (Sadeghipour and Mathias 2017). Another mechanism has been proposed by DosSantos and others (2020), using the information that some stem cells in the olfactory epithelium express low levels of ACE2 (Krolewski and others 2013; Brann and others 2020; Durante and others 2020; Fodoulian and others 2020). It isat least theoreticallypossible that the virus may move from sustentacular cells to stem cells, which generate immature olfactory receptor neurons, and when these turn into mature olfactory receptor neurons (with axons extending into the olfactory bulb), they may transfer the virus directly to the olfactory bulb and beyond ().

All mammals have a collection of neurons with cell bodies dispersed along the course of the olfactory nerve and olfactory bulb that are thought to have chemosensory and/or autonomic/endocrine functions, including regulation of mucous secretion in the nasal mucosa. They connect the nasal epithelium with brain centers caudal to the olfactory bulbthe medial forebrain (septum), preoptic area, and hypothalamus (Larsell 1950). These neurons are relatively sparse in humans (301500 cells); they are much larger in number in some marine mammals (10,00020,000, Larsell 1950; Oelschlger and others 1987). Whether these cells express ACE2 or TMPRSS2 is currently not known, but ACE2 expression may be hypothesized, based on the presumed function of regulating blood flow in marine mammals (Oelschlger and others 1987). In mouse, the nervus terminalis cells are known to innervate not only blood vessels (including fenestrated capillaries)thus resembling circumventricular organsbut some of the cells are also in direct contact with the subarachnoid space (Jennes 1987). These properties make the nervus terminalis a nearly ideal conduit for SARS-CoV-2 transmission to caudal brain centers, to the cerebrospinal fluid, and into the vascular system (), especially if virus entry proteins are expressed. The targets of the nervus terminalisincluding the hypothalamusmay also transfer the virus in the brain parenchyma via ACE2-expressing neurons (Nampoothiri and others 2020; Pal and Banerjee 2020). SARS-CoV-1 has been shown in humans and in an animal model to accumulate in the hypothalamus (Gu and others 2005; Netland and others 2008).

Cerebrospinal fluid (CSF) drains through the cribriform plate into lymphatic vessels and this space is in immediate vicinity of, and between, the olfactory nerve fibers (Norwood and others 2019). Although the flow is primarily in the direction from the brain toward the nasal cavity, it is conceivableand there is precedentthat some compounds can travel in the opposite direction (Lochhead and Thorne 2012). Substances that cross the nasal epithelium and reach the lamina propria may either absorb into the vasculature, or they may enter spaces between the perineural sheaths surrounding the olfactory nerve and thereby gain access to the CSF and the brain (Lochhead and Thorne 2012), as illustrated in .

The nasal passages are highly vascular. Substances that enter the blood vessels may cross the blood-brain barrier in circumventricular organs, or they may bypass the blood-brain barrier via direct nose-to-brain pathways to enter the brain as described above. The faster transport from the nasal epithelium to the olfactory bulb and brainstem is thought to be mediated by extracellular bulk flow within perivascular spaces of cerebral blood vessels rather than via intracellular transport along cranial nerves (Lochhead and Thorne 2012). Circumventricular organs, as illustrated in , may take up the virus from the vasculature through ACE2-expressing tanycytes (Nampoothiri and others 2020).

It is known from animal models that different viruses use different pathways and combinations of pathways to invade the brain from the periphery (Dub and others 2018; Perlman and others 1990; Plakhov and others 1995). Some viruses transfer from neuron to neuron, using anterograde and retrograde axonal transport, which takes approximately one day for a directly connected neuron (Dub and others 2018; Netland and others 2008), while other viruses can enter spaces containing cerebrospinal fluid, for example, in openings of the cribriform plate, from where they rapidly distribute throughout the ventricular spaces in the brain and infect neurons, including some that have no direct connections with the olfactory system (Netland and others 2008; Plakhov and others 1995).

When human ACE2 was overexpressed in a mouse model using the cytokeratin K18 promoter (see Box 1), the virus responsible for SARS, SARS-CoV-1, rapidly infected the brain after intranasal inoculation (McCray and others 2007; Netland and others 2008), and the mice died within less than a week from brain infection, apparently due to death of virus-infected neurons in the brainstem. Since cytokeratin K18 happens to be expressed in sustentacular cells, but not in olfactory receptor neurons (Schwob and others 1995), the SARS virus appears to have taken a route that originated with the support cells in this mouse model, enabled by the abundant (because overexpressed) ACE2 protein in these cells. Interestingly, the pathway of SARS-CoV-1 from the nose to the brainstem could not be explained solely by olfactory neuron-to-neuron transport, because in some cases, the olfactory bulb was spared (McCray and others 2007), and because transport was too fast, and rapidly reached neurons not connected to the olfactory system (Netland and others 2008).

Genetically Modified Mouse Models for the Study of Coronavirus Neurotropism

Mouse models expressing human ACE2 protease, the SARS-CoV-1 and SARS-CoV-2 host receptor, are fundamental tools for progress in COVID-19 research. During the SARS epidemic several mouse models were developed. The first and best known was a mouse overexpressing human ACE2 under the epithelial-specific K18 promoter created in Stanley Perlmans laboratory (McCray and others 2007). A second mouse line, created at the Chinese Academy of Medical Sciences (Yang and others 2007), expresses human ACE2 with likely more physiological levels as its expression was controlled by a murine ACE2 promoter. Unfortunately, this second mouse model was not made commercially available. A third humanized ACE2 model was developed in Ralph Barics laboratory (Menachery and others 2016). In this mouse line, human ACE2 is overexpressed under control of lung ciliated epithelial cell-specific FOXJ1 promoter. The Baric mouse was recently infected intranasally with SARS-CoV-2, and it was concluded that the symptoms observed in this model resemble human COVID-19 symptoms (Jiang and others 2020). In contrast to the Perlman mouse, most of the infected mice recovered and did not accumulate viral particles in the brain, except in a few deceased mice. Another overexpressor mouse that uses a strong artificial CAG promoter was developed in the Tseng laboratory. However, all three hACE2 overexpressing mouse models suffer from possible artefacts caused by random transgene integration into the mouse genome, and they possibly have different pattern of hACE2 expression in the olfactory epithelium due to the usage of different promoters (). Transcriptome analysis reveals that the K18 promoter used in the Perlman mouse has more sustentacular cell-specific expression in the olfactory epithelium, while the FOXJ1 promoter used in the Baric mouse likely has more neuronal expression. However, none of the overexpressing mice developed for SARS-Cov-1 studies have spatiotemporal expression of hACE2 identical to endogenous murine ACE2. Therefore, these mice lines are not ideal models to perform clear-cut experiments elucidating SARS-CoV-2 trafficking within the olfactory pathway.

Recently, Sun and others (2020b) developed a much-anticipated humanized ACE2 knock-in mouse by using CRISPR/Cas9 technology. This mouse expresses human hACE2 under murine endogenous promoter and a transgene is inserted within the murine ACE2 locus. This in theory ensures human ACE2 expression at physiological levels and in a spatiotemporal pattern characteristic for endogenous murine ACE2. On intranasal injection of SARS-CoV-2, these hACE2 mice accumulate high viral loads not only in the lungs but also in the brain (Sun and others 2020b). In some of the mouse models, but not all, SARS-CoV was found in the brain (), but so far, the route to the brain has been investigated only in the Perlman mouse (Netland and others 2008). It can be expected that studies in additional mouse lines will soon be forthcoming that determine whether viral particles can transfer from the olfactory epithelium to the brain along olfactory axons or by alternative routes. Such studies will be most convincing when mouse models are used that express human ACE2 under endogenous promoters, similar to the Sun mouse.

Another recent approach to establish a new mouse model for COVID-19 research was recently reported by Sun and others (2020a). The authors showed that reliable and transient expression of human ACE2 may be achieved by transduction with recombinant adenoviral vector. Their viral CMV promoter drives hACE2 expression mostly in pulmonary epithelial cells; thus, almost exclusively pulmonary and no neurological symptoms were observed. To use similar transient hACE2 mice in studies of SARS-CoV-2 in the nervous system, another promoter such as synapsin 1 must be used. The advantage of this approach is that the model may be created without time-consuming breeding.

We expect that several lines of mice will soon be created that express hACE2 within so-called safe harbor ROSA26 locus. Inserting the hACE2 within this locus will eliminate the possibility that the transgene causes artefacts by having effects on the expression of nearby genes (Friedrich and Soriano 1991). The use of the ROSA26 strategy will also enable mice to express hACE2 under different promoters, including native ROSA26 promoter, strong artificial promoters, and tissue-specific promoters. Tissue-specific expression of hACE2 will be possible after crossing the ROSA26-hACE2 line containing a STOP codon flanked by loxP sites with the mouse line in which Cre recombinase is controlled by a tissue-specific promoter. In addition, the creation of a recombinant SARS-CoV-2 virus containing Cre recombinase will allow tracking infected cells in vivo after infection of a reporter mouse in which the fluorescent marker protein is expressed only after removal of the stop codon by Cre. COVID-19 research requires multiple optimal mouse models. Some genetically modified lines are more suitable for vaccine and therapeutic testing, while other lines will be better suited to study SARS-CoV-2 biology in the nervous system. We predict that the aforementioned mouse models will soon contribute to significant progress in understanding the molecular mechanisms of olfactory dysfunction as well as axonal transport and brain infection in COVID-19.

Taken the above into account, we expand the hypothesis proposed by Li and others (2020b): Since sustentacular cells extend the entire thickness of the olfactory epithelium, SARS-CoV-2 can gain access to the lamina propria, and may be extruded into the cerebrospinal fluid-containing spaces within the cribriform plate, and then spread rapidly throughout the ventricular system, infecting initially cell types that are close to the ventricular ependyma (such as dorsal raphe in the brainstem, neurons in the hypothalamus and basal ganglia), but rarely reach brain parts that are remote from the ventricular system (e.g., the cerebellum). This hypothesis is consistent with the findings of both, human studies (Meinhardt and others 2020; Nampoothiri and others 2020) as well as animal models examining the neurotropism of viruses, including coronaviruses (Perlman and others 1990; Netland and others 2008).

A recent study has reported how frequently brain regions contained SARS-CoV-2 virus in COVID-19 patients (Meinhardt and others 2020). Although this study did not provide the timeline after infection, only the endpoint, it is interesting to compare with the brain nuclei that contained SARS-CoV-1 virus in the animal model (McCray and others 2007; Netland and others 2008). Of particular interest is that in humans, even though the olfactory mucosa had the highest viral load in nearly all cases that were examined (Meinhardt and others 2020), the medulla oblongata was more often positive for the virus than the olfactory bulb, which speaks against a neuron-to-neuron transfer of the virus along the olfactory nerve, and is more consistent with a spread through the cerebrospinal fluid compartment, as indicated also by the animal model (McCray and others 2007; Netland and others 2008). The study on this mouse model has also provided some information on the timing and sequence in which the virus appears in the brain after intranasal infection (Netland and others 2008). Interestingly, the arrival of the virus in the olfactory bulb did not precede other sites, as one would expect if it was transferred from olfactory receptor neurons to mitral cells and then to second- and third-order targets of the olfactory bulb, but rather appeared simultaneously in the olfactory bulb, raphe neurons in the medulla and in neurons of the hypothalamus and basal ganglia (Netland and others 2008), suggesting that the neuron-to-neuron transport was not the only route in the brain. Similarly, in humans with COVID-19 and high viral loads in the olfactory epithelium, more cases with significant amounts of detectable virus actually involved the medulla than the olfactory bulb, and they were equal between the olfactory bulb and trigeminal ganglion (Meinhardt and others 2020). Taken together with the mouse time course studies, the currently available data suggest that there probably is a transfer of the virus from the olfactory epithelium through the cribriform plate to the brain, but in addition to being anterogradely transported along axons and transferred to second-order neurons in the olfactory bulb, the virus also appears to utilize another route, likely cerebrospinal fluid spaces which penetrate the cribriform plate along with the olfactory nerve fibers, and by entering channels formed by olfactory ensheathing cells (Butowt and Bilinska 2020; Li and others 2020b; Norwood and others 2019; van Riel and others 2015), or by using nervus terminalis cells as conduits (). Accessing the cerebrospinal fluid would allow the virus to rapidly distribute throughout the ventricular system, reaching first nuclei that have periventriclar locations, such as raphe and hypothalamuswhich is where Netland and others (2008) describe heavy accumulation coincident with infection of the olfactory bulb. Animal models with physiological levels of human ACE2 expression will be valuable tools to determine the precise pathway of SARS-CoV-2 to brain infection (Box 1).

Is there ACE2-independent virus entry and transfer? For the interpretation of data obtained in the study mentioned above, it must also be considered that the novel coronavirus may utilize an ACE2-independent route to transfer from sustentacular cells to olfactory receptor neurons. SARS-CoV-1 and other coronaviruses may use additional lower-affinity co-receptors besides the main high-affinity receptor. For example, it was shown that SARS-CoV-1, in addition to ACE2, may use CD209 glycoproteins as alternative host receptors (Jeffers and others 2004). SARS-CoV-2 can utilize CD147 to enter some cell types (Wang and others 2020a). Although olfactory receptor neurons do not express any or very little ACE2, they do express CD147 as shown by multiple microarray and RNAseq studies (Krolewski and others 2013; Nickell and others 2012; Saraiva and others 2015). Therefore, it is possible that some viral particles pass from sustentacular cells to olfactory neurons by using a CD147-dependent mechanism. Alternatively, the virus may utilize an exosome pathway that is known to allow viruses to transfer between cells (Sadeghipour and Mathias 2017). Furthermore, it is possible that SARS-CoV-2 itself upregulates ACE2 in host tissues (Nampoothiri and others 2020; Ziegler and others 2020)which adds another level of complexity in identifying relevant cell types and potential routes of infection.

Once a virus has entered the brain, it can persist there for many years, and such long-term presence may lead to inflammation that is thought to play a role in chronic neurological diseases (Desforges and others 2019; Dub and others 2018). These are additional reasons why it is important to better understand whether and how the novel SARS-CoV-2 virus may utilize a route through the cribriform plate to the brain. COVID-19 patients can present with a variety of neurological symptoms (Mao and others 2020; Wang and others 2020b). The long-term presence of the virus in the brain may lead to inflammation and perhaps initiate or aggravate chronic neurological diseases such as multiple sclerosis and Parkinsons disease (Desforges and others 2019; Dub and others 2018; Serrano-Castro and others 2020). The pathway from the nose to the brain must be considered among other potential routes of SARS-CoV-2 from the periphery to the brain (Baig and others 2020; Butowt and Bilinska 2020; DosSantos and others 2020; Li and others 2020b). Given that the olfactory epithelium has such intense expression of the entry proteins for the SARS-CoV-2 virusthe highest expression level in the nasal cavityand is located on the main route of infection through aerial spread, neurologists need to be vigilant to the possibility of brain infection by SARS-CoV-2 using a route from the nose to the brain.

In summary, the olfactory/gustatory dysfunctions of COVID-19 patients provide both, daunting challenges due to the early, very high viral load and possibilities of super-spreading and a nasal route to brain infection, and also potentially fortunate opportunities, namely to utilize anosmia as a rapid screening tool to identify early, and otherwise asymptomatic, carriers of the novel coronavirus. An emerging field of interest and a major novel hypothesis is that genetic differences in the prevalence of chemosensory defects may be caused by variations in the binding affinity of the ACE2 receptor for the virus and therefore may dictate infectivity and spreading of the virus. Differences between populations in this regard remain to be verified by future studies, but if confirmed, they would have considerable implications for defining which populations are most vulnerable to COVID-19 infection and how to best and most effectively manage the pandemic by a customized approach, that takes into account the infectivity of different populations. Whether a nasal route to the brain exists for SARS-CoV-2, especially after prolonged virus exposure, requires further studies, and it will be important to precisely define the short-term and potential long-term consequences of SARS-CoV-2 in the brain.

The authors thank Matthias Bochtler (International Institute of Molecular and Cell Biology, Warsaw) for helpful comments.

Author Contributions: Both authors contributed equally to the writing of this article.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Excellence InitiativeResearch University ID-UB program at the Nicolaus Copernicus University and by the National Institutes of Health. CSvB is supported by a grant from the National Institute of General Medical Sciences (GM103554). The funders had no role in the preparation, review, or approval of the manuscript or decision to submit the manuscript for publication.

ORCID iDs: Rafal Butowt https://orcid.org/0000-0001-9614-4022

Christopher S. von Bartheld https://orcid.org/0000-0003-2716-6601

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Anosmia in COVID-19: Underlying Mechanisms and Assessment ...

Bumetanide, a drug already approved to treat swelling associated with conditions such as heart failure, improved performance on cognitive tests and reduced the buildup of amyloid plaques in mice with an Alzheimers-like condition, researchers report. Furthermore, in cultured human neurons derived from stem cells, bumetanide reversed gene expression changes associated with Alzheimers, and the electronic health records of millions of patients point to a link between the drug and reduced odds of being diagnosed with the disease.

On the basis of these results, published this week (October 10) in Nature Aging, Gladstone Institutes neurobiologist and study coauthor Yadong Huang tells STAT that he and his team are now pursuing a clinical trial to test the drug in human patients with at least one copy of the APOE4 variant, a well-known risk factor for the disease.

Bumetanide blocks ion channels in the cell membrane, thereby altering salt balances and reducing water retention, but how this mechanism might affect neural function is not known. The mechanism of the drug is well-known, but what the authors havent addressed is how that mechanism is related to what they think might happen if they were to give this drug to Alzheimers patients, Johns Hopkins University neurologist Shilpa Kadam, who was not involved in the study, tells STAT.

While bumetanide did shrink amyloid plaques in a mouse model of Alzheimers, the drug is not thought to target these protein aggregations directly as many experimental Alzheimers drugs have. Many such drugs have failed, and one that was recently approved, Biogens Aduhelm, has been mired in controversy, with some questioning its efficacy and the legitimacy of its regulatory review.

The new study supports a growing body of evidence that amyloid plaques are but one piece of the puzzle. In Alzheimers patients with at least one copy of APOE4, nearly 2,000 genes showed altered expression compared with healthy controls, Huang and his colleagues found. These included genes involved with circadian rhythms, morphine addiction, and the neurotransmitter GABA.

There are many cellular and molecular changes in Alzheimers disease patients besides plaques, but we usually dont talk about them, Huang tells STAT. He adds that patients may have different underlying cellular mechanisms that lead to their neurodegeneration, and thus may require different treatments. More and more people are accepting this concept, but its definitely still an emerging idea.

Jeffrey Cummings, director of the Chambers-Grundy Center for Transformative Neuroscience at the University of Nevada Las Vegas, tells STATthat the new study reveals a repertoire of pathways that have not been adequately investigated, but notes that bumetanide can cause dehydration and electrolyte imbalances. This drugs relationship to Alzheimers disease is not quite proven and its side effect profile is undesirable in older people, he says.

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Repurposed Drug Reverses Signs of Alzheimers in Mice, Human Cells - The Scientist

When Sandy Morris found out she would die of ALS, she resolved that she would bravely, peacefully and legally end her own life, surrounded by her beloved family and views of the Sierra Nevada.

The challenge is: How?

Californias End of Life Option Act requires that people take their own lethal medications, without assistance but the cruel reality for Sandy and others dying of neuromuscular disease is that they cant. They need help.

On Friday, the iron-willed 55-year-old wife, mother and former athlete, joined by other patients and physicians, filed suit in federal court asserting discrimination under the states historic law. Because they are disabled, they say, theyre denied access to the dignified death available to all other Californians.

It is so incredibly cruel that nobody can help me take these medications, said Morris, confined to her bed in Sierraville, north of Lake Tahoe. I am terrified to think that if I wait too long if I wake up tomorrow or the next day and cant move my thumbs or swallow that suddenly this is no longer an option for me.

If the courts allow her doctor to help administer the drugs she needs for a peaceful goodbye, I can stay with my children a few extra weeks, or days, or hours, she said, her voice breaking.

But Ill have to leave this beautiful world earlier thanI want to, she said, while I still have the use of my hands and while I can still swallow.

Under the End of Life Option Act, used by 1,816 Californians since it went into effect in 2016, it is legal for doctors and family members to prepare medications, put them in a drink or pour them into a syringe or pump attached to a feeding tube.

But the patient needs to suck the straw on their own. They cant help the patient push a plunger on the syringe. If the medications get stuck while flowing from a bag into a feeding tube, risking a dangerous partial dose, they cant fix it by squeezing the bag.

Thats considered assisting a suicide a felony, punishable by up to three years in prison and/or a $10,000 fine. Doctors could lose their licenses.

More than two-thirds of patients who use the Act are dying of cancer.

But the second-largest category of underlying illness accounting for 10% of all cases are people with common neurological diseases and movement disorders such as amyotrophic lateral sclerosis (ALS), Parkinsons, multiple sclerosis, stroke or paralysis from spinal injury.

Theyre faced with a terrible decision: die early or suffer.

They come to this place where they feel pressured to act, said attorney Kathryn Tucker of Emerge Law Group, who is filing the civil rights class-action suit.

For Sandy, choosing to wait might mean suffocating to death. ALS is a progressive neurodegenerative illness that affects nerve cells in the brain and the spinal cord, eventually paralyzing your chest muscles. Often called Lou Gehrigs disease, after the death of the famed Yankee first baseman, it also claimed the lives of playwright Sam Shepard, jazz musician Charles Mingus and San Francisco 49ers receiver Dwight Clark.

Her mind is still razor sharp. She can still feel every sensation. With difficulty, she is still able to speak. But nothing else moves. My brain will say kick, and my feet are ready. Theyre still beautiful, she said. But the neurons have died. They are no longer able to send the message.

Doctors who help the terminally ill confront a legal dilemma: Disability law mandates assistance and equal access to health care, while the aid-in-dying law mandates the opposite.

I am trapped between two contradictory laws, said Dr. Lonny Shavelson of Berkeley, chair of the American Clinicians Academy on Medical Aid in Dying. When working with a patient with neuromuscular disease or various other neurological diseases, Im forced to break one law or the other. Theres no other choice.

Californias law, modeled after Oregons statute, was written by politicians and advocates, not doctors and ethicists, said Dr. Robert Brody of San Francisco General Hospital and Professor of Medicineand Family and Community Medicine at UC San Francisco.

To appease opponents of the act, the language was very restrictive, he said. Rules not only preclude help but also require patients to be of clear mind and capable of making three requests, orally and in writing, separated by a minimum of 15 days. Two witnesses are required for a patients signature on the written request. Patients must sign a final attestation form no more than 48 hours before ingesting the drug.

Now its time to improve the law, Brody said, with the political courageto take on the vested interests who didnt want this law in the first place, who dont want the law now and who have demanded these so-called safeguards, he said.

These safeguards have turned out to be barriers, he said.

According to bioethicist Alicia Ouellette, dean of New Yorks Albany Law School and an expert in health law and disability rights, the law prevents competent, terminally ill people with neurologic diseases from accessing aid in dying because they cannot physically administer the medications. The unassisted self-administration requirement creates a barrier to health services available to people without those disabilities. This barrier runs contrary to disability rights laws.

Opponents say safeguards are essential to prevent an heir or abusive caregiver from coercing the patient to take the deadly drugs. People with disabilities may feel theyre a burden on loved ones, and abuse is a growing but often undetected problem, according to the group Not Dead Yet, a New York-based disability rights group that calls aid-in-dying laws a deadly form of discrimination.

Clinicians are allowed to administer medicine in almost every other jurisdiction in the world that allows aid in dying, such as Canada, Australia, New Zealand, Colombia, Spain, Netherlands, Belgium and Luxembourg. Switzerland and the U.S. require self-administration.

The law should not discriminate against people with disabilities by forcing them to consider this most personal decision before they are ready, said Fred Fisher, CEO of the ALS Association Golden West Chapter. The group neither supports nor opposes the law, saying it is a matter of individual conscience.

Sandy Morris was once an energetic woman who skied, hiked, ran the Lake Tahoe Marathon and worked for years as global analytics business manager for Hewlett-Packard. Married to her best friend, she was fiercely committed to family life, organizing fancy birthday parties, planning college tours and waking before dawn to help braid the mane of her daughters paint horse, Sunny, for show competition.

We had a fairytale upbringing. I woke up every morning knowing that I was completely safe and held, said her daughter, Kylan, 24. I want every minute that shes still here on Earth with us.

Sandy was only 51 when she was diagnosed, after noticing that her right foot slapped the sidewalk when she walked. Desperate for a cure, she joined a clinical trial at California Pacific Medical Center, endured three spinal infusions and four lumbar punctures, and flew to South Korea for a stem-cell experiment.

As the disease progresses, its like an anaconda snake that swallows you whole, then squeezes you to death, she said. And theres no way out.

For four years, I fought this disease to the best of my ability, she said. While she knew it was fatal, she took solace that the End of Life Options Act meant that my children and my husband would not have to watch me gasp for my last breath.

Shes frustrated that help is available for every possible need from eating and bathing to scratching an itch yet not for dying.

It feels so unfair that because I am disabled, Im going to have to pick a day, and leave this world earlier than I want to, she said.

Ill miss the weddings and the grandchildren, she said. At least let me stay for the very last second, until my bravery is over, with my babies and my husband and my beautiful life.

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When aid-in-dying means you have to go before youre ready - Monterey Herald

MELVILLE, N.Y., Aug. 11, 2021 (GLOBE NEWSWIRE) -- BioRestorative Therapies, Inc. (the Company or BioRestorative) (OTC: BRTX), a life sciences company focused on stem cell-based therapies, today reminded its stockholders that its annual meeting of stockholders will be held on Tuesday, August 17, 2021 at 10 a.m. EDT.

Lance Alstodt, President and Chief Executive Officer of the Company, stated At the stockholders meeting, certain proposals, including the approval of our reincorporation from Delaware to Nevada or, in the alternative, the authorization of a reverse split of our common stock will be submitted for a vote of the stockholders. These matters are discussed in the proxy materials mailed or made available to BioRestorative stockholders by Broadridge Financial Solutions.

We cannot complete the reincorporation or reverse split unless the holders of a majority of the outstanding shares of common stock entitled to vote approve the proposal.

If you are a stockholder of record as of June 24, 2021, we ask you to take a moment to vote your shares online at Proxyvote.com.

We appreciate your continued support.

About BioRestorative Therapies, Inc.

BioRestorative Therapies, Inc. (www.biorestorative.com) develops therapeutic products using cell and tissue protocols, primarily involving adult stem cells. Our two core programs, as described below, relate to the treatment of disc/spine disease and metabolic disorders:

Disc/Spine Program (brtxDISC): Our lead cell therapy candidate, BRTX-100, is a product formulated from autologous (or a persons own) cultured mesenchymal stem cells collected from the patients bone marrow. We intend that the product will be used for the non-surgical treatment of painful lumbosacral disc disorders or as a complementary therapeutic to a surgical procedure. The BRTX-100 production process utilizes proprietary technology and involves collecting a patients bone marrow, isolating and culturing stem cells from the bone marrow and cryopreserving the cells. In an outpatient procedure, BRTX-100 is to be injected by a physician into the patients damaged disc. The treatment is intended for patients whose pain has not been alleviated by non-invasive procedures and who potentially face the prospect of surgery. We have received authorization from the Food and Drug Administration to commence a Phase 2 clinical trial using BRTX-100 to treat chronic lower back pain arising from degenerative disc disease.

Metabolic Program (ThermoStem): We are developing a cell-based therapy candidate to target obesity and metabolic disorders using brown adipose (fat) derived stem cells to generate brown adipose tissue (BAT). BAT is intended to mimic naturally occurring brown adipose depots that regulate metabolic homeostasis in humans. Initial preclinical research indicates that increased amounts of brown fat in animals may be responsible for additional caloric burning as well as reduced glucose and lipid levels. Researchers have found that people with higher levels of brown fat may have a reduced risk for obesity and diabetes.

Forward-Looking Statements

Certain statements in this communication may constitute forward-looking statements that reflect managements current views with respect to future events and financial performance. Forward-looking statements are projections in respect of future events or our future financial performance. In some cases, you can identify forward-looking statements by terminology such as may, should, expects, plans, anticipates, believes, estimates, predicts, potential or continue or the negative of these terms or other comparable terminology. These statements include statements regarding the intent, belief or current expectations of us and members of our management team, as well as the assumptions on which such statements are based. Prospective investors are cautioned that any such forward-looking statements are not guarantees of future performance and involve risk and uncertainties, and that actual results may differ materially from those contemplated by such forward-looking statements. These statements are only predictions and involve known and unknown risks, uncertainties and other factors, including the risks set forth in the section entitled Risk Factors in our Annual Report on Form 10-K for the fiscal year ended December 31, 2020, as filed with the SEC on April 30, 2021, and our Quarterly Report on Form 10-Q for the quarter ended March 31, 2021, as filed with the SEC on May 17, 2021, any of which may cause the Companys or our industrys actual results, levels of activity, performance or achievements to be materially different from any future results, levels of activity, performance or achievements expressed or implied in our forward-looking statements. These risks and factors include, by way of example and without limitation:

Although we believe that the expectations reflected in the forward-looking statements are reasonable, we cannot guarantee future results, levels of activity, or performance. Except as required by applicable law, including the securities laws of the United States, we do not intend to update any of the forward-looking statements to conform these statements to actual results.

Readers are urged to carefully review and consider the various disclosures made by us in this communication and in our reports filed with the SEC. We undertake no obligation to update or revise forward-looking statements to reflect changed assumptions, the occurrence of unanticipated events, or changes in the future operating results over time, except as required by law. We believe that our assumptions are based upon reasonable data derived from and known about our business and operations. No assurances are made that actual results of operations or the results of our future activities will not differ materially from our assumptions.

CONTACT:Email: ir@biorestorative.com

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BioRestorative Therapies Discusses Upcoming Annual Meeting - GlobeNewswire

Mesoblast (NASDAQ:MESO) and Titan Pharmaceuticals (NASDAQ:TTNP) are both small-cap medical companies, but which is the better stock? We will contrast the two companies based on the strength of their valuation, institutional ownership, risk, earnings, analyst recommendations, dividends and profitability.

Profitability

This table compares Mesoblast and Titan Pharmaceuticals net margins, return on equity and return on assets.

Volatility & Risk

Mesoblast has a beta of 1.82, indicating that its share price is 82% more volatile than the S&P 500. Comparatively, Titan Pharmaceuticals has a beta of 1.18, indicating that its share price is 18% more volatile than the S&P 500.

Analyst Ratings

This is a breakdown of recent ratings for Mesoblast and Titan Pharmaceuticals, as provided by MarketBeat.

Mesoblast currently has a consensus price target of $12.83, indicating a potential upside of 28.21%. Titan Pharmaceuticals has a consensus price target of $1.00, indicating a potential upside of 274.67%. Given Titan Pharmaceuticals stronger consensus rating and higher probable upside, analysts plainly believe Titan Pharmaceuticals is more favorable than Mesoblast.

Insider and Institutional Ownership

2.7% of Mesoblast shares are held by institutional investors. Comparatively, 1.5% of Titan Pharmaceuticals shares are held by institutional investors. 18.8% of Mesoblast shares are held by company insiders. Comparatively, 2.0% of Titan Pharmaceuticals shares are held by company insiders. Strong institutional ownership is an indication that hedge funds, endowments and large money managers believe a company will outperform the market over the long term.

Valuation & Earnings

This table compares Mesoblast and Titan Pharmaceuticals top-line revenue, earnings per share (EPS) and valuation.

Titan Pharmaceuticals has lower revenue, but higher earnings than Mesoblast. Mesoblast is trading at a lower price-to-earnings ratio than Titan Pharmaceuticals, indicating that it is currently the more affordable of the two stocks.

Summary

Mesoblast beats Titan Pharmaceuticals on 9 of the 14 factors compared between the two stocks.

Mesoblast Company Profile

Mesoblast Limited, a biopharmaceutical company, develops and commercializes allogeneic cellular medicines. Its proprietary regenerative medicine technology platform is based on specialized cells known as mesenchymal lineage adult stem cells. The company's products under the Phase III clinical trials include MSC-100-IV for steroid refractory acute graft versus host disease; MPC-150-IM for advanced heart failure; and MPC-06-ID for chronic low back pain due to degenerative disc disease. It is also developing MPC-300-IV that is in Phase II clinical trials for the treatment of biologic refractory rheumatoid arthritis, diabetic kidney diseases, and type 2 diabetic nephropathy. It operates in the United States, Australia, Singapore, the United Kingdom, and Switzerland. Mesoblast Limited has strategic partnerships with Tasly Pharmaceutical Group to offer MPC-150-IM for heart failure and MPC-25-IC for heart attacks in China; and JCR Pharmaceuticals Co. Ltd. for the treatment of wound healing in epidermolysis bullosa. The company was founded in 2004 and is headquartered in Melbourne, Australia.

Titan Pharmaceuticals Company Profile

Titan Pharmaceuticals, Inc., a pharmaceutical company, develops proprietary therapeutics for the treatment of serious medical disorders. It develops products based on ProNeura, a proprietary long-term drug delivery platform that focuses primarily on treatments for chronic diseases. The company offers Probuphine, a product candidate for maintenance treatment of opioid dependence, which maintains a stable, around the clock blood level of the drug buprenorphine in patients for six months following a single treatment. It also develops ProNeura-Ropinirole, an implant to provide delivery of ropinirole, a dopamine agonist for the treatment of Parkinson's disease; and triiodothyronine, an implant for the treatment of hypothyroidism. The company has a collaboration with Nevada Center for Behavioral Health to evaluate a medication-assisted treatment program utilizing Probuphine (buprenorphine) implant for Opioid Use Disorder (OUD) patients. Titan Pharmaceuticals, Inc. was founded in 1992 and is based in South San Francisco, California.

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Contrasting Mesoblast (NASDAQ:MESO) and Titan Pharmaceuticals (NASDAQ:TTNP) - Riverton Roll

A Nevada man suffering from Leukemia received a bone marrow transplant from a donor, four years ago. Now, he has discovered he is a chimera: a rare condition where people live with two sets of DNA in their body.

The man named Chris Long, who works at the Washoe County sheriff's office in Nevada, learned of his condition after undergoing genetic tests, thanks to his colleagues from the forensics unit. "I thought that it was pretty incredible that I can disappear and someone else can appear," Long told The New York Times.

The procedure had replaced his blood DNA with that of his donor's. This is on expected lines, say experts. After bone marrow transplantation, patients have the donor's DNA in their blood.

But what left Long and his colleagues puzzled was the extent of infiltration in his body. The test revealed that the donor's DNA found its way into Long's cheeks, lips and semen.

"Any place blood cells can traffic could have traces of donor DNA present.The donor DNA, however, should not be the dominant DNA present in those other body areas," Dr. Timothy Fenske, Medical College of Wisconsin, told MEA WorldWide (MEAWW).

Patients who undergo the procedure are expected to have their own DNA in the vast majority of their cells. "We were kind of shocked that Chris was no longer present at all," Darby Stienmetz, Longs colleague told the New York Times.

However, Long has retained his DNA in the hair on his head and chest, where it has remained entirely unchanged.

Furthermore, according to experts, foreign DNA does not interfere with a person's identity. "Their brain and their personality should remain the same," Dr. Andrew Rezvani, the medical director of the inpatient Blood & Marrow Transplant Unit at Stanford University Medical Center, told the New York Times.

Neither will chimera's like Long pass on the donor's DNA into their future offspring, according to bone marrow transplant experts. "There shouldn't be any way for someone to father someone else's child," added Dr. Rezvani.

"I know of no evidence that marrow or blood stem cell transplantation could lead to chimerism in the actual sperm or eggs that would make no sense really.There must have been traces of DNA in the semen (semen is mostly prostatic fluid and not the same as sperm)," Freske told MEAWW.

Long's case could open up questions on the reliability of DNA tests which are considered unquestionable evidence during criminal investigations. When dealing with chimera's like Long, DNA tests could mislead investigations, said experts.

Nearly 23,000 bone marrow or umbilical cord blood transplants were performed in the US in 2017. And if one among them responded similarly to a transplant and that person went on to commit a crime, it could mislead investigators, according to Brittney Chilton, a criminalist at the Sheriff's Office forensic science division.

A case in point is one in Alaska. In 2004, investigators in Alaska recovered traces of DNA from a crime scene, which matched a profile on a criminal DNA database.

However, the match was to a man who was already in prison at the time of the assault. Later, the investigators realized that this man received a bone marrow transplant from his brother, who was eventually convicted.Scientists say that Long is a living, breathing case study of one, and it's impossible to say how many other people respond to bone marrow transplants the same way he did.

It is simply one of those curious possibilities that forensic analysts may want to consider when DNA results are not adding up, said people who have reviewed Long's case, as reported by The New York Times.

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Nevada cancer survivor found to have two different sets of DNA after bone marrow transplant 4 years ago - MEAWW