Medicinal leech therapy-an overall perspective

Exploring a Hirudin variant from nonhematophagous leeches: Unraveling full-length sequence, alternative splicing, function, and potential as a novel anticoagulant polypeptide

ETHNOPHARMACOLOGICAL RELEVANCE

Leeches exhibit robust anticoagulant activity, making them useful for treating cardiovascular diseases in traditional Chinese medicine. Whitmania pigra, the primary source species of leech-derived medicinal compounds in China, has been demonstrated to possess formidable anticoagulant properties. Hirudin-like peptides, recognized as potent thrombin inhibitors, are prevalent in hematophagous leeches. Considering that W. pigra is a nonhematophagic leech, the following question arises: does a hirudin variant exist in this species?

AIM OF THE STUDY

In this study we identified the hirudin-encoding gene (WP_HV1) in the W. pigra genome. The goal of this study was to assess its anticoagulant activity and analyze the related mechanisms.

MATERIALS AND METHODS

In this study, a hirudin-encoding gene, WP_HV1, was identified from the W. pigra genome, and its accurate coding sequence (CDS) was validated through cloning from cDNA extracted from fresh W. pigra specimens. The structure of WP_HV1 and the amino acids associated with its anticoagulant activity were determined by sequence and structural analysis and prediction of its binding energy to thrombin. E. coli was used for the expression of WP_HV1 and recombinant proteins with various structures and mutants. The anticoagulant activity of the synthesized recombinant proteins was then confirmed using thrombin time (TT).

RESULTS

Validation of the WP_HV1 gene was accomplished, and three alternative splices were discovered. The TT of the blank sample exceeded that of the recombinant WP_HV1 sample by 1.74 times (0.05 mg/ml), indicating positive anticoagulant activity. The anticoagulant activity of WP_HV1 was found to be associated with its C-terminal tyrosine, along with the presence of 9 acidic amino acids on both the left and right sides. A significant reduction in the corresponding TT was observed for the mutated amino acids compared to those of the wild type, with decreases of 4.8, 6.6, and 3.9 s, respectively. In addition, the anticoagulant activity of WP_HV1 was enhanced and prolonged for 2.7 s when the lysine-67 residue was mutated to tryptophan.

CONCLUSION

Only one hirudin-encoding variant was identified in W. pigra. The active amino acids associated with anticoagulation in WP_HV1 were resolved and validated, revealing a novel source for screening and developing new anticoagulant drugs.

Comparative genomics of two Asian medicinal leeches Hirudo nipponia and Hirudo tianjinensis: With emphasis on antithrombotic genes and their corresponding proteins

Leeches secrete various biologically active substances which have important medical and pharmaceutical values in antithrombotic treatments. Here, we provide a high quality genome of two Asian medicinal leeches Hirudo nipponia and Hirudo tianjinensis, based on which, we identified 22 antithrombotic gene families, including fourteen coagulation inhibitors, four platelet aggregation inhibitors, three fibrinolysis enhancers, and one tissue penetration enhancer. The total numbers of antithrombotic genes were similar between H. nipponia (N = 86) and H. tianjinensis (N = 83). Molecular evolution analysis showed that no significant differences were detected between the two species in any of the three selection indices (dN, dS, and dN/dS), nor in the number of sites under positive/purifying selection. RNA-Seq based gene expression analysis showed that the overall expression patterns of the antithrombotic gene families were not significantly deviated between the two species. Our results indicated that there were rather close similarities between the two leeches on genomic characteristics, especially for the molecular evolution and expression of antithrombotic genes. Our study provides the most comprehensive collection of antithrombotic biomacromolecules from the two Asian medicinal leeches to date. These results will greatly facilitate the research and application of leech derivatives for medical and pharmaceutical purposes of thrombosis.

Pathophysiology and management of testicular ischemia/reperfusion injury: Lessons from animal models

Testicular torsion is a urological emergency that involves the twisting of the spermatic cord along its course. Compelling pieces of evidence have implicated oxidative stress-sensitive signaling in pathogenesis of testicular I/R injury. Although, surgical detorsion is the mainstay management; blockade of the pathways involved in the pathogenesis may improve the surgical outcome. Experimental studies using various testicular I/R models have been reported in a bid to explore the mechanisms associated with testicular I/R and evaluate the benefits of potential therapeutic measures; however, most are limited by their shortcomings. Thus, this review was intended to describe the details of the available testicular I/R models as well as their merits and drawbacks, the pathophysiological basis and consequences of testicular I/R, and the pharmacological agents that have being proposed to confer testicular benefits against testicular I/R. This provides an understanding of the pathophysiological events and available models used in studying testicular I/R. In addition, this research provides evidence-based molecules with therapeutic potentials as well as their mechanisms of action in testicular I/R.

From bloodthirsty parasites to surgical superstars: The humble leech, a suck-cess story in surgical history

This historical review delves into the extensive and intriguing history of leeches in surgery. The utilisation of leeches in medical practice dates back thousands of years, from ancient civilisations to the modern era. The therapeutic properties of leeches have led to their persistent presence in surgical procedures. The 'Age of Leeches' during the 18th and 19th centuries witnessed a heightened utilisation of leeches in surgical treatment, given their perceived ability to promote postoperative wound healing and alleviate blood congestion. However, advancements in medical knowledge subsequently diminished their popularity as emerging technologies overshadowed them. Nevertheless, recent years have witnessed a resurgence in the use of leeches in reconstructive surgery, driven by both a greater understanding of their biological mechanisms and their potential source of therapeutic agents. This historical review provides a comprehensive exploration of the historical timeline, societal perceptions and scientific advancements surrounding the use of leeches in surgical practice.

Efficacy and potential mechanism of atherosclerosis prevention by the active components of leech based on network pharmacology combined with animal experiments

Introduction

Leeches are flesh-eating and bloodsucking parasitic worms. They are being used as a traditional Chinese medicine for centuries in activating blood and dissolving statis, dreging the meridims and tick. Hirudin, an active peptide product present in leech, has blood anticoagulant property and can assist in the treatment of thrombosis and diseases related to blood circulation. The efficacy and potential mechanism of action of leeches in such diseases should be further explored.

Materials and methods

First, network pharmacology was used to screen the predicted potential targets of the active constituents of leech and AS. The common targets of the active constituents of leech and AS were obtained using Venn diagram. Further, the drug-active-constituent-target network diagram, protein-protein interaction, and GO and KEGG pathway enrichment analyses were used to construct the active-constituent-AS target-pathway network diagram. Subsequently, the protein-drug molecule docking model was drawn. Finally, the results of network pharmacology were validated using a mouse model of AS.

Results

In total, 34 active constituents of leech and 1172 AS-related gene targets were selected, took the drug action targets and potential disease targets to get the common targets, and took the top 10 of degree value as the main active constituents for the treatment of atherosclerosis. There were 89 common targets and 12 core targets. The main targets included MAPK, EGFR, PIK3CB, etc. Potential regulatory pathways included cancer pathways, EGFR tyrosine kinase inhibitor resistance, Rap1 signaling pathway, PPAR signaling pathway, PI3K-Akt signaling pathway, C-type lectin receptor signaling pathway, and AGE-RAGE signaling pathway in diabetic complications. Animal experiments using mouse model of AS confirmed that AS plaques were smaller after treatment with leeches. SRC level was measured using western blotting. Expression of SRC in myocardial tissue was remarkably lower in the mice treated with leech than in the mice from model group fed on high-fat chow.

Conclusions

To the best of our knowledge, this is the first study to explore the mechanism of action of the active components of leech in AS prevention. The active components of leeches play a coordinated role in preventing AS through multicomponent, multitarget, and multichannel mechanism of action related to inflammatory response, oxidative stress, and lipid metabolism. This study provided a reference for subsequent cellular and animal experiments.

Biomedical waste generation at Ayurveda hospitals in South Asia: A mini review of the composition, quantities and characteristics

Ayurveda hospitals generate biomedical wastes (BMW). However, details on composition, quantities and characteristics are very scarce, details which are important to formulate a proper waste management plan for subsequent implementation and continual improvement. Therefore, this article presents a mini review of the composition, quantities and characteristics of BMW generated from Ayurveda hospitals. Additionally, this article presents some best possible treatment and disposal procedures. Most of the information was gleaned from peer-reviewed journals, although some information was collected by the author and from grey literature available to the author; 70-99% (by wet weight) of the solid waste is non-hazardous; biodegradables contributing to 44-60% by wet weight due to more used Kizhi (medicinal bags for fomentation) and other medicinal/pharmaceutical wastes (excluding waste medicated oils, which is 12-15% of the liquid medicinal waste stream and are not readily biodegradable) largely derived from plants. The hazardous waste component includes infectious wastes, sharps, blood as pathological wastes (from Raktamoksha - bloodletting), heavy metal containing pharmaceutical wastes, chemical wastes and heavy metal rich wastes. Quantities of infectious wastes followed by sharps and blood form a major portion of hazardous wastes. Most of the infectious waste material contaminated with blood or other body fluids and sharps from Raktamoksha are very similar (appearance, moisture content and bulk density) to what is generated from hospitals practicing Western medicine. However, hospital-specific waste studies are required in future to better understand the sources, areas of generation, types, quantities and characteristics of BMW, and hence to formulate more accurate waste management plans.

Functional Nasal Surgery in a Compromised Soft Tissue Envelope

Functional nasal surgery in the setting of a compromised soft tissue envelope (STE) requires significant planning and preparation. Proper preoperative evaluation is imperative to assess the degree of STE compromise and determine the best surgical approach. Alternative approaches to functional nasal surgery, such as limited access surgical approaches, should be considered to minimize complications while achieving functional improvement. Given the increased risk of ischemia and necrosis in individuals with a history of a compromised STE, a comprehensive postoperative treatment algorithm is necessary to identify and treat signs of early vascular compromise.

Revisiting the Asian Buffalo Leech (Hirudinaria manillensis) Genome: Focus on Antithrombotic Genes and Their Corresponding Proteins

Leeches are well-known annelids due to their obligate blood-feeding habits. Some leech species secrete various biologically active substances which have important medical and pharmaceutical value in antithrombotic treatments. In this study, we provided a high-quality genome of the Asian buffalo leech (Hirudinaria manillensis), based on which we performed a systematic identification of potential antithrombotic genes and their corresponding proteins. Combining automatic and manual prediction, we identified 21 antithrombotic gene families including fourteen coagulation inhibitors, three platelet aggregation inhibitors, three fibrinolysis enhancers, and one tissue penetration enhancer. A total of 72 antithrombotic genes, including two pseudogenes, were identified, including most of their corresponding proteins forming three or more disulfide bonds. Three protein families (LDTI, antistasin, and granulin) had internal tandem repeats containing 6, 10, and 12 conserved cysteines, respectively. We also measured the anticoagulant activities of the five identified hirudins (hirudin_Hman1 ~ hirudin_Hman5). The results showed that three (hirudin_Hman1, hirudin_Hman2, and hirudin_Hman5), but not the remaining two, exhibited anticoagulant activities. Our study provides the most comprehensive collection of antithrombotic biomacromolecules from a leech to date. These results will greatly facilitate the research and application of leech derivatives for medical and pharmaceutical purposes in the treatment of thrombotic diseases.

Umbilical Incarcerated Hernia With Omental Eventration Caused by a Leech Bite in a Pediatric Patient

Medicinal leech therapy (MLT) is used in various medical disciplines, among which are reconstructive surgery and microsurgery. Medicinal leech therapy is also often adopted by alternative and traditional medicine, aiming to treat various common medical symptoms, such as fever and arthritis. Congenital umbilical hernia is a rather common physical finding in the pediatric population, where every third Caucasian newborn, roughly, is being diagnosed with the condition, and even more so among the African population. Fortunately, most cases resolve spontaneously in the first years of life. Toddlers whose hernia does not close typically require umbilical hernia repair. This article describes the case of a five-year-old girl with an asymptomatic congenital umbilical hernia who was admitted to the ER due to an omental eventration that occurred following the placement of a leech on her umbilicus in her parents' attempt to treat a febrile episode. She subsequently underwent an urgent umbilical exploration and a repair of her umbilical hernia. The main known risks of leeching are bacterial infection, anemia, prolonged bleeding, and, less frequently, pruritus, allergies, marked edema, and cellulitis. This article presents yet another possible complication that, to the best of our knowledge, has not been documented before in the literature. Several old-school therapies transcended over time into medical disciplines. Given that "traditional" practices often take place within households and communities, it is of crucial importance to point out potential complications, both rare and common, that can be caused by those practices in order to reduce the risk of severe, undesired outcomes. Indeed, the growing interface between traditional, alternative therapies and modern, conventional medicine urges better parental guidance and improved education regarding potentially harmful and unauthorized interventions.

Medicinal Leeches to Aid in Post-procedural Hematoma Evacuation

Patients presenting with a post-invasive procedure hematoma can be treated with medicinal leeches to evacuate the hematoma. Our patient, a postmenopausal woman in her 60s, with a past medical history of hypothyroidism, presented to the outpatient clinic with pain, redness, warmth, and swelling on her right thigh. Ten days prior, the patient had undergone a subcutaneous pellet implant procedure in the right thigh for hormonal replacement therapy. The patient developed post-procedure cellulitis and soft tissue infection and was treated with antibiotics. The patient developed a progressively enlarged hematoma at the implant site. The hematoma was treated with medicinal leeches. Two weeks after treatment, the implant area healed. The patient had a family history of von Willebrand disease and a history of prolonged bleeding during childbirth, menstruation, and dental procedures. A von Willebrand panel was obtained, and the results were consistent with a new diagnosis of von Willebrand disease.

Alternative Non-Drug Treatment Options of the Most Neglected Parasitic Disease Cutaneous Leishmaniasis: A Narrative Review

With more than 12 million cases worldwide, leishmaniasis is one of the top 10 neglected tropical diseases. According to the WHO, there are approximately 2 million new cases each year in foci in around 90 countries, of which 1.5 million are cutaneous leishmaniasis (CL). Cutaneous leishmaniasis (CL) is a complex cutaneous condition that is caused by a variety of Leishmania species, including L. (Leishmania) major, L. (L) tropica, L. (L) aethiopica, L. (L) mexicana, L. (Viannia) braziliensis, and L. (L) amazonensis. The disease imposes a significant burden on those who are affected since it typically results in disfiguring scars and extreme social stigma. There are no vaccines or preventive treatments available, and chemotherapeutic medications, including antimonials, amphotericin B, miltefosine, paromomycin, pentamidine, and antifungal medications, have a high price tag, a significant risk of developing drug resistance, and a variety of systemic toxicities. To work around these limitations, researchers are continuously looking for brand-new medications and other forms of therapy. To avoid toxicity with systemic medication use, high cure rates have been observed using local therapy techniques such as cryotherapy, photodynamic therapy, and thermotherapy, in addition to some forms of traditional therapies, including leech and cauterization therapies. These CL therapeutic strategies are emphasized and assessed in this review to help with the process of locating the appropriate species-specific medicines with fewer side effects, lower costs, and elevated cure rates.

Structural insights into thrombolytic activity of destabilase from medicinal leech

Destabilase from the medical leech Hirudo medicinalis belongs to the family of i-type lysozymes. It has two different enzymatic activities: microbial cell walls destruction (muramidase activity), and dissolution of the stabilized fibrin (isopeptidase activity). Both activities are known to be inhibited by sodium chloride at near physiological concentrations, but the structural basis remains unknown. Here we present two crystal structures of destabilase, including a 1.1 Å-resolution structure in complex with sodium ion. Our structures reveal the location of sodium ion between Glu34/Asp46 residues, which were previously recognized as a glycosidase active site. While sodium coordination with these amino acids may explain inhibition of the muramidase activity, its influence on previously suggested Ser49/Lys58 isopeptidase activity dyad is unclear. We revise the Ser49/Lys58 hypothesis and compare sequences of i-type lysozymes with confirmed destabilase activity. We suggest that the general base for the isopeptidase activity is His112 rather than Lys58. pKa calculations of these amino acids, assessed through the 1 μs molecular dynamics simulation, confirm the hypothesis. Our findings highlight the ambiguity of destabilase catalytic residues identification and build foundations for further research of structure-activity relationship of isopeptidase activity as well as structure-based protein design for potential anticoagulant drug development.

Molecular cloning and functional analysis of HnSaratin from Hirudo nipponia

In order to finish a bloodmeal successfully, hematophagous organisms often stored a variety of anticoagulant proteins in their salivary glands, such as proteins that inhibit platelet aggregation. When they ingest a bloodmeal, these proteins are injected into the host to prevent the blood from clotting. As one of the origins of leeches used in traditional Chinese medicine, H. nipponia was proved to be clinically effective in treatment of cardiovascular and cerebrovascular diseases. This study cloned the sequence of HnSaratin cDNA derived from salivary glands of H. nipponia. The sequence contains an open reading frame of 387 bp, encoding a protein of 128 amino acids containing a signal peptide of 21 amino acids. After removal of the signal peptide, the molecular mass of mature HnSaratin was 12.37 kDa, with a theoretical isoelectric point (pI) of 3.89. The N-terminal of mature HnSaratin was folded into a globular structure, in which 3 disulfide bonds, a ββαβββ topology and 2 Glu residues that binds collagenous Lys2 were located, and the C-terminal formed a flexible region. The fusion HnSaratin protein was obtained by a prokaryotic expression system. The protein showed anti-platelet aggregation activity, and was observed to prevent blood clotting in rats. The significant high expression of HnSaratin mRNA in salivary glands was induced by bloodmeal ingestion of H. nipponia. Briefly, our work provides theoretical basis for further development and utilization of H. nipponia.

Protective efficacy of Eglin C from Hirudo medicinalis against Eimeria papillata-induced coccidiosis

The current study aimed to find a new therapeutic agent from Hirudo medicinalis for murine coccidiosis. Ion-exchange chromatography was performed to separate different fractions of HEA (hirudo extract antigens). Eight different fractions were experimentally tested against murine eimeriosis induced by Eimeria papillate. The oocysts output was counted to determine the most effective fractions. For the five most effective fraction groups, jejunal histological examination and goblet cells count as well as mRNA expression of MUC2 gene using RT-PCR were performed. The data indicated that these fractions significantly decreased the oocysts output and the number of parasite developmental stages, while the goblet cell numbers and the expression of MUC2 were increased. Effective fractions were subjected to SDS-PAGE and proteomic analysis for detection of their bioactive macromolecules. The fractions reveled only a protein at 8 kDa while the results of spectroscopy and bioinformatics identified the protein as Eglin C. The pooled fractions containing Eglin C were tested in vitro to determine its stimulation for the intestinal lymphocyte proliferation and IFN-γ together with IL-6 release in the supernatant. The results showed that higher Eglin C concentrations reduced the stimulation index of lymphocyte proliferation as well as the stimulation index of IFN-γ and IL-6 production. In conclusion, Eglin C protein can be used as a target for therapeutic treatment or as an anti-inflammatory agent for coccidiosis infection.

Invertebrates and herptiles for livelihoods-ethnozoological use among different ethnic communities in Jammu and Kashmir (Indian Himalayas)

BACKGROUND

Ethnic communities have relied on animals and their derived products for ages, and their use is often intricately related to many cultural features. In remote regions across the globe, indigenous peoples have been using invertebrates and herptiles for a variety of purposes (medicine, food, culture, and spiritual importance); however, related scientific research is sparse, particularly in the western Himalayas. In this respect, we collected useful information on invertebrates and herpetofauna from Jammu and Kashmir, India, across different ethnic groups, i.e., Gujjar, Bakarwal, Dogra, Kashmiri, and Pahari.

METHODOLOGY

The data were gathered using semi-structured interviews followed by group discussions. The information gathered was analyzed using ordination techniques (principal component analysis). The Venn diagram was used to investigate cross-cultural similarities and differences between ethnic groups.

RESULTS

We documented 30 species belonging to five classes and 20 families used for different ethnozoological practices (medicinal, magico-religious, food, costume, omen, poultry, and agricultural purposes). The use of fauna resources varied across ethnic groups, and cross-cultural examination revealed that Kashmiri and Pahari populations were more similar in their species utilization. The maximum number of species (27%) was uniquely used by Kashmiri, followed by Pahari (17%), and the least by Dogra and Gujjar (3% each). The ethnozoological use of all documented species is unprecedented. In addition to ethnozoological usage, various documented species (Apis cerana, Apis mellifera, Hirudinaria granulosa, and Bombyx mori) were also important for the local population's livelihoods.

CONCLUSION

Our findings can be considered the baseline for understanding the relationship of invertebrates and herptiles with specific ethnic groups and will aid in the development of future research projects that can assess the interaction between local fauna and the diverse ethnic groups.

Keratitis following leech therapy for periocular eczematous dermatitis: a case report

BACKGROUND

The medicinal leech therapy (MLT) is a kind of complementary treatment method used for various diseases. The leeches (Hirudo medicinalis) have been used for more than 2500 years by surgeons. The substances presenting in the saliva of leeches have anti-inflammatory, anticoagulant, platelet inhibitory, thrombin regulatory, analgesic, extracellular matrix degradative and antimicrobial effects. The method is cheap, easy to apply, effective and its mechanisms of action have been clarified for specific diseases. Infection particularly Aeromonas infection is the most common complication of MLT.

CASE PRESENTATION

In this case report, a keratitis case developing after leech therapy applied for the periocular and facial eczematous dermatitis lesions will be presented. The patient referred to our hospital with decreased vision, ocular pain, stinging, redness and lacrimation complaints. A large corneal epithelial defect with irregular margins, dying by fluorescein, involving more than inferior half of cornea and conjunctival hyperemia were seen in the right eye. No agent was determined in microbiological investigation, as the patient had used topical moxifloxacin eye drop which was commenced in another clinic before applying to us. The patient was treated with fortified vancomycin and ceftazidime, before using besifloxacin with the diagnosis of bacterial keratitis. Three weeks later epithelial defect improved completely leaving an opacity and neovascularization.

CONCLUSIONS

MLT should be performed by certified physicians with sterile medicinal leeches and precautious antibiotics should be used before MLT for prevention against potential infections.

Leech Application-related Upper Gastrointestinal Bleeding: A Case Report

Leech therapy (Hirudotherapy) is a method used in the treatment of many diseases since ancient times. Although many complications have been reported following the use of this method, no systemic life-threatening bleeding has yet been described. A-43-year-old male patient was diagnosed with upper gastrointestinal bleeding following leech application that he had received for infertility one week earlier. The complications of hirudotherapy typically spontaneously improve due to the local effects of this treatment. The most frequently reported complications are local infections, and less commonly allergies and prolonged local bleeding can occur. However, in this case report, we describe a life-threatening upper gastrointestinal bleeding as a new complication. Gastrointestinal bleeding appearing a week after leech therapy does not necessarily mean that leeches caused gastrointestinal bleeding in this case. Nevertheless, considering the development time of gastrointestinal bleeding, it can be deduced that it was possibly due to hirudotherapy. Patients should be informed about alarming symptoms that can indicate complications following leech application.

How do i salvage that flap?; An evidence-based primer on salvage techniques for head & neck microvascular free flaps

Interventional strategies for dealing with microvascular free flap failure are varied among institutions and even individual surgeons. This systematic review aims to identify the published methods for salvaging a failing free flap and provide surgeons with a comprehensive toolset for successful intervention. A title and abstract search of the PubMed, Embase, and Web of Science databases was performed. 1694 abstracts were screened by three reviewers according to Prisma guidelines. 62 full text articles meeting inclusion criteria detailed techniques which were separated into the categories of thrombectomy, thrombolysis, leech therapy, vascular fistula, and an "other" category outlining techniques which did not fit into the prior framework. Assessment of the efficacy of individual salvage techniques is limited due to limited empirical data, however, the approach to successful salvage should be based on timely identification of flap compromise, followed by the implementation of one or several of the aforementioned techniques.

Study on the effect of medicinal leech therapy (Hirudo medicinalis) on full-thickness excisional wound healing in the animal model

The possible impacts of alternative and conventional medicines on wound healing are now of growing interest. This study aimed to evaluate and elucidate the wound healing activity of medicinal leech therapy in wound excision of the rat model. After a round, full-thickness excision was made in the dorsal region of the body, the animals (n = 30) were randomly divided into three equal groups: I) the treatment group (MLT), where the wounds received leech treatment; II) the positive control group (PC), where the wounds received 1% sodium phenytoin treatment; and III) the negative control group (NC), where the wounds did not receive any treatment. On days 6 and 16, wound biopsy specimens were taken, and prepared sections were stained using various methods. The contraction rate differed significantly (P < 0.05) between the NC group and the other groups. The histopathological evaluation revealed that MLT group showed an accelerated healing process and lower inflammatory response compared to other groups. In ML-treated group maturation and remodeling of collagen had occurred, while in 1% sodium phenytoin treated group, proliferation was the prominent feature. Results showed that the fibroblast was significantly lower in the NC group in comparison to other groups. The number of MNC, s, and PMN, s was significantly higher in the NC group compared to other groups (P < 0.0001). In our study, medicinal leech therapy had a higher success rate in healing for the treatment of excisional wounds in animal models.

Case Reports and Experts Opinions about Current Use of Leech Therapy in Dermatology and Cosmetology

This article aimed to determine the experts’ opinion on the use of hirudotherapy in cosmetology, to supplement knowledge, and to identify factors that, in the opinion of experts, affect the effectiveness and frequency of use of this method in eliminating skin problems. The study was conducted using the expert interview method. The research tool was a categorized expert interview questionnaire using the CAWI (Computer Assisted Web Interview) technique. Hirudotherapy is one of the oldest healing methods. The mechanism of action is based on the therapeutic properties of bioactive substances isolated from leech saliva. It has been shown to have a wide range of applications in the treatment of numerous diseases in various fields of medicine, including dermatology and cosmetology. Despite its therapeutic properties and effectiveness, hirudotherapy is a rarely used tool in cosmetology. It has been found effective in the treatment of many dermatoses. The most spectacular effects have been observed in the treatment of rosacea, local inflammations, lipomas, skin scars, hard to heal wounds and contusions.

Cellulitis Caused by Hirudo orientalis Bites That Lead to an Allergic reaction

The allergic reaction due to leech bites is frequently reported due to complications of leech therapy and also unwanted leech infestation. Regularly, the urticarial papules are common, and itching lasts less than 24 h. In the case of leech biting, dermal infection could be caused by leech gut bacterial flora such as Aeromonas spp and histamine from leech saliva. In this case report, a 30-year-old diabetic woman, who works in the field of leech breeding, was bitten by Hirudo orientalis during breeding. Her clinical signs were inflammation, swelling, pain, and redness in the back of her left hand. A microbiological examination revealed that the isolated leech was infected with Aeromona hydrophila. The risk of death due to anaphylactic shock and sepsis is high in some cases of underlying diabetes and immunocompromised individuals. The study pointed out the hazards of leech bites and proposed preventative measures such as using gloves and boots for farm workers.

Therapeutic effects of Hirudo medicinalis extract antigens on modulation of CD4+CD25+Foxp3 T cell activity in murine eimeriosis

Eimeriosis is a common parasitic disease in the chicken industry. The aim of this study was to assess the protective role of Hirudo extract antigens (HEA) against murine eimeriosis induced by Eimeria papillate. The oocyst output, developmental stages, goblet cells and oxidative stress, were investigated. Immunohistochemistry was used to detect anti-apoptotic Bcl2 marker and the number of both CD4+ and CD25+ cells in jejunal tissue, while ELISA was used to quantify TGF-β, IL-10 and IL-22 in jejunal tissue homogenate. Real-time PCR was also used to detect mRNA expression of mucin 2 (MUC2), inducible nitric oxide synthase (iNOS), IL-1β, IFN-γ, TNF-α, IL-6, and FoxP3. The most effective dose (5 µg/mice) reduced the oocyst output by 82.95 ± 1.02% (P ˂ 0.001). Similarly, the same dose reduced the jejunal developmental stages by 66.67 ± 0.49% (P ˂ 0.001). Furthermore, HEA therapy increased the number of jejunal goblet cells by 12.8 ± 1 (P ˂ 0.001) and the expression of MUC2 by 0.83 ± 0.06 (P ˂ 0.001). In contrast, TNF-α, IFN-γ, IL-6, iNOS, and IL-1β expression as well as apoptosis were reduced. The number of CD4+ and CD25+ in the jejunal tissue was increased (14.6 ± 1.2 (P ˂ 0.001), 6.84 ± 1 (P ˂ 0.01), respectively) after HEA therapy. The molecular analysis showed an increased expression of intestinal Foxp3 (3.2 ± 0.13 (P ˂ 0.001), while IL-22 was reduced (124 ± 10 (P ˂ 0.001)) versus an increase in TGF-β (250 ± 17 (P ˂ 0.01)) and IL-10 (236 ± 16 (P ˂ 0.001)) after HEA treatment in comparison to the non-treated infected group. With respect to the infected group, HEA reduced lipid peroxidation (LPO) (15.7 ± 1.12 (P ˂ 0.001)) and nitric oxide (NO) (13 ± 1.3 (P ˂ 0.001)) but increased reduced glutathione (GSH) (3.7 ± 0.26 (P ˂ 0.001)). In conclusion, HEA therapy protected against intestinal tissue damage by activation of CD4+CD25+Foxp3 cells which showed anti-inflammatory action. Hence, HEA can be recommended as a therapeutic treatment for eimeriosis.

Life without blood: Molecular and functional analysis of hirudins and hirudin-like factors of the Asian non-hematophagous leech Whitmania pigra

BACKGROUND

Several leech species of the genera Hirudo, Hirudinaria, and Whitmania are widely used in traditional Chinese medicine (TCM) for the oral treatment of disorders associated with blood stasis. Among them, the non-hematophagous leech Whitmania pigra expresses a variety of components that have the potential to act on the vertebrate blood coagulation system.

OBJECTIVE

Whether the thrombin inhibitor hirudin, probably the most prominent leech-derived anticoagulant, is actually present in Whitmania pigra, is still a matter of debate. To answer that open question was the aim of the study.

METHODS

We identified several putative hirudin-encoding sequences in transcriptome data of Whitmania pigra. Upon gene synthesis and molecular cloning the respective recombinant proteins were expressed in Escherichia coli, purified, processed, and eventually functionally characterized for thrombin-inhibitory potencies in coagulation assays.

RESULTS

We were successful in the identification and functional characterization of several putative hirudins in Whitmania pigra. Some, but not all, of these factors are indeed thrombin inhibitors. Whitmania pigra hence expresses both hirudins (factors that inhibit thrombin) and hirudin-like factors (that do not or only very weakly inhibit thrombin). Furthermore, we revealed the exon/intron structures of the corresponding genes. Coding sequences of some putative hirudins of Whitmania pigra were present also in transcriptome datasets of Hirudo nipponia, a hematophagous leech that is likewise used in TCM.

CONCLUSIONS

Based on both structural and functional data we provide very strong evidence for the expression of hirudins in Whitmania pigra. This is the first description of hirudins in a non-hematophagous leech.

Comparative Transcriptome Sequencing Analysis of Hirudo nipponia in Different Growth Periods

Hirudo nipponia is the only blood-sucking leech included in Chinese Pharmacopoeia having distinct features of anticoagulation, exorcizing blood stasis, and promoting menstruation. Despite such significant characteristics, very little is known about its molecular genetics and related physiological mechanisms. In this study, the transcriptomes of H. nipponia at three developmental stages (larvae, young, and adults), revealed a total of 1,348 differentially expressed genes (DEGs), 223 differentially expressed lncRNAs, and 88 novel mRNAs. A significant diverse gene expression patterns were observed at different developmental stages which were analyzed by differential gene expression trends, and the overall gene expression trends consist of three overall down-regulated trends, and two overall up-regulated trends. Furthermore, the GO and KEGG enrichment functional annotation analysis revealed that these DEGs were mainly associated with protein hydrolysis, signal transduction, energy metabolism, and lipid metabolism while growth, development, metabolism, and reproduction-related DEGs were also found. Additionally, real-time quantitative PCR results confirmed deep sequencing results based on the relative expression levels of nine randomly selected genes. This is the first transcriptome-based comprehensive study of H. irudo nipponia at different developmental stages which provided considerable deep understanding related to gene expression patterns and their relevant developmental pathways, neurodevelopmental and reproductive characteristics of the leech.

Retrograde Lymph Flow in the Lymphatic Vessels in Limb Lymphedema

OBJECTIVE

Retrograde movement of lymph due to damaged and/or incompetent valves in the lymphatic vessels has been considered a pathological feature of lymphedema. This study aimed to determine the prevalence of retrograde lymph flow and the characteristics of patients with this condition using indocyanine green (ICG) lymphography.

METHODS

An audit of 679 patients with upper or lower limb swelling who underwent ICG lymphography was undertaken over a 4-year period. Harvey's technique was applied to identify retrograde flow in the lymph collecting vessel during ICG lymphography. The characteristics of patients with retrograde lymph flow were recorded.

RESULTS

Twenty-one patients (3.7%, lower limb: n=19, upper limb: n=2) were identified as having retrograde flow in lymph collecting vessels out of 566 confirmed lymphedema patients (lower limb: n=275, upper limb: n=291). Of the two patients with upper limb lymphedema, one had a short segment of retrograde lymph flow in the forearm. The other patient with upper limb lymphedema and one patient with lower limb lymphedema were previously diagnosed with Lymphedema-Distichiasis Syndrome. Of the remaining 18 patients with lower limb lymphedema and retrograde lymph flow, nine had initiating insect bites with lymphangitis and three had palpable benign enlarged inguinal lymph nodes evident prior to lower limb swelling onset. None had cancer-related lower limb lymphedema.

CONCLUSIONS

Retrograde lymph flow with valve incompetence in the lymph collecting vessels was a rare finding in upper limb lymphedema and a relatively uncommon in lower limb lymphedema, contradicting conventional understanding of pathological changes in lymphedema. ICG lymphography identified anticipated retrograde lymph flow in two patients with Lymphedema-Distichiasis. In the remaining patients, retrograde lymph flow may have resulted from toxic or asymptomatic lymphangitis but no association with secondary cancer-related lymphedema. These findings have implication for conservative management as well as lymphovenous anastomosis surgery where both ends of a transected lymph collecting vessel would be potential targets for anastomoses.

Early venous congestion after diep flap breast reconstruction: case report of a successful management

BACKGROUND AND AIM

More than 250 000 women estimated to be diagnosed with breast cancer in the USA every year. Mastectomy is primary treatment for more than a third of those with early-stage disease. Most of the patients undergoing mastectomy receive breast reconstruction. A number of. Surgical techniques have been described to reconstruct the breast. With autologous tissue breast reconstruction, the plastic surgeon uses patient's own tissues, taken from a different part of the body where there is an excess of fat and skin. Deep inferior epigastric perforator (DIEP) flap is the autologous breast reconstruction technique of choice in our department due to long lasting results, low donor site morbidity and positive patient reported outcomes have been described.   Case Report: We present the case of a 42-year-old woman who underwent neoadjuvant chemotherapy followed by left breast simple mastectomy, axillary lymph-nodes dissection and later adjuvant radiation therapy (RT). After conclusion of RT a DIEP flap breast reconstruction was performed. Nine-hours after the operation, signs of acute venous congestion were noted. The venous congestion was treated by a combined surgical and medical approach based on pedicle discharge and ICU resuscitation protocol. After take back surgery, the patient was tightly monitored in the intensive care unit where intravenous heparin infusion and leech therapy were performed for 2 days. Flap congestion resolved completely, and the patient was discharged.   Conclusions: Venous congestion is very difficult to treat due to its potential multifactorial nature. The most important step is to recognize this kind of emergency because irreversible microvascular damages will develop in 6-8 hours. Because of multiple causes of venous congestion a timely multidisciplinary approach is mandatory, to maximize flap salvage and success rates.

Purification and characterization of a novel thermostable anticoagulant protein from medicinal leech Whitmania pigra Whitman

ETHNOPHARMACOLOGICAL RELEVANCE

The prevalence of cardiovascular disease (CVD) is increasing worldwide. Despite significant improvements in novel targeted treatment agents, natural products purified from medicinal animals with minimal side effects have attracted much attention. Several native proteins explored from suck-blood leeches, such as non-thermostable hirudin and its variants, revealed potent anticoagulant activity. Traditional Chinese medicine clinics have proved that non-suck-blood leech Whitmania pigra Whitman (W. pigra) also played notable roles in CVD treatments even after decoction. However, only a few natural proteins and peptides have been identified from the fresh material of this medicinal species.

AIM OF THE STUDY

We aimed to purify and characterize thermostable anticoagulant proteins from W. pigra for further development of a therapeutic agent for thrombosis.

MATERIALS AND METHODS

W. pigra crude extract was prepared by decoction in water. Anticoagulant proteins were purified by DEAE cellulose DE-52, Sephadex G-75, and reversed-phase liquid chromatography sequentially and analyzed by SDS-PAGE and LC-MS/MS for structural information. In addition, we conducted in vitro anticoagulant experiments, including plasma recalcification time (PRT) assay, fibrinolytic assay, activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time (TT), fibrinogen (Fib) assay, and cell viability assays. Furthermore, a carrageenan-induced chronic thromboembolism model was employed in ICR mice, and four coagulation factors (APTT, PT, TT, and Fib) activities were determined after intragastric administration.

RESULTS

The anticoagulant protein WP-77 has a relative molecular weight of ca. 20.8 kDa. It was effective over a broad temperature range from 20 °C to 100 °C and a pH 2-8 condition. The anticoagulant activity of WP-77 was retained after incubation with pepsin but was greatly inhibited by trypsin (P < 0.01). It significantly prolonged APTT and TT (P < 0.05) but had little effect on PT and Fib in vitro. Furthermore, WP-77 of a low concentration resulted in the recovery of injured EA.hy926 by thrombin. The protein also significantly prolonged APTT and TT (P < 0.01) and inhibited thrombus formation in carrageenan-induced thrombosis mice, demonstrating its antithrombotic effect in vivo.

CONCLUSION

Our results suggest that WP-77 from W. pigra plays a distinct role in treating thrombotic diseases, and it is an essential substance of anticoagulant activity of non-suck-blood medicinal leeches. This thermostable anticoagulant protein could be a promising candidate for the development of clinical antithrombosis medicines.

A new species of medicinal leech in the genus Hirudo Linnaeus, 1758 (Hirudiniformes, Hirudinidae) from Tianjin City, China

Medicinal leeches in the genus Hirudo have been utilized for therapeutic procedures for thousands of years. To date, six known species of Hirudo are widely distributed in different regions of the Eurasian continent. In this study, a new medicinal leech species Hirudotianjinensis Liu, sp. nov. is described based upon specimens collected from Tianjin City, China. The new species can be distinguished from its congeners by a combination of characters: blackish green dorsum with five continuous yellow longitudinal stripes; six sensillae on dorsal annulus a2 of segments VIII–XXV; greyish green ventrum with irregular bilateral dark brown spots; dorsum and abdomen separated by a pair of pale yellow stripes; front half atrium wrapped by white prostate; apparent albumen gland; epididymis massive in relation to ejaculatory bulb. The phylogenetic tree based upon COI implies a sister relationship to H.nipponia Whitman, 1886. A key to the known species is provided.

Non-Pharmacological Treatments of Psoriasis in Persian Medicine a Narrative Review

Psoriasis is a chronic disease that has no definitive cure. In this review study, the main sources of Persian Medicine (PM) such as the Canon of Medicine (by Avicenna) and Al-Havi (by Rhazes) were assessed to identify non-pharmacological treatments for psoriasis. Several treatments that are recommended for this disease include nutritional advice, lifestyle modifications, and manipulation therapy such as wet cupping (Hijamah), leech therapy, and phlebotomy (Fasd). These recommendations may help to prevent recurrence and be useful in improving psoriasis. The efficacy of PM recommendations to improve psoriasis should be evaluated in future studies.

Insights into gut microbiota communities of Poecilobdella manillensis, a prevalent Asian medicinal leech

AIMS

Medicinal leeches (Annelida: Hirudinea) are fresh water ectoparasitic species which have been applied as traditional therapy. However, gut microbiota could bring high risks of opportunistic infections after leeching, and arouses great interests. Here gut bacterial and fungal communities of an Asian prevalent leech Poecilobdella manillensis, were characterized and analyzed through culture-independent sequencing.

METHODS AND RESULTS

With high coverage in 18 samples (>0.999), a more complicated community was apparent after comparing with previous leech studies. A total of 779/939 OTUs of bacteria and fungi were detected from leech guts. The bacterial community was dominated by phylum Bacteroidetes and Synergistetes. Genera Mucinivorans and Fretibacterium accounted mostly at the genus level. And genus Aeromonas showed an extremely low abundance (2.02%) on average. The fungal community was dominated by phylum Ascomycota and Basidiomycota. At the genus level, the dominant OTUs included Mortierella, Geminibasidium and Fusarium. The analysis of core taxa included those above dominant genera and some low-abundance genera (>1%). The functional annotation of bacterial community showed a close correlation with metabolism (34.8 ± 0.6%). Some fungal species were predicted as opportunistic human pathogens including Fusarium and Chaetomiaceae.

CONCLUSIONS

The present study provides fundamental rationales for further studies of such issues as bacteria-fungi-host interactions, host fitness, potential pathogens and infecting risks after leeching. It shall facilitate in-depth explorations on a safe utilization of leech therapy.

SIGNIFICANCE AND IMPACT OF STUDY

Present paper is the first-ever exploration on microbiota of a prevalent Asian medicinal leech based on culture-independent technical. And it is also the first report of gut fungi community of medicinal leech. The diversity and composition of bacteria in P. manillensis was far different from that of the European leech. The main components and core OTUs indicate a particular gut environment of medicinal leech. Unknown bacterial and fungal species were also recovered from leech gut.

Protocol based pain management by Ayurveda parasurgical procedures W.S.R to musculoskeletal pain and its critical appraisal - An open labeled clinical trial

BACKGROUND

Pain has globally become an attention problem which causes discomfort by affecting the body as well as the mind. The International association of pain estimated that 1 in 5 patients experiences the pain, i.e. 30% of world population. 19.3% (180-200 million) of the total population in India suffer from chronic pain and its severity appeals early approach of patients to hospitals. Ayurveda being the oldest medical science emphasized its importance and treatment of pain with both pharmacological and non-pharmacological (Parasurgical) methods.

OBJECTIVE

To evaluate the efficacy of non-pharmacological (para surgical) procedures in the management of pain.

MATERIALS AND METHOD

Total 100 patients with chronic musculoskeletal pain fulfilling the inclusion criteria were recruited by assessing the site, severity and nature of pain. A special protocol was framed by incorporating Ayurveda treatment principles by using Para surgical procedures such as Agnikarma (Therapeutic burn), Jalauka (leech therapy), Alabu (Cupping therapy) and Siravyadha (Vein puncture). The parameters like VAS and VDS pertaining to pain were assessed from baseline and at various time points. Statistical analysis was performed by using Wilcoxon match paired test to assess the results.

RESULTS

The VAS and VDS scale were used to assess the efficacy of para-surgical procedures which was found to be significant (p < 0.0001) from baseline and at various time points.

CONCLUSION

Protocol based pain management by various para surgical procedures was found effective in the management of chronic musculoskeletal pain. The ambiguity in selection of proper parasurgical procedure for pain management is justified by following the protocol.

Hirudotherapy for limb ischemia in the pediatric intensive care unit: A retrospective observational cohort

BACKGROUND

Acute limb ischemia due to microvascular malperfusion may be refractory to initial therapies. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and reconstructive surgery to improve venous congestion in ischemic flaps; however, there are minimal reports related to ischemia secondary to arterial malperfusion. We evaluated a pediatric cohort from an academic intensive care unit with refractory limb ischemia in whom hirudotherapy was attempted to elucidate its use and outcomes.

METHOD

Institutional patient database was queried to identify pediatric patients (<18 years) who received hirudotherapy in the pediatric critical care unit and met inclusion/exclusion criteria. Patient charts were evaluated for indices including demographics, primary disease, coagulative status, vascular access, vasoactive medication dosing, bleeding, leech use, limb and mortality outcomes. Data was evaluated to identify trends or suspected impact on outcomes.

RESULTS

Hirudotherapy was used in 7 patients for limb ischemia, 5 with congenital heart disease, and 2 others with viremic shock. Time to leech application following recognition of ischemia averaged 3 days, with duration of use averaging 3.9 days. Five patients discontinued therapy due to bleeding. Mortality rate was 57%, all secondary to multiorgan failure. In 3 surviving patients, 4 of 5 treated limbs resulted in at minimum partial amputation. Vasoactive-inotropic score tended higher prior to leech application, suggesting a vasoconstrictive pathway for arterial malperfusion. No identifiable trends appeared associated with salvaged limb or adverse effects. Blood loss predictably increased with leech application, as did total transfusion requirement.

CONCLUSION

This case series establishes baseline data for use of hirudotherapy in critically ill children with acute limb ischemia caused by arterial malperfusion. Based on this retrospective cohort, we cannot recommend routine use of hirudotherapy for acute limb ischemia from arterial malperfusion in the pediatric intensive care unit. Application of leeches should be aligned with a protocol defining start and stop parameters, standardized leech utilization, and monitoring for adverse outcomes. Future study would benefit from consensus definitions of study outcomes, including perfusion recovery, tissue/limb salvage and bleeding manifestations. Additional prospective studies are needed prior to any standard or systematic recommendations for use.

Management of folliculitis decalvans with ayurveda- A case report

INTRODUCTION

The superficial infection that involves the hair follicle with bogginess or induration of involved parts of the scalp along with pustules, erosions, crusts, ulcers, and scales resulting in hair fall is known as folliculitis decalvans (FD). This condition accounts for approximately 11% of all cases with primary cicatricial alopecia. Based on clinical features like Keshadhwansha (hair fall) with Harsha (hypersensitivity), Kandu (itching), Toda (pain), FD can be correlated with Raktaja Krimi Vikara (RKV).

OBSERVATION AND RESULTS

A 24 years' male patient with the chief complaint of patchy hair loss in the scalp region associated with scale formation, itching, and pain for 2 months. He had a history of pustules-like eruption over the frontal and parietal regions. He tried various topical and oral medications for 8 days but didn't get any sign of improvement and came to NIA hospital for Ayurveda treatment. Due to the signs like pustules over the scalp, hair loss with honey-colored crusting, scarring, mild itching, and pain; he was diagnosed with RKV ∼ FD. After treatment with Ayurveda medicine and leech therapy, complete remission of the scar, lesions, itching, pain, and hair loss was obtained, and there was new hair growth over the scalp with normal distribution. The patient was on follow-up for 33 months with no signs of itching, pain, and hair fall.

CONCLUSION

Complete remission of FD was achieved by Ayurveda medicine along with Jalaukavacharana and it seems highly effective on the basis of remission period compared to contemporary treatment modalities. It is suggested to have further clinical studies with large samples to analyze its effectiveness.

Leech therapy of nipple-areolar complex (NAC) congestion in reduction mammoplasty: A case report

Leech therapy is a safe, easy-to-use, cost-effective traditional treatment to save reattached body parts and flaps in reconstructive plastic surgery especially in cases with blood circulatory problems.

Leech therapy (Hirudo medicinalis) attenuates testicular damages induced by testicular ischemia/reperfusion in an animal model

BACKGROUND

Testicular torsion/detorsion triggers tissue ischemia/reperfusion, leading to reactive oxygen species overgeneration and apoptosis. The saliva of leeches is full of anti-inflammatory, anticoagulants, antioxidants, and antimicrobial agents. Therefore, this study aimed to assess the protective mechanism of leech therapy on testicular ischemia/reperfusion damage.

METHODS

18 adult male rats were randomly divided into three groups: 1-Sham-operated group (SO). 2-Torsion/detorsion (T.D) group: two hours of testicular torsion with two hours of testicular detorsion was performed. 3-Torsion/detorsion + Leech therapy (TDL) group. Sperm parameters (motility, vitality, morphology, and concentration), oxidative stress biomarkers (MDA, CAT, GPx, and TAC), histopathological factors (Mean seminiferous tubular diameter, Germinal epithelial cell thickness, Testicular capsule thickness, Johnson's score, and Cosentino's score), and immunohistochemical markers for apoptosis detection (Bax, Bcl-2, and Caspase-3) were measured.

RESULTS

There was a significant difference for all sperm parameters in the T. D group compared to the sham group. Leech therapy significantly increased progressive motility and normal morphology and reduced non-progressive motility. In the TDL group, MDA concentration significantly reduced, and levels of GPx, TAC, and CAT remarkably increased. All evaluated histopathological parameters in the TDL group significantly increased compared to the T. D group except for the testicular capsule thickness. T. D notably increased the expression of Bax and Caspase-3, while the treatment group slowed the rate of apoptosis compared to the control group. Bcl-2 expression in the T. D group was significantly lower than that in the sham group. Leech therapy increased the Bcl-2 expression.

CONCLUSION

Leech therapy attenuates damages to testicular tissue following torsion/detorsion due to its antioxidant, anti-inflammatory, and anti-apoptotic effects. Hence, it can be considered as an effective remedy for testicular ischemia/reperfusion.

Intraoral Hirudotherapy for Venous Congestion following Free Flap Head and Neck Reconstruction: Novel Intraoral Technique

Intraoral hirudotherapy is traditionally used for venous congestion following head and neck free flap reconstruction. Many institutions and healthcare teams have been reluctant to use intraoral leech therapy due to risks such as migration into the airway, increased infection from intraoral manipulation, and patient discomfort. Several protocols recommend blocking the path to the oropharynx via gauze or leaving a tracheotomy in place to protect the airway. This report pre-sents a novel technique for intraoral hirudotherapy that is safe and simple for treatment of free flap venous congestion. The base of a clear cup or a plastic lid is utilized, and the leech is attached onto the inside of the lid with 2 sutures near each end. Several cups with leeches attached are made at a time to reduce delay and difficulty of application by less experienced clinical staff. The leech is then applied onto the compromised flap and then simply removed once it has unlatched from the flap. This method allows the leech to be applied with ease by multiple members of the healthcare team, decreases the need for intraoral manipulation, and reduces the risk of migration into the aerodigestive tract. Future prospective studies are warranted to assess the efficacy of this technique.

Functional morphology of the suckers and teeth of the medicinal leech Hirudo verbana Carena, 1820 (Annelida; Clitellata; Hirudinida): A scanning electron microscope study

In this study, the triple jaws and suckers of the leeches belonging to the Hirudo verbana Carena, 1820 (Annelida; Clitellata; Hirudinida) were examined using the stereomicroscopy and scanning electron microscopy. In H. verbana, suckers are seen on the first annulus and last annulus of the body. The mouth opens in the center of the front suction cup, and behind this opening is a movable triple jaw apparatus with many teeth. The posterior sucker disc consists of the last seven body segments and lacks an opening. The shape of the jaw is trignatous. The pharynx is equally located around of the three muscular jaws. The jaws are muscular covered with cuticle and carry a row of teeth arranged at the tip. In this study, it was determined that secretory canal holes were identified between the teeth. The results show that the size of teeth determines long-term bleeding so revealing the structure and working mechanism of the teeth has importance for medicinal leeches. At the same time, the difference of teeth and jaw structures of leeches may be a criterion in the classification of medicinal leeches.

Hirudotherapy (medicinal leeches) for treatment of upper airway obstruction in a dog

OBJECTIVE

To describe upper airway obstruction (UAO) in a dog treated with medicinal leeches (hirudotherapy) as an ancillary therapy to hasten recovery.

CASE SUMMARY

A 10-month-old neutered female Mastiff presented for acute respiratory distress. On admission, the dog was tachycardic, cyanotic, and orthopneic; stridor was audible. A 10-cm soft tissue swelling in the right ventral cervical region and bruising around the rostral mandible were noted. At the time of endotracheal intubation, the trachea was deviated to the right as a consequence of severe soft tissue swelling that was contiguous with the sublingual hematoma and cervical region, causing loss of visualization of the arytenoids. A computed tomography with contrast scan of the head, neck, and thorax was performed, showing severe soft tissue swelling of the tongue, obliteration of the common pharyngeal/laryngeal regions from suspected hemorrhage, and rightward displacement of pharynx, larynx, and proximal trachea. Marked diffuse bronchial/bronchiolar thickening associated with bronchiolectasis and diffuse opacification of the pulmonary parenchyma with regions of consolidation were noted. The dog was minimally hypercoagulable on thromboelastography. The imaging results together with results of bronchoalveolar lavage cytology supported a comorbidity of eosinophilic bronchopneumopathy. Intubation was maintained with infusions of propofol and fentanyl, with minimal changes in oropharyngeal swelling within the first 18 hours of treatment. Medicinal leeches were then applied to the sublingual and cervical regions. There was continued slow bleeding from the sites of leech detachment, and the dog was able to be extubated at 44 hours, followed by hospital discharge.

NEW/UNIQUE INFORMATION PROVIDED

Leeches are utilized in human medicine for treatment of UAO. Although UAO from hemorrhage has been described in dogs, this is the first report of medicinal leeches (Hirudo verbana) as complementary treatment for sublingual hematoma that contributed to UAO.

Improving Symptoms of Peripheral Artery Disease With Hirudotherapy

Peripheral artery disease (PAD) is a significant cause of morbidity and mortality in the world. Critical limb ischemia is a complication of PAD that leads to severe pain at rest, numbness, and absent or diminished pulses in the legs or feet. Revascularization with surgery or endovascular intervention is required to re-establish blood flow to the affected areas. Failure to respond to medical and/or surgical treatment can lead to amputations. The decision to amputate one’s limb can be very challenging. Here, we report a patient with critical limb ischemia who refused a below-the-knee amputation and self-treated with medicinal leech therapy, or hirudotherapy. His symptoms including his pain, burning, and numbness improved significantly following six months of therapy.

Identification and characterization of a novel elastase inhibitor from Hirudinaria manillensis

A large number of protease inhibitors have been found from leeches, which are essential in various physiological and biological processes. In the curret study, a novel elastase inhibitor was purified and characterized from the leech of Hirudinaria manillensis, which was named HMEI-A. Primary structure analysis showed that HMEI-A belonged to a new family of proteins. HMEI-A exerted inhibitory effects on elastase and showed potent abilities to inhibit elastase with an inhibition constant (K_i) of 1.69 × 10^-8 mol·L^-1. Further study showed that HMEI-A inhibited the formation of neutrophil extracellular trap (NET). These results suggested that HMEI-A from the leech of H. manillensis is a novel elastase inhibitor which can suppress NET formation. It may play a significant role in blood-sucking of leeches and is a potential candidate as an anti-inflammatory agent.

Evaluation of Zhilong Huoxue Tongyu capsule in the treatment of acute cerebral infarction: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Zhilong Huoxue Tongyu capsule (ZL) is a Chinese patent medicine and used for the treatment of acute cerebral infarction (ACI) and its clinical application has gradually been widely recognized in China. However, the effects of ZL for patients with ACI have never been systematically evaluated.

PURPOSE

A systematic review and meta-analysis was performed to evaluate the efficacy of ZL in ACI.

STUDY DESIGN

A systematic review and meta-analysis of randomized clinical trials (RCTs).

MATERIALS AND METHODS

A systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The comprehensive literature search was accomplished in 6 electronic databases to find relevant randomized controlled trials from their inception until October 31, 2020. The Cochrane Handbook for Systematic Reviews of Interventions was used for methodological quality and independent evaluation. Review Manager 5.3 was used to analyze all the data obtained. The Clinical Effective Rate (CER) was the primary outcome, and the National Institutes of Health Stroke Score (NIHSS), Barthel Index (BI), and Modified Rankin Scale (MRS) were the secondary outcomes.

RESULTS

Seven clinical studies recruiting 571 eligible patients were included in this meta-analysis. The results of meta-analysis suggested that compared with conventional treatment alone, ZL combined with conventional treatment significantly improved CER (RR = 1.20, 95% CI: 1.12-1.29, p < 0.00001), decrease National Institutes of Health Stroke Scale Score (NIHSS) (MD = -2.60, 95% CI: -3.41-1.79, p < 0.00001), Barthel Index (BI) (MD = -9.75, 95% CI: 7.15-12.36, p < 0.00001) and Modified Rankin Scale (MRS) (MD = -0.57, 95% CI: -0.84-0.30, p < 0.00001). There were no reported adverse events in the studies. Most results were robust and the quality of evidence was from moderate to low.

CONCLUSION

ZL combined with conventional treatment can improve the short-term outcomes of ACI patients, indicating ZL is a promising treatment choice for ACI and may be used as adjunctive treatment to the conventional treatment of ACI. However, due to the limitations of included clinical trials, high-quality clinical trials with longer follow-ups are still needed to further assess the effectiveness and safety of ZL for ACI patients.

[Cutaneous pseudolymphoma after hirudotherapy : Case report and review]

Unter dem Begriff Pseudolymphom (PSL) versteht man eine benigne, reaktive Lymphoproliferation der Haut, die klinisch und/oder histologisch ein malignes Lymphom simulieren kann. Die genaue Ätiopathogenese ist bis heute nicht gänzlich geklärt. Man unterscheidet die primären, idiopathischen PSL ohne erkennbare Ursache von den sekundären PSL mit bekanntem Stimulus. Wir berichten über das Auftreten von Pseudolymphomen nach einer Behandlung mit medizinischen Blutegeln (Hirudotherapie). Bisher wurden nach bestem Wissen und Gewissen insgesamt nur 9 Fälle von kutanen PSL nach Hirudotherapie in der Literatur beschrieben.

Hirudotherapy for neonatal limb ischemia during ECMO support: A word of caution

INTRODUCTION

Disordered coagulation, clot formation and distal limb ischemia are complications of extracorporeal membrane oxygenation (ECMO) with significant morbidity and mortality. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and orthopedic surgeries to improve venous congestion and salvage ischemic flaps. To our knowledge this has not been reported in pediatric cardiac surgery or during ECMO support. We present a complex neonate whose ECMO course was complicated by distal limb ischemia for whom leech therapy was attempted.

PATIENT AND INTERVENTION

A 2-week-old 2.7 kg infant required ECMO support secondary to perioperative multiorgan system dysfunction following repair of critical coarctation and ventricular septal defect. Despite systemic anticoagulation, his clinical course was complicated by arterial thrombus, vasopressor-induced vascular spasm and bilateral distal limb ischemia. Medicinal leech therapy was tried after initially failing conventional measures.

RESULT

Following the third leech application, this patient developed significant hemorrhage from the web space adjacent to the left great toe. An estimated 450 ml of blood loss occurred and more than 300 ml of blood product transfusions were required. He ultimately progressed to irreversible systemic end organ dysfunction and comfort care was provided.

CONCLUSION

The use of medicinal leech therapy in pediatric cardiac surgery may be considered to minimize the consequences of advanced limb ischemia and venous congestion. However, this should be used with caution while patients are systemically anticoagulated during ECMO support. A directed review is presented here to assist in determining optimal application and potential course of therapy.

Wound healing potential of bark paste of Pongamia pinnata along with hirudotherapy: A case report

Chronic wound is one of a leading cause of amputation worldwide. Successful management of chronic wound has become a challenge to all existing medical systems across the world. Sri Lankan Traditional and Ayurvedic medicine reveals many promising herbal and alternative remedies for chronic wounds. We hereby report a successfully managed case of an 80-year-old female patient suffering from a chronic wound for two years, when presenting has advised for amputation of the leg. The treatment protocol included the application of hirudotherapy along with the bark paste of Pongamia pinnata followed by Flueggea leucopyrus with recommended other external and internal remedies. At the end of the treatment protocol, pain, exudates, odor, burning sensation, and itching were reduced completely while swelling and wound size was reduced remarkably and showed a significant healing in the wounded area.

Toxic Animal-Based Medicinal Materials Can Be Effective in Treating Endometriosis: A Scoping Review

Animal toxins and venoms have recently been developed as cancer treatments possessing tumor cell growth-inhibitory, antiangiogenesis, and proapoptotic effects. Endometriosis is a common benign gynecological disorder in reproductive-age women, and no definite treatment for this disorder is without severe side effects. As endometriosis and malignant tumors share similar characteristics (progressive, invasive, estrogen-dependent growth, and recurrence), animal toxins and venoms are thought to be effective against endometriosis. The objective of this study was to outline studies using toxic animal-based medicinal materials (TMM) as endometriosis treatment and to explore its clinical applicability. Preclinical and clinical studies using TMM were searched for in four databases from inception to October 2020. A total of 20 studies of TMM on endometriosis were included. In eight clinical studies, herbal medicines containing TMM were effective in relieving symptoms of endometriosis, with no side effects. In twelve experimental studies, the main therapeutic mechanisms of TMM against endometriosis were proapoptotic, antiangiogenesis, estrogen level-reducing, and possible anti-inflammatory effects. TMM are thus considered promising sources for the development of an effective treatment method for endometriosis. Further studies are needed to clarify the therapeutic mechanism of TMM against endometriosis and to provide sufficient grounds for clinical application.

Hirudo (Leech) for proliferative vitreous retinopathy: A protocol for systemic review and meta-analysis

INTRODUCTION

Proliferative vitreous retinopathy (PVR) is characterized by proliferation of cells and contraction of membranes on either the retinal surface or in the vitreous cavity, which leads to retinal detachment and visual impairment. PVR is commonly seen in patients with rhegmatogenous retinal detachment and diabetic retinopathy, which seriously affects the patient's work and life. Previous studies indicated that Hirudo (Leech) or compound prescription containing Hirudo (Leech) for treatment of PVR would be effective. However, due to the lack of evidence, there are no specific methods or suggestions, so it is necessary to carry out systematic evaluations on Hirudo (Leech) for PVR and provide effective evidence for further research.

METHODS AND ANALYSIS

The following 8 databases will be searched: Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, EMBASE, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Database, and Wanfang Database. All randomized controlled trials in English or Chinese related to Hirudo (Leech) for PVR will be included. Outcomes will include change in Vitreous opacity, Vision changes, production of the anterior macular membrane, and retinal detachment again. The incidence of adverse events will be assessed for safety evaluation. Study inclusion, data extraction and quality assessment will be performed independently by 2 reviewers. Assessment of risk of bias and data synthesis will be performed using Review Manager V.5.3.

RESULTS

In this systematic review and meta-analysis, we will synthesize the studies to assess the safety and efficacy of Hirudo (Leech) for PVR.

CONCLUSION

The summary of our study will clarify whether Hirudo (Leech) therapy could be an efficient and safe method for PVR, which can further guide the promotion and application of it.

OPEN SCIENCE FRAMEWORK OSF REGISTRATION NUMBER

10.17605/OSF.IO/FP7VG (https://osf.io/fp7vg).

Leech extract: A candidate cardioprotective against hypertension-induced cardiac hypertrophy and fibrosis

ETHNOPHARMACOLOGICAL RELEVANCE

The prevalence of cardiovascular diseases (CVDs) has been increasing worldwide. Despite significant improvements in therapeutics and on-going developments of novel targeted-treatment regimens, cardiac diseases lack effective preventive and curative therapies with minimal side effects. Therefore, there is an urgent need to identify and propagate alternative and complementary therapies against cardiovascular diseases. Some traditional Chinese medicines can contribute to the prevention and treatment of CVDs and other chronic diseases, with few side effects. Hirudo, a medicinal leech, has been acclaimed for improving blood circulation and overcoming blood stagnation; however, the precise molecular mechanisms of leech extract treatment against pathological cardiac remodeling remain elusive. In this study, we aimed to delineate the molecular mechanisms of medicinal leech extract in the treatment of cardiac hypertrophy and fibrosis, using both in vitro and in vivo assessments.

MATERIALS AND METHODS

We conducted in vitro and in vivo animal experiments, including cell-viability assays, fluorescence microscopy, immunoblotting, immunohistochemistry, and Masson's trichrome staining.

RESULTS

Pre-treatment with leech extract conferred a survival benefit to spontaneously-hypertensive rats (SHRs) and significantly reduced angiotensin II (ANG II)-induced cardiac hypertrophy and fibrosis. ANG II-stimulated cardiac hypertrophy markers were attenuated by leech extract treatment, versus controls. Translational expression of stress-associated mitogen-activated protein kinases (MAPKs) was also repressed. In vivo, leech extract treatment significantly ameliorated the cardiac hypertrophy phenotype in SHRs and diminished interstitial fibrosis, accompanied with reduced fibrosis markers.

CONCLUSION

Leech extract treatment under a hypertensive condition exerted significant cardio-protective benefits by reducing the expression of cardiac hypertrophy-related transcription factors, stress-associated MAPKs, and fibrosis mediators. Our findings imply that medicinal leach extract may be effective against hypertension-induced cardiac hypertrophy and fibrosis.