The Effects of Supplementation with Probiotic on Biomarkers of Oxidative Stress in Adult Subjects: a Systematic Review and Meta-analysis of Randomized Trials

Mitochondrial Glutathione in Cellular Redox Homeostasis and Disease Manifestation

Mitochondria are critical for providing energy to maintain cell viability. Oxidative phosphorylation involves the transfer of electrons from energy substrates to oxygen to produce adenosine triphosphate. Mitochondria also regulate cell proliferation, metastasis, and deterioration. The flow of electrons in the mitochondrial respiratory chain generates reactive oxygen species (ROS), which are harmful to cells at high levels. Oxidative stress caused by ROS accumulation has been associated with an increased risk of cancer, and cardiovascular and liver diseases. Glutathione (GSH) is an abundant cellular antioxidant that is primarily synthesized in the cytoplasm and delivered to the mitochondria. Mitochondrial glutathione (mGSH) metabolizes hydrogen peroxide within the mitochondria. A long-term imbalance in the ratio of mitochondrial ROS to mGSH can cause cell dysfunction, apoptosis, necroptosis, and ferroptosis, which may lead to disease. This study aimed to review the physiological functions, anabolism, variations in organ tissue accumulation, and delivery of GSH to the mitochondria and the relationships between mGSH levels, the GSH/GSH disulfide (GSSG) ratio, programmed cell death, and ferroptosis. We also discuss diseases caused by mGSH deficiency and related therapeutics.

Modulation of the Immune System Mechanisms using Probiotic Bacteria in Allergic Diseases: Focus on Allergic Retinitis and Food Allergies

Allergic illnesses occur when an organism's immune system is excessively responsive to certain antigens, such as those that are presented in the environment. Some people suffer from a wide range of immune system-related illnesses including allergic rhinitis, asthma, food allergies, hay fever, and even anaphylaxis. Immunotherapy and medications are frequently used to treat allergic disorders. The use of probiotics in bacteriotherapy has lately gained interest. Probiotics are essential to human health by modulating the gut microbiota in some ways. Due to probiotics' immunomodulatory properties present in the gut microbiota of all animals, including humans, these bacterial strains can prevent a wide variety of allergic disorders. Probiotic treatment helps allergy patients by decreasing inflammatory cytokines and enhancing intestinal permeability, which is important in the battle against allergy. By altering the balance of Th1 and Th2 immune responses in the intestinal mucosa, probiotics can heal allergic disorders. Numerous studies have shown a correlation between probiotics and a reduced risk of allergy disorders. A wide range of allergic disorders, including atopic dermatitis, asthma, allergic retinitis and food allergies has been proven to benefit from probiotic bacteria. Therefore, the use of probiotics in the treatment of allergic diseases offers a promising perspective. Considering that probiotic intervention in the treatment of diseases is a relatively new field of study, more studies in this regard seem necessary.

Remarkable impacts of probiotics supplementation in enhancing of the antioxidant status: results of an umbrella meta-analysis

Introduction

Numerous meta-analyses have demonstrated the beneficial effects of probiotics on oxidative stress biomarkers, although some studies have contradictory results. Therefore, the current research was conducted to obtain a precise and definite understanding on the impact of probiotics on oxidative stress biomarkers in adults.

Methods

We conducted a comprehensive systematic search of results on Scopus, PubMed, Embase, Web of Science, and Google Scholar dating up to March 2022. Fifteen meta-analyses were included in this umbrella meta-analysis. The random-effects model was employed to obtain the overall effect size. Subgroup analyses were carried out based on supplementation dosage and duration, mean age, and study population.

Results

Our results indicated that probiotics supplementation meaningfully decreased serum malondialdehyde (MDA) (ESWMD = -0.56, 95% CI: -0.72, -0.39; p < 0.001, and ESSMD = -0.50, 95% CI: -0.66, -0.34; p < 0.001). Moreover, the findings showed that probiotics resulted in a significant increase in total antioxidant capacity (TAC) (ESWMD = 29.18, 95% CI: 16.31, 42.04; p < 0.001, and ESSMD = 0.25, 95% CI: 0.02, 0.47; p = 0.032), total glutathione (GSH) (ESWMD: 30.65; 95% CI: 16.94, 44.35, p < 0.001), and nitric oxide (NO) (ESWMD: 1.48; 95% CI: 0.31, 2.65, p = 0.013; I2 = 51.7%, p = 0.043).

Discussion

Probiotics could be considered a strong agent in the reinforcement of antioxidant status and preventing the incidence of chronic diseases.

A systematic review and meta-analysis of randomized controlled trials investigating the effects of probiotics on oxidative stress in healthy adults

BACKGROUND

The oxidative stress (OS) theory of disease stipulates that a chronic imbalance in the ratio of oxidants to antioxidants in the cellular environment leads to a variety of debilitating conditions, including type 2 diabetes, cardiovascular and liver diseases. Metabolites in the gut microbiome have been associated with increases in reactive oxygen species (ROS). Many randomized controlled trials (RCTs) have thus investigated the potential of probiotics as a nutraceutical intervention to improve parameters of OS.

AIM

The objective of this paper is to review relevant human RCTs exploring the potential of probiotic supplementation to prevent OS in metabolically healthy individuals.

METHODS

This systematic review and meta-analysis was registered on PROSPERO (CRD42021297210). The PubMed database was searched using keywords related to probiotics and OS. In total, out of the 652 studies were screened, 9 respected the inclusion criteria.

RESULTS

Total antioxidant capacity (TAC) (SMD: 0.83 mmol/L, 95% CI: 0.25-1.40, p = 0.005) and glutathione (GSH) (SMD: 0.45, 95% CI: 0.13-0.77, p = 0.006) are improved with probiotic ingestion, although there are no alterations in superoxide dismutase (SOD) (SMD: 0.33, 95% CI: -0.27-0.93, p = 0.28). Decreases in plasma concentrations of the OS biomarker malondialdehyde (MDA) (SMD: -0.55, 95% CI: -1.11-0.00, p = 0.05) are also detected.

CONCLUSION

Probiotics improve AS and OS in metabolically healthy individuals. However, more studies are needed to address the moderate to high degree of heterogeneity in methodology.

The Influence of Probiotic Supplementation on the Severity of Anxiety and Depressive Symptoms; Function and Composition of Gut Microbiota; and Metabolic, Inflammation, and Oxidative Stress Markers in Patients with Depression-A Study Protocol

This article aims to present the theoretical basis, methodology, and design of a clinical trial we will conduct. The study will be prospective, randomized, placebo-controlled, and double-blind. Each intervention period will last 8 weeks and the trial will be conducted on 100 patients in total, who will be randomly divided into two groups consisting of 50 patients each. We plan to investigate the impact of Lactobacillus helveticus Rosell and Bifidobacterium longum Rosell on the depressive, anxiety, and stress levels in patients with depressive disorders with possible comorbid anxiety. In addition to assessing the influence of probiotics on the clinical condition, we also plan to study the clinical and biochemical parameters of metabolic syndrome, which often coexists with depression. Both depressive and metabolic issues may have part of their etiopathology in common, e.g., inflammation, oxidative stress, and dysbiosis. This is why we will additionally investigate the parameters related to gut microbiota, inflammatory, and oxidative statuses. Thus, the primary endpoint of the study will be the change in depression score measured with the Montgomery-Åsberg Depression Rating Scale. The secondary endpoints will include changes in anxiety and stress levels, as well as metabolic, inflammation, and oxidative stress parameters.

Live and Heat-Killed Probiotic Lactobacillus paracasei PS23 Accelerated the Improvement and Recovery of Strength and Damage Biomarkers after Exercise-Induced Muscle Damage

Excessive, high-intensity or inappropriate exercise may cause muscle damage. How to speed up recovery and reduce exercise discomfort are currently very important issues for athletes and sports people. Past research has shown that probiotics can improve inflammation and oxidative stress, as well as improve exercise performance and antifatigue. However, further research is needed to confirm the recovery benefits for muscle damage. In this double-blind design study, all subjects were randomly assigned to placebo, a live Lactobacillus paracasei group (L-PS23, 2 × 1010 colony forming unit (CFU)/day), or a heat-killed L. paracasei group (HK-PS23, 2 × 1010 cells/day), and supplemented for six consecutive weeks. Afterwards, subjects completed 100 maximal vertical jumps to bring about exercise-induced muscle damage (EIMD). Countermovement jump (CMJ), isometric mid-thigh pull (IMTP), and Wingate anaerobic test (WAnT), as well as blood tests for markers of muscle damage and inflammation were made pre-exercise and 3, 24, 48 h post exercise. The results show that both L-PS23 and HK-PS23 supplementation significantly slowed the loss of muscle strength after muscle injury, and they significantly reduced the production of markers of muscle damage and inflammation (p < 0.05). In addition, L-PS23 and HK-PS23 had the benefits of accelerating the recovery and improvement of muscle strength, the blood markers of muscle injury and inflammation, and slowing the decline in testosterone concentrations (p < 0.05). Especially in the HK-PS23 supplemented group, there was a better trend. In conclusion, we found that L-PS23 or HK-PS23 supplementation for six weeks prevented strength loss after muscle damage and improved blood muscle damage and inflammatory markers, with protective, accelerated recovery and anti-fatigue benefits.

Gut microbial evidence chain in high-salt diet exacerbates intestinal aging process

Although excessive salt consumption appears to hasten intestinal aging and increases susceptibility to cardiovascular disease, the molecular mechanism is unknown. In this study, mutual validation of high salt (HS) and aging fecal microbiota transplantation (FMT) in C56BL/6 mice was used to clarify the molecular mechanism by which excessive salt consumption causes intestinal aging. Firstly, we observed HS causes vascular endothelial damage and can accelerate intestinal aging associated with decreased colon and serum expression of superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and increased malondialdehyde (MDA); after transplantation with HS fecal microbiota in mice, vascular endothelial damage and intestinal aging can also occur. Secondly, we also found intestinal aging and vascular endothelial damage in older mice aged 14 months; and after transplantation of the older mice fecal microbiota, the same effect was observed in mice aged 6–8 weeks. Meanwhile, HS and aging significantly changed gut microbial diversity and composition, which was transferable by FMT. Eventually, based on the core genera both in HS and the aging gut microbiota network, a machine learning model was constructed which could predict HS susceptibility to intestinal aging. Further investigation revealed that the process of HS-related intestinal aging was highly linked to the signal transduction mediated by various bacteria. In conclusion, the present study provides an experimental basis of potential microbial evidence in the process of HS related intestinal aging. Even, avoiding excessive salt consumption and actively intervening in gut microbiota alteration may assist to delay the aging state that drives HS-related intestinal aging in clinical practice.

The Use of Probiotics Combined with Exercise Affects Thiol/Disulfide Homeostasis, an Oxidative Stress Parameter

Background: Intestinal microbiota play a role in the health and performance of athletes, and can be influenced by probiotics. Thus, in this study, we aimed to investigate the effect of the use of probiotics combined with chronic exercise on the thiol/disulfide homeostasis, a novel marker of oxidative stress. Methods: Male Wistar rats were randomly divided into four groups: control (Cn), exercise (Ex), probiotics (P), and probiotics + exercise (PEx). A capsule containing 6 × 10⁸ CFU of L. rhamnosus, L. paracasei, L. acidophilus, and B. lactis was given daily for eight weeks to all the experimental animals. The total thiol (TT, μmol/L) and native thiol (NT, μmol/L) concentrations were measured to determine the oxidative stress parameters. The dynamic disulfide (DD, %), reduced thiol (RT, %), oxidized thiol (OT, %), and thiol oxidation reduction (TOR, %) ratios were analyzed. Results: The TT level was found to be significantly higher in the Ex group (p = 0.047, η² = 0.259). The DD level, a marker of oxidation, was significantly lower in the PEx group (p = 0.042, η² = 0.266); the highest value of this parameter was found in the Ex group. The use of probiotics alone had no effect on thiol/disulfide homeostasis. Conclusions: We showed, for the first time, that probiotics administered “with exercise” decreased dynamic disulfide and significantly reduced oxidative damage. Therefore, we speculate that the use of probiotics in sports involving intense exercise might be beneficial to reduce oxidative stress.

The Effects of Probiotics Supplementation on Clinical Status and Biomarkers of Oxidative Damage and Inflammation in Children with Brucellosis: A Randomized, Double-Blind, and Placebo-Controlled Trial

Background

Increased levels of inflammatory cytokines and oxidative damage may play crucial roles in the pathogenesis of brucellosis. The purpose of this trial was to evaluate the impact of probiotics administration on clinical status and biomarkers of oxidative damage and inflammation in pediatric patients diagnosed with brucellosis.

Methods

This randomized, double-blind, and placebo-controlled trial was performed by recruiting 40 patients, 8–15 years of age, who had been diagnosed with brucellosis. Study participants were randomly allocated into two groups to receive either probiotics supplement or placebo (n = 20 each group) for 8 weeks. Blood samples were collected at the onset and after 8 weeks of intervention to quantify biochemical parameters. Clinical status was examined by a pediatric infectious disease specialist.

Results

Following 8-week intervention, probiotics supplementation substantially improved total antioxidant capacity (P < 0.001) and malondialdehyde (P=0.002). Furthermore, the difference between probiotics group and placebo group for the duration of fever (P=0.02) and musculoskeletal pain (P=0.001) was statistically significant, though probiotics administration had no significant effects on high-sensitivity C-reactive protein, total glutathione, and other clinical outcomes compared with placebo.

Conclusion

Overall, probiotics intake had beneficial impact on clinical status and body antioxidative defense system in pediatric patients with brucellosis.

The Effects of Probiotics on Inflammation, Endothelial Dysfunction, and Atherosclerosis Progression: A Mechanistic Overview

INTRODUCTION

The relationship between the intestinal microbiota dysbiosis, inflammation, and cardiovascular disorders (CVDs) has become evident, based on a growing body of literature from animal models and human studies. On the other hand, probiotics are believed to have promising effects on modifying dysbiosis and protecting against CVDs.

OBJECTIVE

This narrative review provides an overview of the link between gut microbiota, inflammation, endothelial dysfunction, and atherosclerosis. The influences of probiotic supplementation on biomarkers contributing to these conditions as the primary underlying risk factors for developing CVDs are also discussed.

METHODS

An up-to-date review was performed of the available evidence from experimental studies, clinical trials, and meta-analyses, considering their challenges and limitations. It also aimed to provide mechanistic insight into the likely mechanisms of probiotics that could prevent atherosclerosis initiation and progression.

RESULTS

Probiotic supplementation seems to be associated with reduced levels of inflammation and oxidative stress biomarkers (C-reactive protein, tumour necrosis factor-α, interleukin (IL)-6, IL-12, and malondialdehyde). Further, these agents might enhance antioxidant factors (IL-10, total antioxidant status, total antioxidant capacity, glutathione, and nitric oxide). Probiotics also appear to improve intestinal barrier integrity, reduce leakage of harmful metabolites (e.g., lipopolysaccharides), inhibit pro-inflammatory signalling pathways, and possibly suppress the formation of trimethylamine/trimethylamine oxide. Probiotics have also been found to enhance endothelial function and halter thrombosis.

CONCLUSION

The current clinical evidence underlines belief that probiotics might be associated with reduced levels of inflammation biomarkers. Experimental evidence reports that the beneficial effects of probiotics seem to be mainly imposed by triggering the secretion of short-chain fatty acids and bile acids, in addition to suppressing the NF-κB signalling pathway. However, the current studies are still in their infancy and it is of high priority to design further research on the topic.

Effects of Probiotic Supplementation on Exercise with Predominance of Aerobic Metabolism in Trained Population: A Systematic Review, Meta-Analysis and Meta-Regression

The scientific literature about probiotic intake and its effect on sports performance is growing. Therefore, the main aim of this systematic review, meta-analysis and meta-regression was to review all information about the effects of probiotic supplementation on performance tests with predominance of aerobic metabolism in trained populations (athletes and/or Division I players and/or trained population: ≥8 h/week and/or ≥5 workouts/week). A structured search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA®) statement and PICOS guidelines in PubMed/MEDLINE, Web of Science (WOS), and Scopus international databases from inception to 1 November 2021. Studies involving probiotic supplementation in trained population and execution of performance test with aerobic metabolism predominance (test lasted more than 5 min) were considered for inclusion. Fifteen articles were included in the final systematic review (in total, 388 participants were included). After 3 studies were removed due to a lack of data for the meta-analysis and meta-regression, 12 studies with 232 participants were involved. With the objective of assessing the risk of bias of included studies, Cochrane Collaboration Guidelines and the Physiotherapy Evidence Database (PEDro) scale were performed. For all included studies the following data was extracted: authors, year of publication, study design, the size of the sample, probiotic administration (dose and time), and characteristics of participants. The random effects model and pooled standardized mean differences (SMDs) were used according to Hedges’ g for the meta-analysis. In order to determine if dose and duration covariates could predict probiotic effects, a meta-regression was also conducted. Results showed a small positive and significant effect on the performance test with aerobic metabolic predominance (SMD = 0.29; CI = 0.08−0.50; p < 0.05). Moreover, the subgroup analysis displayed significant greater benefits when the dose was ≥30 × 109 colony forming units (CFU) (SMD, 0.47; CI, 0.05 to 0.89; p < 0.05), when supplementation duration was ≤4 weeks (SMD, 0.44; CI, 0.05 to 0.84; p < 0.05), when single strain probiotics were used (SMD, 0.33; CI, 0.06 to 0.60; p < 0.05), when participants were males (SMD, 0.30; CI, 0.04 to 0.56; p < 0.05), and when the test was performed to exhaustion (SMD, 0.45; CI, 0.05 to 0.48; p < 0.05). However, with references to the findings of the meta-regression, selected covariates did not predict probiotic effects in highly trained population. In summary, the current systematic review and meta-analysis supported the potential effects of probiotics supplementation to improve performance in a test in which aerobic metabolism is predominant in trained population. However, more research is needed to fully understand the mechanisms of action of this supplement.

Probiotic Bacteria with High Alpha-Gal Content Protect Zebrafish against Mycobacteriosis

Mycobacteriosis affects wild fish and aquaculture worldwide, and alternatives to antibiotics are needed for an effective and environmentally sound control of infectious diseases. Probiotics have shown beneficial effects on fish growth, nutrient metabolism, immune responses, disease prevention and control, and gut microbiota with higher water quality. However, the identification and characterization of the molecules and mechanisms associated with probiotics is a challenge that requires investigation. To address this challenge, herein we used the zebrafish model for the study of the efficacy and mechanisms of probiotic interventions against tuberculosis. First, bacteria from fish gut microbiota were identified with high content of the surface glycotope Galα1-3Galβ1-(3)4GlcNAc-R (α-Gal) that has been shown to induce protective immune responses. The results showed that probiotics of selected bacteria with high α-Gal content, namely Aeromonas veronii and Pseudomonas entomophila, were biosafe and effective for the control of Mycobacterium marinum. Protective mechanisms regulating immunity and metabolism activated in response to α-Gal and probiotics with high α-Gal content included modification of gut microbiota composition, B-cell maturation, anti-α-Gal antibodies-mediated control of mycobacteria, induced innate immune responses, beneficial effects on nutrient metabolism and reduced oxidative stress. These results support the potential of probiotics with high -Gal content for the control of fish mycobacteriosis and suggested the possibility of exploring the development of combined probiotic treatments alone and in combination with -Gal for the control of infectious diseases.

The effects of probiotic/synbiotic supplementation compared to placebo on biomarkers of oxidative stress in adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

During the last decades, there has been a burst of scientific literature hypothesizing the antioxidant effect of probiotics. However, the results of these studies are inconsistent and a final conclusion has yet to be reached. Thus, the aim of this study was to assess the effects of probiotic/synbiotic supplementation on serum total antioxidant capacity (TAC), glutathione (GSH), malondialdehyde (MDA) and nitric oxide (NO) levels in adults.

METHODS AND RESULTS

The following online databases were searched until August 26th 2020: PubMed/Medline, Scopus, Clarivate Analytics Web of Science, Cochrane Central Register of Controlled Trials, Science Direct, Google Scholar and Igaku Chuo Zasshi. The effect sizes were expressed as the weighted mean difference (WMD) with 95% confidence intervals (CI). A total of 31 eligible trials with 1681 participants (839 cases and 842 controls) were included in this meta-analysis. The results revealed that the supplementation with probiotics/synbiotics, significantly increased serum TAC (WMD: 54.14 mmol/L, 95% CI: 27.87, 80.40, P < 0.001), GSH (WMD: 40.38 μmol/L, 95% CI: 20.72, 60.03, P < 0.001) and NO (WMD: 3.54 μmol/L, 95% CI: 1.73, 5.34, P < 0.001) levels. In addition, MDA levels were significantly reduced (WMD: -0.45 μmol/L, 95% CI: -0.58,-0.32, P < 0.001) following probiotic/synbiotic supplementation. None of the variables showed a significant change in the sensitivity analysis.

CONCLUSION

Available evidence suggests that probiotic/synbiotic supplementation can significantly increase serum TAC, GSH and NO, as well as reduce MDA levels in adults. Therefore, probiotic/synbiotic supplementation may play a role in improving antioxidant indices and reducing oxidative stress in the body.

Probiotics, prebiotics, and synbiotics for the improvement of metabolic profiles in patients with chronic kidney disease: A systematic review and meta-analysis of randomized controlled trials

This systematic review and meta-analysis of randomized controlled trials (RCTs) was performed to quantify the effects of probiotic, prebiotic, and synbiotic supplementation on biomarkers of inflammation and oxidative stress, as well as lipid profiles among patients with chronic kidney disease (CKD). Electronic databases, including PubMed, the Cochrane Database, and the Web of Science were searched from January 1, 2000, to May 15, 2019. All RCTs that investigated the effect of prebiotics, probiotics, and synbiotics on a circulating (serum and plasma) inflammatory marker (C-reactive protein [CRP]), oxidative stress indicators (malondialdehyde [MDA], glutathione [GSH], and total anti-oxidant capacity [TAC]); and lipid profiles (total cholesterol [TC], triglycerides [TG], low-density lipoprotein cholesterol [LDL-c], and high-density lipoprotein cholesterol [HDL-c]) among patients with CKD were included. Data were pooled and expressed as a standardized mean difference (SMD) with a 95% confidence interval (CI). The protocol for this meta-analysis is registered with PROSPERO; No. CRD42019139090. Thirteen trials that included 671 patients were identified for analysis. The methodological quality varied across studies. Meta-analysis indicated that microbial therapies significantly reduced CRP (SMD, -0.75; 95% CI, -1.03 to -0.47; p = 0.000), MDA (SMD, -1.06; 95% CI, -1.59 to -0.52; p = 0.000), TC (SMD, -0.33; 95% CI, -0.52 to -0.13; p = 0.000), and LDL-c (SMD, -0.44; 95% CI, -0.86 to -0.02; p = 0.000) levels; they also increased the GSH (SMD, 0.44; 95% CI, 0.25 to 0.65; p = 0.000), TAC (SMD, 0.61; 95% CI, 0.07 to 1.15; p = 0.000), and HDL-c (SMD, 0.45; 95% CI, 0.03 to 0.87; p = 0.000) levels in CKD patients, as compared to the placebo groups; however, there was no statistically significant TG concentration among patients with CKD. Subgroup analyses showed that other key factors, such as the duration of intervention, participants' baseline body mass index (BMI), type of intervention, and age, had an effect of microbial therapies on outcomes. This meta-analysis supports the potential use of probiotic, prebiotic, and synbiotic supplements in the improvement of established biomarkers of inflammation and oxidative stress, as well as lipid profiles among patients with CKD, which are well-known cardiovascular risk factors. Further research into these interventions should consider the limitations of our study to explore the effect of long-term administration of these supplements in the CKD population.

Myalgic encephalomyelitis/chronic fatigue syndrome: From pathophysiological insights to novel therapeutic opportunities

Myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS) is a common and disabling condition with a paucity of effective and evidence-based therapies, reflecting a major unmet need. Cognitive behavioural therapy and graded exercise are of modest benefit for only some ME/CFS patients, and many sufferers report aggravation of symptoms of fatigue with exercise. The presence of a multiplicity of pathophysiological abnormalities in at least the subgroup of people with ME/CFS diagnosed with the current international consensus "Fukuda" criteria, points to numerous potential therapeutic targets. Such abnormalities include extensive data showing that at least a subgroup has a pro-inflammatory state, increased oxidative and nitrosative stress, disruption of gut mucosal barriers and mitochondrial dysfunction together with dysregulated bioenergetics. In this paper, these pathways are summarised, and data regarding promising therapeutic options that target these pathways are highlighted; they include coenzyme Q₁₀, melatonin, curcumin, molecular hydrogen and N-acetylcysteine. These data are promising yet preliminary, suggesting hopeful avenues to address this major unmet burden of illness.