New medicinal properties of mangostins: Analgesic activity and pharmacological characterization of active ingredients from the fruit hull of Garcinia mangostana L

Garcinone E suppresses breast cancer growth and metastasis by modulating tumor-associated macrophages polarization via STAT6 signaling

Cancer metastasis remains the most common cause of death in breast cancer patients. Tumor-associated macrophages (TAMs) are a novel therapeutic target for the treatment of metastatic breast cancer. Despite the good anti-cancer activity of garcinone E (GE), there are no reports on its therapeutic effects on breast cancer metastasis. The objective of this study was to examine the anti-cancer effects of GE on metastatic breast cancer. RAW 264.7 and THP-1 cells were polarized to M2 macrophages by IL-4/IL-13 in vitro. A 4T1 mouse breast cancer model and the tail vein breast cancer metastasis model were used to explore the effect of GE on breast cancer growth and metastasis in vivo. In vitro studies showed that GE dose-dependently suppressed IL-4 + IL-13-induced expression of CD206 in both RAW 264.7 cells and differentiated THP-1 macrophages. However, GE did not affect the LPS + IFN-γ-induced polarization to the M1-like macrophages in vitro. GE inhibited the expression of the M2 macrophage specific genes in RAW 264.7 cells, and simultaneously impaired M2 macrophage-induced breast cancer cell proliferation and migration, and angiogenesis. In animal studies, GE significantly suppressed tumor growth, angiogenesis, and lung metastasis in 4T1 tumor-bearing mice, without causing toxicity. In both tumor and lung tissues, the proportion of M2-like TAMs was significantly decreased while the proportion of M1-like TAMs was markedly increased by GE treatment. Mechanistically, GE inhibited phosphorylation of STAT6 in vitro and in vivo. Our results demonstrate for the first time that GE suppresses breast cancer growth and pulmonary metastasis by modulating M2-like macrophage polarization through the STAT6 signaling pathway.

Biochemical features and therapeutic potential of α-Mangostin: Mechanism of action, medicinal values, and health benefits

α-Mangostin (α-MG) is a natural xanthone obtained from the pericarps of mangosteen. It exhibits excellent potential, including anti-cancer, neuroprotective, antimicrobial, antioxidant, and anti-inflammatory properties, and induces apoptosis. α-MG controls cell proliferation by modulating signaling molecules, thus implicated in cancer therapy. It possesses incredible pharmacological features and modulates crucial cellular and molecular factors. Due to its lesser water solubility and pitiable target selectivity, α-MG has limited clinical application. As a known antioxidant, α-MG has gained significant attention from the scientific community, increasing interest in extensive technical and biomedical applications. Nanoparticle-based drug delivery systems were designed to improve the pharmacological features and efficiency of α-MG. This review is focused on recent developments on the therapeutic potential of α-MG in managing cancer and neurological diseases, with a special focus on its mechanism of action. In addition, we highlighted biochemical and pharmacological features, metabolism, functions, anti-inflammatory, antioxidant effects and pre-clinical applications of α-MG.

General toxicity studies of alpha mangostin from Garcinia mangostana: A systematic review

Alpha mangostin (AM), the main xanthone derivative contained in mangosteen pericarp (Garcinia mangostana/GM), has many pharmacological activities such as antioxidant, antiproliferation, antiinflammatory, and anticancer. Several general toxicity studies of AM have been previously reported to assess the safety profile of AM. Toxicity studies were carried out by various methods such as on test animals, interventions, and various routes of administration, but the test results have not been well documented. Our study aimed to systematically summarizes research on the safety profile of GM containing AM through general toxicity tests to get the LD₅₀ and NOAEL values, and so, can be used as a database related to AM toxicity profiles. This could facilitate other researchers in determining further development of GM-or-AM-based products. Pubmed, Google scholar, ScienceDirect, and EBSCO were chosen to collect the articles while ARRIVE 2.0 was used to evaluate the quality and risk-of-bias of the in vivo toxicity studies included in this systematic review. A total of 20 articles met the eligibility criteria and were reviewed to predict the LD₅₀ and NOAEL of AM. The results showed that the LD₅₀ of AM is between >15.480 mg/kgBW to ≤6000 mg/kgBW while the NOAEL value is between <100 and ≤2000 mg/kgBW.

Multi-target modulation of ion channels underlying the analgesic effects of α-mangostin in dorsal root ganglion neurons

BACKGROUND

α-Mangostin is a xanthone isolated from the pericarps of mangosteen fruit with, and has analgesic properties. Although the effects suggest an interaction of α-mangostin with ion channels in the nociceptive neurons, electrophysiological investigation of the underlying mechanism has not been performed.

HYPOTHESIS

We hypothesized that α-Mangostin exerts its analgesic effects by modulating the activity of various ion channels in dorsal root ganglion (DRG) neurons.

METHODS

We performed a whole-cell patch clamp study using mouse DRG neurons, HEK293T cells overexpressing targeted ion channels, and ND7/23 cells. Molecular docking (MD) and in silico absorption, distribution, metabolism, and excretion (ADME) analyses were conducted to obtain further insights into the binding sites and pharmacokinetics, respectively.

RESULTS

Application of α-mangostin (1-3 µM) hyperpolarized the resting membrane potential (RMP) of small-sized DRG neurons by increasing background K⁺ conductance and thereby inhibited action potential generation. At micromolar levels, α-mangostin activates TREK-1, TREK-2, or TRAAK, members of the two-pore domain K⁺ channel (K2P) family known to be involved in RMP formation in DRG neurons. Furthermore, capsaicin-induced TRPV1 currents were potently inhibited by α-mangostin (0.43 ± 0.27 µM), and partly suppressed tetrodotoxin-sensitive voltage-gated Na⁺ channel (Na_V) currents. MD simulation revealed that multiple oxygen atoms in α-mangostin may form stable hydrogen bonds with TREKs, TRAAK, TRPV1, and Na_V channels. In silico ADME tests suggested that α-mangostin may satisfy the drug-likeness properties without penetrating the blood-brain barrier.

CONCLUSION

The analgesic properties of α-mangostin might be mediated by the multi-target modulation of ion channels, including TREK/TRAAK activation, TRPV1 inhibition, and reduction of the tetrodotoxin-sensitive Na_V current. The findings suggest that the phytochemical can be a multi-ion channel-targeting drug and an alternative drug for effective pain management.

Effects of Ethanolic and Aqueous Extracts of Garcinia gardneriana Leaves in an In Vivo Experimental Model Induced by a Hyperlipidic Diet

The study of medicinal plants, such as the genus Garcinia (Clusiaceae), in the treatment of non-communicable chronic diseases has aroused the interest of researchers. However, there are no studies in the literature that have investigated the effects of Garcinia gardneriana in experimental models of obesity for possible metabolic alterations. Swiss mice receiving a high-fat diet were supplemented with aqueous or ethanolic extract of G. gardneriana at doses of 200 or 400 mg/kg/day. It was found that there was a reduction in food consumption in experimental groups compared with the control groups, and the group supplemented with aqueous extract at a dose of 200 mg/kg/daydisplayed a reduction in weight. The results showed an increase in the values of high density lipoprotein (HDL-c), total cholesterol, triglycerides and fasting blood glucose. G. gardneriana did not protect against insulin resistance, and caused in an increase in monocyte chemoattractant protein-1 (MCP-1) concentrations and a reduction in interleukin 10 (IL-10). In addition, hepatic steatosis and microvesicular steatosis were indicated. It was revealed that, under the experimental conditions in the study, G. gardneriana did not prevent weight gain or comorbidities; that is, a different behavior was obtained from that described in the literature with regard to the medicinal potential of the Garcinia species, which is probably related to the phytochemical properties.

The Current Landscape of Bioactive Molecules against DENV: A Systematic Review

With a 30-fold increase in incidence over the previous 50 years, dengue fever is now the most widespread viral disease transmitted by mosquitoes in the world. The intricate interaction of the human defense system, hereditary predisposition, and specific bitterness elements is more likely to be the pathogenesis of dengue. There are presently no viable treatments for dengue. Synthetic drugs which are used against this ailment also show major side effects. There must be a deeper understanding of the underlying mechanism generating severe symptoms to develop auguring markers, cutting-edge diagnostics, and treatments and finally a well-rounded and secure antiserum. Hence, the aim is to search for safer and more potent drugs derived from plants. Plants or herbs are mainly targeting replication or its enzyme or specific stereotypes, though an exact mechanism of phytoconstituents interfering with the viral replication is still undiscovered. The present attempt provided the update with the objective to bringing up forward pathophysiological eventualities involved in dengue virus along with the naturally derived treatment relevant to provide the impregnable therapy by evading the noxious symptoms for dengue fever. Governor's plum, Cryptocarya chartacea, magnolia berry, and Chinese ginger are such plants exhibiting many effective phytoconstituents against DENV and can be further explored for novel drug discovery by medicinal scientists.

Hypouricemic Actions of the Pericarp of Mangosteen in Vitro and in Vivo

Hyperuricemia is the result of overproduction and/or underexcretion of uric acid, and it is a well-known risk factor for gout, hypertension, and diabetes. However, available drugs for hyperuricemia in the clinic are limited. Recently, a lot of research has been conducted in order to discover new uric acid-lowering agents from plants and foods. We found that the extracts from the pericarp of mangosteen reduced urate. Bioactivity-guided study showed that α-mangostin was the principal constituent. Herein, we reported for the first time the hypouricemic activities and underling mechanism of α-mangostin. The α-mangostin dose- and time-dependently decreased the levels of serum urate in hyperuricemic mice and markedly increased the clearance of urate in hyperuricemic rats, exhibiting a promotion of urate excretion in the kidney. Further evidence showed that α-mangostin significantly decreased the protein levels of GLUT9 in the kidneys. The change in the expression of URAT1 was not observed. Moreover, α-mangostin did not inhibit the activities of xanthine oxidoreductase and uricase in vitro or in vivo. Taken together, these findings suggest that α-mangostin has potential to be developed as a new anti-hyperuricemic agent with promoting uric acid excretion.

A Review of Herbal Medicine-Based Phytochemical of Garcinia as Molecular Therapy for Breast Cancer

Data from globocan statistic in 2020 indicate that breast cancer has become highest incidence rate of cancer. Estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) are known immunohistochemistry (IHC) markers that mediate cell growth and survival signaling. Furthermore, regulator proteins, receptors, and their downstream signaling pathways have emerged as critical components in breast cancer formation and proliferation, and have become well-established therapeutic targets and the core focus of breast cancer therapy research. Garcinia is a big genus in the Clusiaceae family that contains a wide spectrum of biologically active metabolites for the chemical composition of their isolated fruits, stem barks, seeds, leaves, and roots, have resulted including polyisoprenylated benzophenones, polyphenols, bioflavonoids, xanthones, lactones, and triterpenes. This review article aimed to analyze the potential of Garcinia phytochemicals as a molecular therapy of breast cancer. The results showed that phytochemicals of Garcinia (i.e., α-mangostin, Cambogin, Gambogic Acid [GA], Garcinol, Griffipavixanthone, Friedolanostane triterpenoid, Hexane, Neobractatin, 7-Epiclusianone, xanthochymol - guttiferone E, and isoxanthochymol - cycloxanthochymol) have anticancer properties, including apoptosis, inhibition of proliferation, and metastasis. This review is important to provide information regarding phytochemicals of Garcinia as an alternative treatment for breast cancer patients. This article selected 28 article researches based on inclusion criteria with the keyword “Garcinia” and “Breast cancer”, in English, and available in full text and abstract searching on PubMed.

Probing Alterations in MDM2 Catalytic Core Structure Effect of Garcinia Mangostana Derivatives: Insight from Molecular Dynamics Simulations

The MDM2-p53 protein-protein interaction is a promising model for researchers to design, study, and discover new anticancer drugs. The design of therapeutically active compounds that can maintain or restore the binding of MDM2 to p53 has been found to limit the oncogenic activities of both. This led to the current development of a group of xanthone-core and cis-imidazoline analogs compounds, among which γ-Mangostin (GM), α-Mangostin (AM), and Nutlin exhibited their MDM2-p53 interaction inhibitory effects. Therefore, in this study, we seek to determine the mechanisms by which these compounds elicit MDM2-p53 interaction targeting. Unique to the binding of GM, AM, and Nutlin, from our findings, they share the same three active site residues Val76, Tyr50, and Gly41, which represent the top active side residues that contribute to high electrostatic energy. Consequently, the free binding energy contributed enormously to the binding of these compounds, which culminated in the high binding affinities of GM, AM, and Nutlin with high values. Furthermore, GM, AM, and Nutlin commonly interrupted the stable and compact conformation of MDM2 coupled with its active site, where Cα deviations were relatively high. We believe that our findings would assist in the design of more potent active anticancer drugs.

Mangostanin, a Xanthone Derived from Garcinia mangostana Fruit, Exerts Protective and Reparative Effects on Oxidative Damage in Human Keratinocytes

The fruit of Garcinia mangostana (mangosteen) is known in ancient traditional Asian medicine for its antioxidant, anti-inflammatory, immunomodulatory and anticancer activities. These effects are mainly due to the action of polyphenols known as xanthones, which are contained in the pericarp of the fruit. In recent years, there has been a growing interest from pharmaceutical companies in formulating new topicals based on mangosteen full extracts to prevent skin aging. However, the molecules responsible for these effects and the mechanisms involved have not been investigated so far. Here, the arils and shells of Garcinia mangostana were extracted with chloroform and methanol, and the extracts were further purified to yield 12 xanthone derivatives. Their effects were evaluated using in vitro cultures of human epidermal keratinocytes. After confirming the absence of cytotoxicity, we evaluated the antioxidant potential of these compounds, identifying mangostanin as capable of both protecting and restoring oxidative damage induced by H₂O₂. We showed how mangostanin, by reducing the generation of intracellular reactive oxygen species (ROS), prevents the activation of AKT (protein kinase B), ERK (extracellular signal-regulated kinase), p53, and other cellular pathways underlying cell damage and apoptosis activation. In conclusion, our study is the first to demonstrate that mangostanin is effective in protecting the skin from the action of free radicals, thus preventing skin aging, confirming a potential toward its development in the nutraceutical and cosmeceutical fields.

The Protective Effects of α-Mangostin Attenuate Sodium Iodate-Induced Cytotoxicity and Oxidative Injury via Mediating SIRT-3 Inactivation via the PI3K/AKT/PGC-1α Pathway

It is well known that age-related macular degeneration (AMD) is an irreversible neurodegenerative disease that can cause blindness in the elderly. Oxidative stress-induced retinal pigment epithelial (RPE) cell damage is a part of the pathogenesis of AMD. In this study, we evaluated the protective effect and mechanisms of alpha-mangostin (α-mangostin, α-MG) against NaIO3-induced reactive oxygen species (ROS)-dependent toxicity, which activates apoptosis in vivo and in vitro. MTT assay and flow cytometry demonstrated that the pretreatment of ARPE-19 cells with α-MG (0, 3.75, 7.5, and 15 μM) significantly increased cell viability and reduced apoptosis from NaIO3-induced oxidative stress in a concentration-dependent manner, which was achieved by the inhibition of Bax, cleaved PARP-1, cleaved caspase-3 protein expression, and enhancement of Bcl-2 protein. Furthermore, pre-incubation of ARPE-19 cells with α-MG markedly inhibited the intracellular ROS and extracellular H2O2 generation via blocking of the abnormal enzyme activities of superoxide dismutase (SOD), the downregulated levels of catalase (CAT), and the endogenous antioxidant, glutathione (GSH), which were regulated by decreasing PI3K-AKT-PGC-1α-STRT-3 signaling in ARPE-19 cells. In addition, our in vivo results indicated that α-MG improved retinal deformation and increased the thickness of both the outer nuclear layer and inner nuclear layer by inhibiting the expression of cleaved caspase-3 protein. Taken together, our results suggest that α-MG effectively protects human ARPE-19 cells from NaIO3-induced oxidative damage via antiapoptotic and antioxidant effects.

Carbonized biosorbent assisted matrix solid-phase dispersion microextraction for active compounds from functional food

In this study, mangosteen peel based activated carbon was prepared and first applied as adsorbent in matrix solid-phase dispersion (MSPD) for simultaneously extraction of flavonoids from Dendrobium huoshanense prior to their separation and determination by ultra-high performance liquid chromatography coupled with quadrupole time-of-flight tandem mass spectrometry (UHPLC-Q-TOF/MS). The MSPD-UHPLC-Q-TOF/MS method was validated exhaustively. Good linearities (r² ≥ 0.9929) were obtained for all target analytes. The limits of detection was in the range of 0.00387-0.159 μg/g. Satisfactory recoveries of six target compounds were between 80.02 and 99.49% and 85.32-99.86% for the low and high spiked level, respectively. Furthermore, relative to other common sorbent, the prepared mangosteen peel based activated carbon was less expensive and more environmentally-friendly. Consequently, the proposed method was a simple, efficient, low-cost, eco-friendly, time-saving and sensitive approach that could be successfully applied to the extraction and determination of flavonoids compounds in complex matrix.

In vitro and in vivo studies reveal α-Mangostin, a xanthonoid from Garcinia mangostana, as a promising natural antiviral compound against chikungunya virus

Background

Chikungunya virus (CHIKV), a serious health problem in several tropical countries, is the causative agent of chikungunya fever. Approved antiviral therapies or vaccines for the treatment or prevention of CHIKV infections are not available. As diverse natural phenolic compounds have been shown to possess antiviral activities, we explored the antiviral activity of α-Mangostin, a xanthanoid, against CHIKV infection.

Methods

The in vitro prophylactic and therapeutic effects of α-Mangostin on CHIKV replication in Vero E6 cells were investigated by administering it under pre, post and cotreatment conditions. The antiviral activity was determined by foci forming unit assay, quantitative RT-PCR and cell-based immune-fluorescence assay. The molecular mechanism of inhibitory action was further proposed using in silico molecular docking studies.

Results

In vitro studies revealed that 8 µM α-Mangostin completely inhibited CHIKV infectivity under the cotreatment condition. CHIKV replication was also inhibited in virus-infected mice. This is the first in vivo study which clearly showed that α-Mangostin is effective in vivo by significantly reducing virus replication in serum and muscles. Molecular docking indicated that α-Mangostin can efficiently interact with the E2–E1 heterodimeric glycoprotein and the ADP-ribose binding cavity of the nsP3 macrodomain.

Conclusions

The findings suggest that α-Mangostin can inhibit CHIKV infection and replication through possible interaction with multiple CHIKV target proteins and might act as a prophylactic/therapeutic agent against CHIKV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12985-021-01517-z.

A review on α-mangostin as a potential multi-target-directed ligand for Alzheimer's disease

Alzheimer's disease (AD) is an age-related neurodegenerative disease characterized by progressive memory loss, declining language skills and other cognitive disorders. AD has brought great mental and economic burden to patients, families and society. However due to the complexity of AD's pathology, drugs developed for the treatment of AD often fail in clinical or experimental trials. The main problems of current anti-AD drugs are low efficacy due to mono-target method or side effects, especially high hepatotoxicity. To tackle these two main problems, multi-target-directed ligand (MTDL) based on "one molecule, multiple targets" has been studied. MTDLs can regulate multiple biological targets at the same time, so it has shown higher efficacy, better safety. As a natural active small molecule, α-mangostin (α-M) has shown potential multi-factor anti-AD activities in a series of studies, furthermore it also has a certain hepatoprotective effect. The good availability of α-M also provides support for its application in clinical research. In this work, multiple activities of α-M related to AD therapy were reviewed, which included anti-cholinesterase, anti-amyloid-cascade, anti-inflammation, anti-oxidative stress, low toxicity, hepatoprotective effects and drug formulation. It shows that α-M is a promising candidate for the treatment of AD.

Medicinal Potential of Garcinia Species and Their Compounds

Garcinia is a genus of Clusiaceae, distributed throughout tropical Asia, Africa, New Caledonia, Polynesia, and Brazil. Garcinia plants contain a broad range of biologically active metabolites which, in the last few decades, have received considerable attention due to the chemical compositions of their extracts, with compounds which have been shown to have beneficial effects in several diseases. Our work had the objective of reviewing the benefits of five Garcinia species (G. brasiliensis, G. gardneriana, G. pedunculata, G. cambogia, and G. mangstana). These species provide a rich natural source of bioactive compounds with relevant therapeutic properties and anti-inflammatory effects, such as for the treatment of skin disorders, wounds, pain, and infections, having demonstrated antinociceptive, antioxidant, antitumoral, antifungal, anticancer, antihistaminic, antiulcerogenic, antimicrobial, antiviral, vasodilator, hypolipidemic, hepatoprotective, nephroprotective, and cardioprotective properties. This demonstrates the relevance of the genus as a rich source of compounds with valuable therapeutic properties, with potential use in the prevention and treatment of nontransmissible chronic diseases.

α-Mangostin, a Dietary Xanthone, Exerts Protective Effects on Cisplatin-Induced Renal Injury via PI3K/Akt and JNK Signaling Pathways in HEK293 Cells

Previous report has confirmed the beneficial effects of α-mangostin (α-MG), a major and representative xanthone distributed in mangosteen (Garcinia mangostana) on the cisplatin-induced rat model. However, the molecular mechanisms related to its renoprotection have not been elucidated exhaustively. The present study investigated the protective effect of α-MG against cisplatin-induced cytotoxicity in the human embryonic kidney (HEK293) cell model. In this study, α-MG prevented cisplatin-induced cell death, accompanied with the decreased levels of malondialdehyde and increased glutathione content. Particularly, α-MG significantly suppressed the overproduction of reactive oxygen species (ROS), restored the activation of phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt), and downregulated the c-JUN N-terminal kinase (JNK) pathways following cisplatin challenge. Subsequently, the cleavage of caspases and poly-ADP-ribose polymerase (PARP) implicating ROS-mediated apoptosis pathways induced by cisplatin was effectively inhibited by α-MG. In conclusion, our findings provided a rationale for the development of α-MG to attenuate cisplatin-induced nephrotoxicity.

Catechol-Functionalized Alginate Nanoparticles as Mucoadhesive Carriers for Intravesical Chemotherapy

This research aimed to synthesize and evaluate mucoadhesive catechol-functionalized alginate (Cat-Alg) nanoparticles (NPs) for bladder cancer. Cat-Alg was synthesized using coupling chemistry, and the structure was verified using NMR and FT-IR. Cat-Alg NPs were generated by ionic gelation between the synthesized Cat-Alg and calcium chloride. Garcinia mangostana L. extract (GM extract) was entrapped into the NPs during particle formation. The physical characteristics, mucoadhesive properties, drug loading and release, cellular uptake, and anticancer activity of the GM extract-loaded NPs were investigated. The Cat-Alg NPs were spherical with sizes in the range of 155-186 nm. The slightly negative surface charge of the NPs provided them with excellent stability. The Cat-Alg NPs could be retained on a porcine bladder mucosa to a greater extent compared with unmodified Alg NPs. High loading efficiency (71.6%) and loading capacity (292 μg/mg) of GM extract in the NPs were achieved, and a constant release of GM extract was obtained for up to 8 h with zero-order kinetics. Moreover, the GM extract-loaded NPs were deposited in bladder tissue and accumulated in MB49 cells at a higher rate compared with GM extract suspension. In addition, the NPs could kill a mouse urothelial carcinoma cell line with low IC₅₀. Therefore, these NPs have the potential to be a mucoadhesive drug delivery system for bladder cancer treatment. However, additional in vivo investigations are needed for clinical application in cancer treatment. Graphical abstract.

Comparative clinical efficacy of three toothpastes in the control of supragingival calculus formation

OBJECTIVES

The purpose of this double-blind, parallel clinical study was to assess clinical efficacy in supragingival calculus formation reduction using Abhaibhubejhr Herbal Toothpaste compared to Colgate Total and Colgate Cavity Protection toothpastes.

MATERIALS AND METHODS

A total of 150 subjects participated in the pretest phase. All subjects were given oral soft/hard tissue evaluation, calculus examination using Volpe-Manhold calculus, and whole mouth oral prophylaxis. They received noncalculus control fluoride toothpaste and a soft-bristled toothbrush to brush for 1 min two times daily for 8 weeks. After which, subjects were given a test phase oral soft/hard tissue evaluation and calculus examination and were randomized into one of the three toothpaste groups. All subjects in the test phase received a whole mouth oral prophylaxis and were given their assigned toothpaste and a soft-bristled toothbrush to brush for 1 min two times a day for 12 weeks. Thereafter, subjects were assessed for their oral soft/hard tissue and calculus formation.

RESULTS

Mean Volpe-Manhold calculus index scores for the Cavity Protection, Abhaibhubejhr, and Total toothpaste groups were 0.78, 0.62, and 0.48, respectively, at the 12-week test phase evaluation. Abhaibhubejhr and Total toothpaste groups show 20.51% and 38.46% significantly less calculus formation than the Cavity Protection toothpaste group (P < 0.05). Total toothpaste group also show 22.58% significantly less calculus formation than the Abhaibhubejhr toothpaste group (P < 0.05).

CONCLUSION

The use of Colgate Total toothpaste over a 12-week period was clinically more effective than either Abhaibhubejhr or Colgate Cavity Protection toothpastes in controlling supragingival calculus formation.

Biological properties in relation to health promotion effects of Garcinia mangostana (queen of fruit)

Purpose

For the prevention and cure of disease, patient use various types of chemical and drug agents. Along with their curative effect, almost all drugs have some destructive effects and side-effects. Due to the minimal and/or none of unwanted side-effect, recently, the use of herbal remedy as the drug of choice becomes the preference choice. The mangosteen, Garcinia mangostana, contains various types of polyphenols. It has been used as a traditional medicine from the ancient times till present days. The purpose of this paper is to investigate the biological properties of mangosteen in relation to health promotion effects.

Design/methodology/approach

Several research papers from well-known database (such as PubMed, Google scholar, Scopus and Sciencedirect) were reviewed without considering publication-times to understand the biological properties of mangosteen.

Findings

Mangosteen and its xanthone exerted diverse biological activities such as anti-oxidant, anti-inflammatory, anti-allergy, anti-bacteria, anti-fungal, anti-malaria, anticancer and anti-diabetes.

Originality/value

Based on these studies, mangosteen is beneficial dietary supplement of overall human health.

Dietary α-Mangostin Provides Protective Effects against Acetaminophen-Induced Hepatotoxicity in Mice via Akt/mTOR-Mediated Inhibition of Autophagy and Apoptosis

Acetaminophen overdose-induced hepatotoxicity is the most common cause of acute liver failure in many countries. Previously, alpha-mangostin (α-MG) has been confirmed to exert protective effects on a variety of liver injuries, but the protective effect on acetaminophen-induced acute liver injury (ALI) remains largely unknown. This work investigated the regulatory effect and underlying cellular mechanisms of α-MG action to attenuate acetaminophen-induced hepatotoxicity in mice. The increased serum aminotransferase levels and glutathione (GSH) content and reduced malondialdehyde (MDA) demonstrated the protective effect of α-MG against acetaminophen-induced hepatotoxicity. In addition, α-MG pretreatment inhibited increases in tumor necrosis factor (TNF-α) and interleukin-1β (IL-1β) caused by exposure of mice to acetaminophen. In liver tissues, α-MG inhibited the protein expression of autophagy-related microtubule-associated protein light chain 3 (LC3) and BCL2/adenovirus E1B protein-interacting protein 3 (BNIP3). Western blotting analysis of liver tissues also proved evidence that α-MG partially inhibited the activation of apoptotic signaling pathways via increasing the expression of Bcl-2 and decreasing Bax and cleaved caspase 3 proteins. In addition, α-MG could in part downregulate the increase in p62 level and upregulate the decrease in p-mTOR, p-AKT and LC3 II /LC3 I ratio in autophagy signaling pathways in the mouse liver. Taken together, our findings proved novel perspectives that detoxification effect of α-MG on acetaminophen-induced ALI might be due to the alterations in Akt/mTOR pathway in the liver.

Bioactivity and pharmacological properties of α-mangostin from the mangosteen fruit: a review

INTRODUCTION

α-Mangostin (α-MG) is the most representative xanthone isolated from the pericarp of mangosteen, possessing extensive biological activities and pharmacological properties, considered as an antineoplastic agent, antioxidant, anti-proliferation and induces apoptosis.

AREAS COVERED

The bioactivity and pharmacological properties of α-MG are being actively investigated by various industrial and academic institutions. The bioactivities of α-MG have been summarized in several previous reviews, which were worthy of high compliment. However, recently, many new literatures about the bioactivities of α-MG have been further reported from 2016 to 2017. Herein, the activities of α-MG are supplemented and summarized in this text.

EXPERT OPINION

As previously said, α-MG possesses good bioactivities pharmacological properties. More recently, it found that α-MG has the effect of maintaining cardiovascular system and gastrointestinal health and controlling free radical oxidation. Furthermore, α-MG has more applications in cosmetics, with the effects of anti-aging, anti-wrinkle, acne treatment, maintenance of skin lubrication. The application of α-MG in treating rheumatoid arthritis has been disclosed and the MG-loaded self-micro emulsion (MG-SME) was designed to improve its pharmacokinetic deficiencies. As mentioned above, α-MG can be a promising drug, also worthy of developing, and further research is crucial for the future application of α-MG.

Protective effects of γ-mangostin on 6-OHDA-induced toxicity in SH-SY5Y cells

γ-Mangostin is a xanthone with hydroxyl groups that confer the substance-free radical scavenging effects. As opposed to the other more extensively studied mangostins, scarce research has been conducted on neuroprotective effects of γ-mangostin on models of Parkinson's disease (PD). Therefore, this investigation aimed to elucidate its antioxidant and neuroprotective effects on 6-OHDA-induced toxicity in SH-SY5Y cells. 6-OHDA treatment, an inducer of PD pathology in vitro studies, decreased cell viability and increased the level of intracellular ROS production. Furthermore, the substance-induced the expression of phosphorylated p38 MAPK, negatively affected the Bax/Bcl-2 ratio and increased caspase-3 activity; all of which were factors that are associated with apoptosis. Pretreatment of cells with γ-mangostin at concentrations of 0.5, 1, and 2.5μM markedly increased cell survival and reduced the level of intracellular ROS formation as shown by DPPH radical scavenging activity of the compound. Furthermore, a significant suppression of p-p38, improved Bax/Bcl-2 ratio expression, and reduced caspase-3 activity was exhibited in the cells after γ-mangostin pretreatment. The reduction of apoptosis was further supported by the reduction of pyknotic nuclei indicated by Hoescht 33342 staining. These findings indicate that γ-mangostin could attenuate 6-OHDA-induced neuronal cell death and that the protective effect of γ-mangostin is associated with its antioxidative potential and through the modulation of the apoptotic signalling pathway. Therefore, γ-mangostin may be an effective xanthone among other mangostins for preventing neurodegeneration in PD caused by oxidative stress.

Optimization of Adhesive Pastes for Dental Caries Prevention

Dental caries prevention products available on the market contain only remineralizing agents or antibacterial agents. This study aimed to develop adhesive pastes containing calcium phosphate and α-mangostin for dental caries prevention using the optimization technique. Calcium phosphate was used as a remineralizing agent, and extracted α-mangostin was used as an antibacterial agent. The effect of the independent variables, which were fumed silica, Eudragit^® EPO, polyethylene glycol, and ethyl alcohol, on the responses was investigated. The drying time, erosion rate, calcium release rate, and α-mangostin release rate were established as the measured responses. An equation and a model of the relationship were constructed. An optimal formulation was obtained, and its effect on dental caries prevention was investigated using the pH-cycling model. The quadratic equation revealed that the drying time, calcium release rate, and α-mangostin release rate tended to decrease when increasing the fumed silica and decreasing other factors. The erosion rate tended to increase when decreasing Eudragit^® EPO and increasing other factors. The observed responses of the optimal adhesive pastes were not significantly different from the predicted responses. This result demonstrated that optimization is an efficient technique in the formulation development of the adhesive pastes. In addition, the optimal adhesive pastes could enhance acid resistance activity to the tooth enamel.

Alpha-mangostin inhibits both dengue virus production and cytokine/chemokine expression

Since severe dengue virus (DENV) infection in humans associates with both high viral load and massive cytokine production - referred to as "cytokine storm", an ideal drug for treatment of DENV infection should efficiently inhibit both virus production and cytokine expression. In searching for such an ideal drug, we discovered that α-mangostin (α-MG), a major bioactive compound purified from the pericarp of the mangosteen fruit (Garcinia mangostana Linn), which has been used in traditional medicine for several conditions including trauma, diarrhea, wound infection, pain, fever, and convulsion, inhibits both DENV production in cultured hepatocellular carcinoma HepG2 and Huh-7 cells, and cytokine/chemokine expression in HepG2 cells. α-MG could also efficiently inhibit all four serotypes of DENV. Treatment of DENV-infected cells with α-MG (20μM) significantly reduced the infection rates of four DENV serotypes by 47-55%. α-MG completely inhibited production of DENV-1 and DENV-3, and markedly reduced production of DENV-2 and DENV-4 by 100 folds. Furthermore, it could markedly reduce cytokine (IL-6 and TNF-α) and chemokine (RANTES, MIP-1β, and IP-10) transcription. These actions of α-MG are more potent than those of antiviral agent (ribavirin) and anti-inflammatory drug (dexamethasone). Thus, α-MG is potential to be further developed as therapeutic agent for DENV infection.

Medicinal properties of mangosteen (Garcinia mangostana L.): A comprehensive update

Garcinia mangostana L. (Clusiaceae) is a tropical tree native to Southeast Asia known as mangosteen which fruits possess a distinctive and pleasant taste that has granted them the epithet of "queen of the fruits". The seeds and pericarps of the fruit have a long history of use in the traditional medicinal practices of the region, and beverages containing mangosteen pulp and pericarps are sold worldwide as nutritional supplements. The main phytochemicals present in the species are isoprenylated xanthones, a class of secondary metabolites with multiple reports of biological effects, such as antioxidant, pro-apoptotic, anti-proliferative, antinociceptive, anti-inflammatory, neuroprotective, hypoglycemic and anti-obesity. The diversity of actions displayed by mangosteen xanthones shows that these compounds target multiple signaling pathways involved in different pathologies, and place them as valuable sources for developing new drugs to treat chronic and degenerative diseases. This review article presents a comprehensive update of the toxicological findings on animal models, and the preclinical anticancer, analgesic, neuroprotective, antidiabetic and hypolipidemic effects of G. mangostana L. extracts and its main isolates. Pharmacokinetics, drug delivery systems and reports on dose-finding human trials are also examined.

Current trends of tropical fruit waste utilization

Recent rapid growth of the world's population has increased food demands. This phenomenon poses a great challenge for food manufacturers in maximizing the existing food or plant resources. Nowadays, the recovery of health benefit bioactive compounds from fruit wastes is a research trend not only to help minimize the waste burden, but also to meet the intensive demand from the public for phenolic compounds which are believed to have protective effects against chronic diseases. This review is focused on polyphenolic compounds recovery from tropical fruit wastes and its current trend of utilization. The tropical fruit wastes include in discussion are durian (Durio zibethinus), mangosteen (Garcinia mangostana L.), rambutan (Nephelium lappaceum), mango (Mangifera indica L.), jackfruit (Artocarpus heterophyllus), papaya (Carica papaya), passion fruit (Passiflora edulis), dragon fruit (Hylocereus spp), and pineapple (Ananas comosus). Highlights of bioactive compounds in different parts of a tropical fruit are targeted primarily for food industries as pragmatic references to create novel innovative health enhancement food products. This information is intended to inspire further research ideas in areas that are still under-explored and for food processing manufacturers who would like to minimize wastes as the norm of present day industry (design) objective.

Synergism and the mechanism of action of the combination of α-mangostin isolated from Garcinia mangostana L. and oxacillin against an oxacillin-resistant Staphylococcus saprophyticus

Background

Globally, staphylococci have developed resistance to many antibiotics. New approaches to chemotherapy are needed and one such approach could be to use plant derived actives with conventional antibiotics in a synergestic way. The purpose of this study was to isolate α-mangostin from the mangosteen (Garcinia mangostana L.; GML) and investigate antibacterial activity and mechanisms of action when used singly and when combined with oxacillin against oxacillin-resistant Staphylococcus saprophyticus (ORSS) strains. The isolated α-mangostin was confirmed by HPLC chromatogram and NMR spectroscopy. The minimum inhibitory concentration (MIC), checkerboard and killing curve were determined. The modes of action of these compounds were also investigated by enzyme assay, transmission electron microscopy (TEM), confocal microscopic images, and cytoplasmic membrane (CM) permeabilization studies.

Results

The MICs of isolated α-mangostin and oxacillin against these strains were 8 and 128 μg/ml, respectively. Checkerboard assays showed the synergistic activity of isolated α-mangostin (2 μg/ml) plus oxacillin (16 μg/ml) at a fractional inhibitory concentration index (FICI) of 0.37. The kill curve assay confirmed that the viability of oxacillin-resistant Staphylococcus saprophyticus DMST 27055 (ORSS-27055) was dramatically reduced after exposure to isolated α-mangostin (2 μg/ml) plus oxacillin (16 μg/ml). Enzyme assays demonstrated that isolated α-mangostin had an inhibitory activity against β-lactamase in a dose-dependent manner. TEM results clearly showed that these ORSS-27055 cells treated with this combination caused peptidoglycan and cytoplasmic membrane damage, irregular cell shapes and average cell areas were significantly larger than the control. Clearly, confocal microscopic images confirmed that this combination caused considerable peptidoglycan damage and DNA leakage. In addition, the CM permeability of ORSS-27055 was also increased by this combination of actives.

Conclusions

These findings provide evidence that isolated α-mangostin alone has not only some activity but also shows the synergistic activity with oxacillin against ORSS-27055. The chromone and isoprenyl structures could play a significant role in its action. This synergistic activity may involve three mechanisms of action. Firstly, potential effects of cytoplasmic membrane disruption and increases permeability. Secondly, inhibit β-lactamase activity. Finally, also damage to the peptidoglycan structure. We proposes the potential to develop a novel adjunct phytopharmaceutical to oxacillin for the treatment of ORSS. Future studies require clinical trials to establish if the synergy reported can be translated to animals and humans.

Hypoglycaemic activity of ethanolic extract of Garcinia mangostana Linn. in normoglycaemic and streptozotocin-induced diabetic rats

Background

Various parts of Garcinia mangostana Linn., including its pericarp, have been traditionally used to treat a variety of ailments. In an attempt to establish its medicinal value, the present study was carried out to determine the hypoglycaemic potential of G. mangostana pericarp ethanolic extract (GME) using the streptozotocin-induced (STZ) diabetic rats.

Methods

GME at 2,000 mg/kg was subjected to a single-dose acute toxicity test. Following this, the effect of GME (50, 100, and 200 mg/kg) on blood glucose level of normoglycaemic and STZ-induced diabetic rats was determined using single-dose (acute) and multiple-dose (subacute) approaches. Subsequent to the multiple-dose study, serum biochemical analysis and liver histopathological examination were also performed. Throughout the experiments, the effect of GME was compared against the standard hypoglycaemic drug, glibenclamide.

Results

GME was safe for oral consumption up to the dose of 2,000 mg/kg. In both single- and multiple-dose studies, GME significantly (p < 0.05) reduced the blood glucose level in normoglycaemic rats and STZ-induced diabetic rats when compared against the normal control group or diabetic control group, respectively. Moreover, GME also significantly (p < 0.05) increased the rats’ body weight in comparison to the diabetic control group in the multiple-dose study. GME also significantly (p < 0.05) reduced the levels of certain biochemical parameters [i.e., triglycerides (TG), total cholesterol (TC), low density lipoprotein (LDL), very low density lipoprotein (VLDL), serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), urea, and creatinine] while increased the others [i.e., high density lipoprotein (HDL) and total protein (TP)] when compared to the diabetic control group. Histopathological assessment of the collected liver revealed a mild increase in the population of β-cells in the diabetic rats.

Conclusion

GME exerts the hypoglycaemic activity possibly by increasing the population of insulin-producing β-cells. This activity could be attributed to the presence of antioxidant-bearing tannins like epicathecin, and xanthones like α-mangostin. Thus, the findings demonstrated that GME could be a potential candidate in the management of diabetes owing to its hypoglycaemic effect.

DNA Protection against Oxidative Damage Using the Hydroalcoholic Extract of Garcinia mangostana and Alpha-Mangostin

Garcinia mangostana, popularly known as “mangosteen fruit,” originates from Southeast Asia and came to Brazil about 80 years ago where it mainly grows in the states of Pará and Bahia. Although mangosteen or its extracts have been used for ages in Asian folk medicine, data on its potential genotoxicity is missing. We, therefore, evaluated genotoxicity/mutagenicity of hydroethanolic mangosteen extract [HEGM, 10 to 640 μg/mL] in established test assays (Comet assay, micronucleus test, and Salmonella/microsome test). In the Comet assay, HEGM-exposed human leukocytes showed no DNA damage. No significant HEGM-induced mutation in TA98 and TA100 strains of Salmonella typhimurium (with or without metabolic activation) was observed and HEGM-exposed human lymphocytes had no increase of micronuclei. However, HEGM suggested exposure concentration-dependent antigenotoxic potential in leukocytes and antioxidant potential in the yeast Saccharomyces cerevisiae. HEGM preloading effectively protected against H₂O₂-induced DNA damage in leukocytes (Comet assay). Preloading of yeast with HEGM for up to 4 h significantly protected the cells from lethality of chronic H₂O₂-exposure, as expressed in better survival. Absence of genotoxicity and demonstration of an antigenotoxic and antioxidant potential suggest that HEGM or some substances contained in it may hold promise for pharmaceutical or nutraceutical application.

c-Jun N-terminal kinase-mediated anti-inflammatory effects of Garcinia subelliptica in macrophages

Garcinia plants have been traditionally used to treat inflammatory diseases, such as skin infections and pain, in many regions including South‑East Asia. Garcinia subelliptica, a plant of the Garcinia species widely distributed from Japan to Thailand, has been reported to contain components similar to other Garcinia plants that exhibit anti‑inflammatory effects. The present study aimed to explore the anti‑inflammatory effects of ethanol extracts of Garcinia subelliptica (EGS) in macrophages, as there are no previous systemic studies that have investigated the effects of Garcinia subelliptica on inflammation. Non‑cytotoxic concentrations of EGS (≤200 µg/ml) were observed to reduce nitric oxide production by modulating iNOS expression in lipopolysaccharide (LPS)‑stimulated RAW 264.7 macrophages. The expression of cyclooxygenase‑2, the enzyme responsible for the production of prostaglandin E2, was notably reduced by EGS. EGS treatment inhibited the production of pro‑inflammatory cytokines, including IL‑6 and IL‑1β, however, not TNF‑α. Reduced production of inflammatory mediators by EGS was followed by reduced phosphorylation of c‑Jun N‑terminal kinase (JNK) however, not of other mitogen‑activated protein kinases and nuclear factor‑κB. These results indicate that EGS selectively inhibits the excessive production of inflammatory mediators in LPS‑stimulated murine macrophages by reducing the activation of JNK, suggesting that EGS is a candidate for modulating severe inflammation.

α-Mangostin Regulates Hepatic Steatosis and Obesity through SirT1-AMPK and PPARγ Pathways in High-Fat Diet-Induced Obese Mice

Previous studies have shown that α-mangostin (α-MG) suppresses intracellular fat accumulation and stimulation of lipolysis in in vitro systems. Together with the relatively high distribution of α-MG in liver and fat, these observations made it possible to propose a plausible hypothesis that an α-MG supplement may regulate hepatic steatosis and obesity. An α-MG supplement (50 mg/kg) reduced the body weight gain (13.8%) and epidymal and retroperitoneal fat mass accumulation (15.0 and 11.3%, respectively), as well as the biochemical serum profiles such as cholesterol [TC (26.9%), LDL-C (39.1%), and HDL-C (15.3%)], glucose (30.2%), triglyceride (29.7%), and fatty acid (30.3%) levels in high-fat fed mice compared with the high-fat diet-treated group, indicating that α-MG may regulate lipid metabolism. In addition, an α-MG supplement up-regulated hepatic AMPK, SirT1, and PPARγ levels compared with the high-fat diet states, suggesting that α-MG regulates hepatic steatosis and obesity through the SirT1-AMPK and PPARγ pathways in high-fat diet-induced obese mice.

Dose-Independent ADME Properties and Tentative Identification of Metabolites of α-Mangostin from Garcinia mangostana in Mice by Automated Microsampling and UPLC-MS/MS Methods

The information about a marker compound's pharmacokinetics in herbal products including the characteristics of absorption, distribution, metabolism, excretion (ADME) is closely related to the efficacy/toxicity. Also dose range and administration route are critical factors to determine the ADME profiles. Since the supply of a sufficient amount of a marker compound in in vivo study is still difficult, pharmacokinetic investigations which overcome the limit of blood collection in mice are desirable. Thus, we have attempted to investigate concurrently the ADME and proposed metabolite identification of α-mangostin, a major constituent of mangosteen, Garcinia mangostana L, in mice with a wide dose range using an in vitro as well as in vivo automated micro-sampling system together. α-mangostin showed dose-proportional pharmacokinetics at intravenous doses of 5–20 mg/kg and oral doses of 10–100 mg/kg. The gastrointestinal absorption of α-mangostin was poor and the distribution of α-mangostin was relatively high in the liver, intestine, kidney, fat, and lung. α-mangostin was extensively metabolized in the liver and intestine. With regards to the formation of metabolites, the glucuronidated, bis-glucuronidated, dehydrogenated, hydrogenated, oxidized, and methylated α-mangostins were tentatively identified. We suggest that these dose-independent pharmacokinetic characteristics of α-mangostin in mice provide an important basis for preclinical applications of α-mangostin as well as mangosteen. In addition, these experimental methods can be applied to evaluate the pharmacokinetics of natural products in mice.

Mechanisms of α-Mangostin-Induced Antinociception in a Rodent Model

Objective:

Elucidate the antinociceptive mechanisms of α-mangostin isolated from Garcinia malaccensis Linn.

Methods:

Male mice/rats ( n = 6/group) were used in this between-group study. To determine α-mangostin’s antinociceptive profile, animals were given α-mangostin orally (3, 30, or 100 mg/kg) 60 min before the start of the abdominal constriction or formalin tests. In the hot plate test, the noxious stimulus was applied before and 60, 90, 120, 150, 180, and 210 min after treatment with test solutions. Positive controls received 100 mg/kg acetylsalicylic acid (ASA; oral) or 5 mg/kg morphine (intraperitoneal injection) for the abdominal constriction and hot plate tests, respectively, and either ASA or morphine for the formalin test. Negative controls received vehicle only. To explore α-mangostin’s mechanisms of action, we performed (i) the hot plate test with naloxone (5 mg/kg) pretreatment to verify involvement of opioid receptors; (ii) the abdominal constriction test with 20 mg/kg l-arginine, NG-nitro-l-arginine methyl esters (l-NAME), methylene blue (MB), l-arginine plus l-NAME, or l-arginine plus MB or 10 mg/kg glibenclamide pretreatment to verify involvement of the l-arginine/nitric oxide (NO)/cyclic guanosine monophosphate (cGMP) and K+-ATP pathways; and (iii) the paw-licking test using capsaicin (1.6 μg capsaicin/paw), glutamate (10 μmol glutamate/paw), or phorbol 12-myristate 13-acetate (PMA; 0.05 µg/paw) to verify involvement of vanilloid receptors, the glutamatergic system, and protein kinase C (PKC).

Results:

α-mangostin significantly inhibited nociception ( p < .05) in all models. Only naloxone, l-arginine, methylene blue, PMA, and glibenclamide affected α-mangostin antinociception significantly ( p < .05).

Conclusion:

α-mangostin exhibits peripheral and central antinociception through modulation of opioid and vanilloid receptors, the glutamatergic system, and the l-arginine/NO/cGMP/PKC/K+-ATP pathways.

Comparison of the biological activity of two different isolates from mangosteen

OBJECTIVE

Mangosteen has been used in traditional medicine for treatment of many diseases. Recent studies have reported the active constituents isolated from this plant. In this study, purified α-mangostin, a major component and partially purified water-soluble fraction found in fruit pericarps, was carefully isolated, and their biological activity was compared, i.e. antioxidative activity and cytotoxic effect in breast cancer cells: SKBR3.

METHODS

Antioxidative activity was determined using the 1,1-diphenyl-2-picrylhydrazyl radicals (DPPH) assay and reactive oxygen species (ROS) assay, whereas the cytotoxic effect was evaluated by the MTT assay and morphological changes by fluorescence staining.

KEY FINDING

The DPPH scavenging capacities of α-mangostin and water-soluble extract were obtained, the IC50 at 183.95 and 54.57 μg/ml, respectively. Meanwhile, the intracellular ROS level was significantly decreased after treatment with α-mangostin and water-soluble extraction at 20 and 200 μg/ml, respectively. α-mangostin exhibited the cytotoxicity at ED50 8.21 μg/ml, while the water-soluble extract was non-toxic to cells at ED50 higher than 160 μg/ml. Both constituents showed antioxidative activity by chemical assay and in cells, but α-mangostin expressed strong cytotoxicity and showed apoptotic bodies.

CONCLUSION

The different isolated constituents would be further studied for future possible use as chemotherapy in cancer and chemoprevention in Alzheimer's disease.