1
|
Stevenson JC, Collins P, Hodis HN. Hormone replacement therapy after myocardial infarction: British Menopause Society Tool for Clinicians. Post Reprod Health 2024; 30:117-119. [PMID: 38803163 DOI: 10.1177/20533691241252300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Affiliation(s)
- John C Stevenson
- National Heart & Lung Institute, Imperial College London, Royal Brompton Hospital, London, UK
| | - Peter Collins
- National Heart & Lung Institute, Imperial College London, Royal Brompton Hospital, London, UK
| | - Howard N Hodis
- Atherosclerosis Research Unit, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
2
|
Ruamyod K, Watanapa WB, Shayakul C. Testosterone rapidly increases Ca 2+-activated K + currents causing hyperpolarization in human coronary artery endothelial cells. J Steroid Biochem Mol Biol 2017; 168:118-126. [PMID: 28223151 DOI: 10.1016/j.jsbmb.2017.02.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 02/14/2017] [Accepted: 02/17/2017] [Indexed: 12/20/2022]
Abstract
Testosterone has endothelium-dependent vasodilatory effects on the coronary artery, with some reports suggesting endothelial ion channel involvement. This study employed the whole-cell patch clamp technique to investigate the effect of testosterone on ion channels in human coronary artery endothelial cells (HCAECs) and the mechanisms involved. We found that 0.03-3μM testosterone significantly induced a rapid, concentration-dependent increase in total HCAEC current (EC50, 71.96±1.66nM; maximum increase, 59.13±8.37%; mean±SEM). The testosterone-enhanced currents consisted of small- and large-conductance Ca2+-activated K+ currents (SKCa and BKCa currents), but not Cl- and nonselective cation currents. Either a non-permeant testosterone conjugate or the non-aromatizable androgen dihydrotestosterone (DHT) could increase HCAEC currents as well. The androgen receptor antagonist flutamide prevented this testosterone, testosterone conjugate, and DHT effect, while the estrogen receptor antagonist fulvestrant did not. Incubating HCAECs with pertussis toxin or protein kinase A inhibitor H-89 largely inhibited the testosterone effect, while pre-incubation with phospholipase C inhibitor U-73122, prostacyclin inhibitor indomethacin, nitric oxide synthase inhibitor L-NAME or cytochrome P450 inhibitor MS-PPOH, did not. Finally, testosterone application induced HCAEC hyperpolarization within minutes; this effect was prevented by SKCa and BKCa current inhibitors apamin and iberiotoxin. This is the first electrophysiological demonstration of androgen-induced KCa current increase, leading to hyperpolarization, in any endothelial cell, and the first report of SKCa as a testosterone target. Our data show that testosterone rapidly increased whole-cell HCAEC SKCa and BKCa currents via a surface androgen receptor, Gi/o protein, and protein kinase A. This mechanism may explain rapid testosterone-induced coronary vasodilation seen in vivo.
Collapse
Affiliation(s)
- Katesirin Ruamyod
- Department of Physiology Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand.
| | - Wattana B Watanapa
- Department of Physiology Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand.
| | - Chairat Shayakul
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand.
| |
Collapse
|
3
|
Pavón N, Cabrera-Orefice A, Gallardo-Pérez JC, Uribe-Alvarez C, Rivero-Segura NA, Vazquez-Martínez ER, Cerbón M, Martínez-Abundis E, Torres-Narvaez JC, Martínez-Memije R, Roldán-Gómez FJ, Uribe-Carvajal S. In female rat heart mitochondria, oophorectomy results in loss of oxidative phosphorylation. J Endocrinol 2017; 232:221-235. [PMID: 27872198 DOI: 10.1530/joe-16-0161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 11/21/2016] [Indexed: 01/13/2023]
Abstract
Oophorectomy in adult rats affected cardiac mitochondrial function. Progression of mitochondrial alterations was assessed at one, two and three months after surgery: at one month, very slight changes were observed, which increased at two and three months. Gradual effects included decrease in the rates of oxygen consumption and in respiratory uncoupling in the presence of complex I substrates, as well as compromised Ca2+ buffering ability. Malondialdehyde concentration increased, whereas the ROS-detoxifying enzyme Mn2+ superoxide dismutase (MnSOD) and aconitase lost activity. In the mitochondrial respiratory chain, the concentration and activity of complex I and complex IV decreased. Among other mitochondrial enzymes and transporters, adenine nucleotide carrier and glutaminase decreased. 2-Oxoglutarate dehydrogenase and pyruvate dehydrogenase also decreased. Data strongly suggest that in the female rat heart, estrogen depletion leads to progressive, severe mitochondrial dysfunction.
Collapse
Affiliation(s)
- Natalia Pavón
- Departamento de FarmacologíaInstituto Nacional de Cardiología Ignacio Chávez, México, Mexico
| | - Alfredo Cabrera-Orefice
- Departamento de Genética MolecularInstituto de Fisiología Celular, Universidad Nacional Autónoma de México, México D.F., Mexico
| | | | - Cristina Uribe-Alvarez
- Departamento de Genética MolecularInstituto de Fisiología Celular, Universidad Nacional Autónoma de México, México D.F., Mexico
| | - Nadia A Rivero-Segura
- Unidad de Investigación en Reproducción HumanaInstituto Nacional de Perinatología-Facultad de Química UNAM, México D.F., Mexico
| | - Edgar Ricardo Vazquez-Martínez
- Unidad de Investigación en Reproducción HumanaInstituto Nacional de Perinatología-Facultad de Química UNAM, México D.F., Mexico
| | - Marco Cerbón
- Unidad de Investigación en Reproducción HumanaInstituto Nacional de Perinatología-Facultad de Química UNAM, México D.F., Mexico
| | - Eduardo Martínez-Abundis
- División Académica Multidisciplinaria de ComalcalcoUniversidad Juárez Autónoma de Tabasco, México, Mexico
| | | | - Raúl Martínez-Memije
- Departamento de Instrumentación ElectromecánicaInstituto Nacional de Cardiología Ignacio Chávez, Tlalpan DF, México, Mexico
| | | | - Salvador Uribe-Carvajal
- Departamento de Genética MolecularInstituto de Fisiología Celular, Universidad Nacional Autónoma de México, México D.F., Mexico
| |
Collapse
|
4
|
Souza NS, Dos-Santos RC, Silveira ALBD, R SC, Gantus MAV, Fortes FS, Olivares EL. Effects of autonomic balance and fluid and electrolyte changes on cardiac function in infarcted rats: A serial study of sexual dimorphism. Clin Exp Pharmacol Physiol 2016; 43:476-83. [DOI: 10.1111/1440-1681.12543] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 10/29/2015] [Accepted: 01/05/2016] [Indexed: 11/29/2022]
Affiliation(s)
- NS Souza
- Multicentre Graduate Program in Physiological Sciences; Department of Physiological Sciences; Institute of Biological and Health Sciences; Federal Rural University of Rio de Janeiro; Seropédica Brazil
| | - RC Dos-Santos
- Graduate Program in Physiological Sciences; Department of Physiological Sciences; Institute of Biological and Health Sciences; Federal Rural University of Rio de Janeiro; Seropédica Brazil
| | - Anderson Luiz Bezerra da Silveira
- Multicentre Graduate Program in Physiological Sciences; Department of Physiological Sciences; Institute of Biological and Health Sciences; Federal Rural University of Rio de Janeiro; Seropédica Brazil
| | - Sonoda-Côrtes R
- Multicentre Graduate Program in Physiological Sciences; Department of Physiological Sciences; Institute of Biological and Health Sciences; Federal Rural University of Rio de Janeiro; Seropédica Brazil
| | - Michel Alexandre Villani Gantus
- Therapy and Cellular and Molecular Physiology Laboratory; Centre for Biological and Health Sciences; West Zone State University Centre; Rio de Janeiro Brazil
| | - FS Fortes
- Graduate Program in Physiological Sciences; Department of Physiological Sciences; Institute of Biological and Health Sciences; Federal Rural University of Rio de Janeiro; Seropédica Brazil
- Therapy and Cellular and Molecular Physiology Laboratory; Centre for Biological and Health Sciences; West Zone State University Centre; Rio de Janeiro Brazil
| | - Emerson Lopes Olivares
- Multicentre Graduate Program in Physiological Sciences; Department of Physiological Sciences; Institute of Biological and Health Sciences; Federal Rural University of Rio de Janeiro; Seropédica Brazil
- Graduate Program in Physiological Sciences; Department of Physiological Sciences; Institute of Biological and Health Sciences; Federal Rural University of Rio de Janeiro; Seropédica Brazil
| |
Collapse
|
5
|
Efectos del estradiol-drospirenona o estradiol-trimegestona sobre los lípidos y lipoproteínas en menopáusicas. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2011. [DOI: 10.1016/j.gine.2009.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
6
|
Zoth N, Weigt C, Laudenbach-Leschowski U, Diel P. Physical activity and estrogen treatment reduce visceral body fat and serum levels of leptin in an additive manner in a diet induced animal model of obesity. J Steroid Biochem Mol Biol 2010; 122:100-5. [PMID: 20298783 DOI: 10.1016/j.jsbmb.2010.03.029] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 03/07/2010] [Accepted: 03/08/2010] [Indexed: 10/19/2022]
Abstract
Estrogen replacement and physical activity have been demonstrated to reduce the risk to develop a metabolic syndrome in postmenopausal women. In this study we investigate the combined effects of endurance training and estrogen substitution in a rat animal model of diet induced obesity. Effects on lipid and glucose metabolism were evaluated. Ovariectomized (OVX) or sham-operated (SHAM) female Wistar rats were fed with a high fat diet (HF) for 9 weeks. After 3 weeks of overnutrition the OVX rats either remained sedentary, performed treadmill training, received 17β-Estradiol (E(2)), or combined treatment. The OVX rats had a greater increase in body weight and serum levels of cholesterol, triglyceride and low-density lipoprotein cholesterol (LDL). These parameters could be reduced by E(2) and more effectively E(2) in combination with exercise. Also the increase of visceral body fat and leptin could be improved by E(2) and exercise. This combination showed synergistic effects. Serum levels of insulin could be reduced by exercise training, E(2) substitution revealed no significant changes. Our results indicate that ovariectomy increases the susceptibility to develop obesity. In addition they show that the combination of hormone replacement therapy (HRT) and physical activity may influence parameters related to lipid metabolism positively in an additive manner. The results of this study provide evidence that the combination of HRT with physical activity could be a very effective strategy to prevent the development of a metabolic syndrome induced by overnutrition.
Collapse
Affiliation(s)
- Nora Zoth
- Department of Cellular and Molecular Sports Medicine, Institute of Cardiovascular Research and Sports Medicine, German Sports University, Cologne, Germany.
| | | | | | | |
Collapse
|
7
|
Herrera-Villalobos O, Luz-Araujo H, Guerra-Velásquez M, Reyna-Villasmil E, Mejía Montilla J, Reyna-Villasmil N, Torres-Cepeda D, Santos-Bolívar J. Perfil lipídico en pacientes menopáusicas tratadas con estradiol-acetato de noretisterona oral o estradiol transdérmico. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2009. [DOI: 10.1016/j.gine.2008.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
8
|
Yang SH, Sarkar SN, Liu R, Perez EJ, Wang X, Wen Y, Yan LJ, Simpkins JW. Estrogen receptor beta as a mitochondrial vulnerability factor. J Biol Chem 2009; 284:9540-8. [PMID: 19189968 PMCID: PMC2666606 DOI: 10.1074/jbc.m808246200] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Indexed: 12/19/2022] Open
Abstract
We recently demonstrated mitochondrial localization of estrogen receptor beta (ERbeta). We herein confirm the mitochondrial localization of ERbeta by the loss of mitochondrial ERbeta immunoreactivity in ERbeta knockdown cells. A phenotype change characterized as an increase in resistance to oxidative stressors is associated with ERbeta knockdown. ERbeta knockdown results in a lower resting mitochondrial membrane potential (Deltapsim) and increase in resistance to hydrogen peroxide-induced Deltapsim depolarization in both immortal hippocampal cells and primary hippocampal neurons. ERbeta knockdown cells maintained ATP concentrations despite insults that compromise ATP production and produce less mitochondrial superoxide under oxidative stress. Furthermore, similar mitochondrial phenotype changes were identified in primary hippocampal neurons derived from ERbeta knock-out mice. These data demonstrate that ERbeta is expressed in mitochondria and function as a mitochondrial vulnerability factor involved in Deltapsim maintenance, potentially through a mitochondrial transcription dependent mechanism.
Collapse
Affiliation(s)
- Shao-Hua Yang
- Department of Pharmacology and Neuroscience, Institute for Aging and Alzheimer's Disease Research, University of North Texas Health Science Center, Fort Worth, Texas 76107, USA.
| | | | | | | | | | | | | | | |
Collapse
|
9
|
|
10
|
Stice JP, Eiserich JP, Knowlton AA. Role of aging versus the loss of estrogens in the reduction in vascular function in female rats. Endocrinology 2009; 150:212-9. [PMID: 18787021 PMCID: PMC2630896 DOI: 10.1210/en.2008-0640] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Although aging is known to lead to increased vascular stiffness, the role of estrogens in the prevention of age-related changes in the vasculature remains to be elucidated. To address this, we measured vascular function in the thoracic aorta in adult and old ovariectomized (ovx) rats with and without immediate 17beta-estradiol (E2) replacement. In addition, aortic mRNA and protein were analyzed for proteins known to be involved in vasorelaxation. Aging in combination with the loss of estrogens led to decreased vasorelaxation in response to acetylcholine and sodium nitroprusside, indicating either smooth muscle dysfunction and/or increased fibrosis. Loss of estrogens led to increased vascular tension in response to phenylephrine, which could be partially restored by E2 replacement. Levels of endothelial nitric oxide synthase and inducible nitric oxide synthase did not differ among the groups, nor did total nitrite plus nitrate levels. Old ovx exhibited decreased expression of both the alpha and beta-subunits of soluble guanylyl cyclase (sGC) and had impaired nitric oxide signaling in the vascular smooth muscle. Immediate E2 replacement in the aged ovx prevented both the impairment in vasorelaxation, and the decreased sGC receptor expression and abnormal sGC signaling within the vascular smooth muscle.
Collapse
Affiliation(s)
- James P Stice
- Molecular and Cellular Cardiology, Cardiovascular Division, Department of Medicine, University of California, Davis, One Shields Avenue, Davis, California 95616, USA
| | | | | |
Collapse
|
11
|
Pharmacodynamic evaluation of oral estradiol nanoparticles in estrogen deficient (ovariectomized) high-fat diet induced hyperlipidemic rat model. Pharm Res 2008; 26:218-23. [PMID: 18787933 DOI: 10.1007/s11095-008-9725-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Accepted: 09/02/2008] [Indexed: 01/29/2023]
Abstract
PURPOSE It is believed that estrogen deficiency contributes importantly to the pathogenesis of menopausal metabolic syndrome and symptoms can be ameliorated with estradiol therapy. The present study reports efficacy of 17-beta estradiol encapsulated nanoparticles in treating the postmenopausal dyslipidemic condition. MATERIALS AND METHODS Estradiol encapsulated poly(lactide-co-glycolide) (PLGA) nanoparticles were prepared by emulsion-diffusion-evaporation method and evaluated in estrogen deficient (ovariectomized) high fat diet induced hyperlipidemic rat model. RESULTS The results obtained showed that estradiol nanoparticles were equally/more effective in treatment of estrogen deficient hyperlipidemic conditions at three times reduced dose and frequency in comparison to that of drug suspension administered orally. CONCLUSION Together, these results demonstrate the ability of nanoparticles in improving oral bioavailability/efficacy of estradiol.
Collapse
|
12
|
Simpkins JW, Yang SH, Sarkar SN, Pearce V. Estrogen actions on mitochondria--physiological and pathological implications. Mol Cell Endocrinol 2008; 290:51-9. [PMID: 18571833 PMCID: PMC2737506 DOI: 10.1016/j.mce.2008.04.013] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 04/08/2008] [Accepted: 04/10/2008] [Indexed: 02/07/2023]
Abstract
Estrogens are potent neuroprotective hormones and mitochondria are the site of cellular life-death decisions. As such, it is not surprising that we and others have shown that estrogens have remarkable effects on mitochondrial function. Herein we provide evidence for a primary effect of estrogens on mitochondrial function, achieved in part by the import of estrogen receptor beta (ERbeta) into the mitochondria where it mediates a number of estrogen actions on this vital organelle. ERbeta is imported into the mitochondria, through tethering to cytosolic chaperone protein and/or through direct interaction with mitochondrial import proteins. In the mitochondria, ERbeta can affect transcription of critical mitochondrial genes through the interaction with estrogen response elements (ERE) or through protein-protein interactions with mitochondrially imported transcription factors. The potent effects of estrogens on mitochondrial function, particularly during mitochondrial stress, argues for a role of estrogens in the treatment of mitochondrial defects in chronic neurodegenerative diseases like Alzheimer's disease (AD) and Parkinson's disease (PD) and more acute conditions of mitochondrial compromise, like cerebral ischemia and traumatic brain injury.
Collapse
Affiliation(s)
- James W Simpkins
- Department of Pharmacology & Neuroscience, Institute for Aging and Alzheimer's Disease Research, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX 76107, USA.
| | | | | | | |
Collapse
|
13
|
Ho KJ, Liao JK. Non-nuclear actions of estrogen: new targets for prevention and treatment of cardiovascular disease. Mol Interv 2008; 2:219-28. [PMID: 14993393 PMCID: PMC2633129 DOI: 10.1124/mi.2.4.219] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Gender-based differences in the incidence of hypertensive and coronary artery disease, the development of atherosclerosis, and myocardial remodeling after infarction are attributable to the indirect effect of estrogen on risk factor profiles, such as cholesterol levels, glucose metabolism, and insulin levels. More recent evidence, however, suggests that activated estrogen receptor (ER) mediates signaling cascades that culminate in direct protective effects such as vasodilation, inhibition of response to vessel injury, limiting myocardial injury after infarction, and attenuating cardiac hypertrophy. Although the ER is usually thought of as a ligand-dependent transcription factor, it can also rapidly mobilize signals at the plasma membrane and in the cytoplasm. Thus, a greater understanding of ER function and regulation may lead to the development of highly specific therapeutics that mediate the prevention and treatment of cardiovascular diseases.
Collapse
Affiliation(s)
- Karen J Ho
- The Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Cambridge, MA 02139, USA
| | | |
Collapse
|
14
|
Genistein potentiates protein kinase A activity in porcine coronary artery. Mol Cell Biochem 2007; 311:37-44. [PMID: 18165926 DOI: 10.1007/s11010-007-9691-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2007] [Accepted: 12/16/2007] [Indexed: 10/22/2022]
Abstract
Soy consumption is associated with a lower risk of atherosclerotic disease in the oriental population. Genistein is a soy isoflavone bearing estrogenic properties. Previous experiments in our laboratory demonstrated the potentiation of endothelium-independent relaxation of coronary artery by both estrogen and genistein. The potentiating effects of both estrogen and genistein were mediated through the cAMP-signaling pathway. We hypothesize that genistein could enhance protein kinase A (PKA) activity in porcine coronary artery smooth muscle, thereby offering a mechanism for the potentiation of vascular relaxation by genistein. In our study, a high concentration of genistein (10(-4.5) M) significantly increased PKA activity in porcine coronary artery rings. While genistein at 10(-5.5) M and forskolin at 10(-7) M had no effect on PKA activity, the combination of the two compounds at the prescribed concentrations caused a significant increase in PKA activity. The increase in PKA activity by genistein was abolished by SQ 22536 (adenylate cyclase blocker), but not by NF 449 (Gs protein blocker) or ICI 182780 (estrogen receptor antagonist). Our results suggest that the action of genistein is mediated via adenylate cyclase, but does not appear to involve Gs protein or ICI 182780-sensitive estrogen receptor.
Collapse
|
15
|
Assessment of hypercoagulability markers and lipid levels in postmenopausal women undergoing either oral or transdermal hormone replacement therapy. J Thromb Thrombolysis 2007; 27:135-40. [DOI: 10.1007/s11239-007-0169-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Accepted: 10/30/2007] [Indexed: 10/22/2022]
|
16
|
Abstract
Observational studies have consistently shown a benefit of hormone replacement therapy (HRT) on coronary heart disease (CHD), but some randomised studies have not shown any significant effect. Thus questions still remains as to whether HRT is beneficial for CHD, and in whom this benefit might be achieved. The biological effects of oestrogen on the cardiovascular system have been extensively studied, and beneficial effects on metabolic CHD risk factors, as well as on arterial function and on surrogate clinical markers of CHD, have been demonstrated. Thus it seems implausible that HRT should not benefit CHD in postmenopausal women. Most randomised trials using clinical outcomes have studied just one dose of one HRT regimen, a dose inappropriately high with the average starting age of the participants being in their mid-60s. The observational population studies largely comprise women starting on HRT at appropriate dose around the age of menopause, i.e. early 50s. In fact, it was the older women in the randomised trials that failed to show benefit, whereas there was a trend to benefit in the younger ones for whom the starting dose of HRT was appropriate. Furthermore, a pilot study of lower dose HRT in older women did not show any cardiovascular harm. Inappropriately high doses of oestrogen could cause cardiovascular harm due to transient disturbances in thrombogenesis and vascular remodelling. Whilst the greatest CHD benefit may be seen by starting HRT in the early postmenopause, this does not exclude benefit in older women given appropriate low dose therapy.
Collapse
Affiliation(s)
- John C Stevenson
- National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, UK.
| |
Collapse
|
17
|
Callejon DR, Franceschini SA, Montes MBA, Toloi MRT. Hormone replacement therapy and hemostasis: Effects in Brazilian postmenopausal women. Maturitas 2005; 52:249-55. [PMID: 16257613 DOI: 10.1016/j.maturitas.2005.02.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2004] [Revised: 02/16/2005] [Accepted: 02/28/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the impact that administration of transdermal estradiol gel combined with medroxyprogesterone acetate (MPA) has on hemostasis. METHODS In this open prospective longitudinal study, thirty postmenopausal women received transdermal estradiol gel (1 mg/day) continuously combined with oral MPA (5 mg/day) for 12 days/month. The following parameters were determined: prothrombin time (PT), activated partial thromboplastin time (aPTT), factors VII, X, and XII activity, fibrinogen levels, thrombin-antithrombin complex levels, protein C and S antigen, antithrombin activity, plasminogen activator inhibitor type 1 (PAI-1) antigen, tissue-type plasminogen activator (t-PA) antigen, plasminogen activity and fibrin degradation products (FbDP) antigen. They were evaluated before and after 6 months of treatment. RESULTS There was a significant decrease in factor VII activity (P=0.001), factor X activity (P=0.016), protein C antigen (P=0.022), antithrombin activity (P=0.025), plasminogen activity (P=0.023), t-PA antigen (P=0.043) and FbDP antigen (P=0.048) compared with baseline values. CONCLUSION The results suggest that the treatment with transdermal estradiol gel combined with MPA avoids any major activation of coagulation and does not produce any overall effect on fibrinolysis. Therefore, this treatment might provide interesting effects on hemostasis in postmenopausal Brazilian women.
Collapse
Affiliation(s)
- Daniel R Callejon
- Department of Clinical, Toxicological and Bromatological Analyses, School of Pharmaceutical Sciences of Ribeirão Preto (FCFRP), University of São Paulo, São Paulo, Brazil
| | | | | | | |
Collapse
|
18
|
Affiliation(s)
- Maryann Lumsden
- Division of Developmental Medicine, University of Glasgow, UK
| |
Collapse
|
19
|
Tentolouris N, Christodoulakos G, Lambrinoudaki I, Mandalaki E, Panoulis C, Maridaki C, Creatsas G, Katsilambros N. Effect of hormone therapy on the elastic properties of the arteries in healthy postmenopausal women. J Endocrinol Invest 2005; 28:305-11. [PMID: 15966502 DOI: 10.1007/bf03347195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of the study was to assess the effect of continuous hormone therapy (HT) for 1 yr on pulse wave analysis and central aortic pressure in healthy postmenopausal women. Sixty-five healthy postmenopausal women were randomly allocated to receive either conjugated equine estrogens 0.625 mg plus medroxyprogesterone acetate 5 mg (CEE/MPA, Premelle 5, Wyeth-Ayerst Lab, Philadelphia, PA, no.=32) or no therapy (no.=33). Treatment was continuous, and the study period lasted 12 months. Central aortic pressure, augmentation and augmentation index (AI) were determined non-invasively using applanation tonometry. All measurements were performed at baseline and at the end of the study by the same person. Ns differences were found between baseline values and values at the end of the study in either the control or the CEE/MPA group in central systolic aortic pressure (107.0 +/- 13.1 vs 107.6 +/- 11.3 mmHg, p=0.80, and 110.8 +/- 10.8 vs 112.3 +/- 11.4 mmHg, p=0.23, respectively), augmentation (12.6 +/- 4.2 vs 11.9 +/- 4.8 mmHg, p=0.45 and 11.7 +/- 3.7 vs 12.6 +/- 4.2 mmHg, p=0.34, respectively), and percentage of AI (36.8 +/- 9.3 vs 36.3 +/- 10.3, p=0.81 and 34.1 +/- 8.9 vs 34.9 +/- 9.8, p=0.72, respectively). The results of this preliminary report suggest that HT for 1 yr does not have any significant effect on central aortic pressure and wave reflection in healthy postmenopausal women.
Collapse
Affiliation(s)
- N Tentolouris
- Department of Propedeutic Medicine, Laiko Hospital, Athens, Greece
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Al-Azzawi F, Wahab M, Sami S, Proudler AJ, Thompson J, Stevenson J. Randomized trial of effects of estradiol in combination with either norethisterone acetate or trimegestone on lipids and lipoproteins in postmenopausal women. Climacteric 2005; 7:292-300. [PMID: 15669554 DOI: 10.1080/13697130400001364] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This double-blind, randomized, multicenter study was designed to compare the blood lipid profiles in postmenopausal women after treatment with either a combined formulation containing estradiol (2 mg) and trimegestone (TMG 0.25 or 0.5 mg) or a standard hormone therapy (HT) containing estradiol and norethisterone acetate. METHOD The serum concentrations of several lipids and lipoproteins were measured in this study, which was conducted over 13 cycles, each of 28 days. A total of 487 subjects were included, 349 of whom completed the study. RESULTS The circulating concentrations of high density lipoprotein (HDL) cholesterol, HDL2 cholesterol and apolipoprotein (apo) AI increased from baseline in both estradiol/trimegestone groups, whilst levels of HDL3 cholesterol were unchanged. In contrast, in the estradiol/norethisterone acetate group, HDL cholesterol, HDL3 cholesterol and apo AI concentrations were reduced from baseline, while HDL2 cholesterol remained unchanged. Total cholesterol, low density lipoprotein (LDL) cholesterol, lipoprotein(a) and apo-B concentrations were reduced in all treatment groups. The concentration of triglycerides was elevated after treatment with the estradiol/trimegestone combinations but was unchanged after treatment with the estradiol/norethisterone acetate combination. The differences in the lipid pattern between the groups may be explained by the different pharmacological properties of the two progestogens: norethisterone exerts an androgenic effect and opposes the estrogen-induced increase in HDL cholesterol, whilst trimegestone has no androgenic effect and does not oppose the estrogenic effect. CONCLUSION Overall, the results of this study suggest that the use of trimegestone in combination with estradiol may be preferable to norethisterone acetate because of the more favorable HDL and apo AI profile.
Collapse
Affiliation(s)
- F Al-Azzawi
- Gynaecology Research Unit, Leicester and Warwick Medical School, University of Leicester, Leicester, UK
| | | | | | | | | | | |
Collapse
|
21
|
Christodoulakos G, Lambrinoudaki I, Panoulis C, Papadias C, Economou E, Creatsas G. Effect of hormone therapy and raloxifene on serum VE-cadherin in postmenopausal women. Fertil Steril 2004; 82:634-8. [PMID: 15374707 DOI: 10.1016/j.fertnstert.2004.03.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2003] [Revised: 03/15/2004] [Accepted: 03/15/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate the effect of continuous combined hormone therapy and raloxifene on serum VE-cadherin. DESIGN The study was double blinded, with a placebo run-in period of 28-50 days. SETTING University menopause clinic. PATIENT(S) Twenty-eight healthy postmenopausal women devoid of climacteric complaints. INTERVENTION(S) Subjects were randomized to 17beta-estradiol (2 mg) + norethisterone acetate (1 mg; E(2)-NETA) or raloxifene hCL (60 mg) for a period of 6 months. MAIN OUTCOME MEASURE(S) Serum VE-cadherin, which was estimated at baseline and at month 6. RESULT(S) Serum VE-cadherin decreased significantly in both E(2)-NETA and raloxifene groups (raloxifene baseline +/- SD: 1.17 +/- 0.44 ng/mL, 6 months: 0.82 +/- 0.29 ng/mL; E(2)-NETA baseline: 1.19 +/- 0.47 ng/mL, 6 months: 0.92 +/- 0.49 ng/mL). Percentage changes from baseline were -21.7 +/- 24.3 for E(2)-NETA and -26.0 +/- 20.6 for raloxifene. CONCLUSION(S) The effect of E(2)-NETA and raloxifene suggests that these drugs may preserve interendothelial junction integrity and control vascular permeability. Although this effect may influence the progress of the atheromatous lesion, its clinical impact on coronary artery disease (CAD) remains uncertain.
Collapse
Affiliation(s)
- George Christodoulakos
- Second Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, Athens, Greece
| | | | | | | | | | | |
Collapse
|
22
|
Hamilton KL, Mbai FN, Gupta S, Knowlton AA. Estrogen, heat shock proteins, and NFkappaB in human vascular endothelium. Arterioscler Thromb Vasc Biol 2004; 24:1628-33. [PMID: 15231513 DOI: 10.1161/01.atv.0000137188.76195.fb] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We hypothesized that estrogen would increase HSP72 in human coronary artery endothelial cells (HCAEC), and that these would be more sensitive to estrogen than our previous observations in myocytes. METHODS AND RESULTS HCAEC were treated with 17beta-estradiol or tamoxifen, ranging from physiological to pharmacological(1 nM to 10 micromol/L) for either 24 hours (early) or 7 days (chronic). HSP expression was assessed by Western blots. Both early and chronic 17beta-estradiol and tamoxifen increased HSP72. Electromobility shift assays (EMSA) showed activation of HSF-1 with early, but not chronic, 17beta-estradiol. 17beta-Estradiol activated NFkappaB within 10 minutes, and the ER-alpha selective inhibitor, ICI 182 780, abolished this effect. Transcription factor decoys containing the heat shock element blocked HSP72 induction. Estrogen pretreatment decreased lactate dehydrogenase release with hypoxia. This protective effect persisted despite blockade of HSF-1 by decoys. However, an NF-kappaB decoy prevented the increase in HSP72 and abolished the estrogen-associated protection during hypoxia. CONCLUSIONS 17beta-Estradiol upregulates HSP72 early and chronically via different mechanisms in HCAEC, and provides cytoprotection during hypoxia, independent of HSP72 induction. NF-kappaB mediates the early increase in HSP72, suggesting that estrogen activates NF-kappaB via a nongenomic, receptor-dependent mechanism, and this leads to activation of HSF-1. Activation of NF-kappaB was critical for estrogen-associated protection. Further studies are needed to elucidate the involved signaling pathways. We hypothesized that estrogen would increase HSP72 in human coronary artery endothelial cells (HCAEC). Both early and chronic treatment increased HSP72. EMSA showed activation of HSF-1 with early, but not chronic, 17beta-estradiol. Transcription factor decoys blocked estrogen-related HSP72 induction. Estrogen decreased LDH release with hypoxia. An NF-kappaB decoy blocked the HSP72 increase and estrogen-associated protection.
Collapse
|
23
|
Christodoulakos GE, Panoulis CPC, Lambrinoudaki IV, Botsis DS, Dendrinos SG, Economou E, Creatsas GC. The effect of hormone therapy and raloxifene on serum matrix metalloproteinase-2 and -9 in postmenopausal women. Menopause 2004; 11:299-305. [PMID: 15167309 DOI: 10.1097/01.gme.0000097848.95550.07] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to investigate the effect of continuous-combined hormone therapy and raloxifene on the total and active forms of serum matrix metalloproteinase (MMP) -2 and -9. DESIGN The study was double-blinded, with a placebo run-in period of 28 to 50 days. Twenty-eight women received either 17beta-estradiol 2 mg + norethisterone acetate 1 mg (E2/NETA) or raloxifene HCL 60 mg for a period of 6 months. Total and active forms of MMP-2 and -9 were estimated at baseline and at month 6. RESULTS Total MMP-2 increased significantly in both E2/NETA and raloxifene groups (raloxifene baseline: 278.1 +/- 18.1 ng/mL; 6 months: 303.1 +/- 29.9 ng/mL, P = 0.008) (E2/NETA baseline: 281.9 +/- 27.5 ng/mL; 6 months: 298.8 +/- 12.7 ng/mL, P = 0.025). Similarly, both treatments increased the active MMP-2 fraction, although only the raloxifene-associated increase acquired significance (raloxifene baseline: 24.9 +/- 8.6 ng/mL; 6 months: 31.6 +/- 15.3 ng/mL, P = 0.045) (E2/NETA baseline: 21.7 +/- 5.7 ng/mL; 6 months: 27.4 +/- 5.8 ng/mL, P = 0.128). Total as well as active fractions of MMP-9 were not significantly affected by either treatment. CONCLUSIONS Both E2/NETA and raloxifene increased the total and active MMP-2 serum levels. MMP-9 was not significantly affected by either regimen. Larger, long-term clinical trials are needed to elucidate the effect of HT and raloxifene on MMPs and the possible clinical implications for cardiovascular health.
Collapse
Affiliation(s)
- George E Christodoulakos
- 2nd Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, Athens, Greece.
| | | | | | | | | | | | | |
Collapse
|
24
|
Santos RL, Abreu GR, Bissoli NS, Moysés MR. Endothelial mediators of 17ß-estradiol-induced coronary vasodilation in the isolated rat heart. Braz J Med Biol Res 2004; 37:569-75. [PMID: 15064820 DOI: 10.1590/s0100-879x2004000400014] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The present study was designed to determine relaxation in response to 17 beta-estradiol by isolated perfused hearts from intact normotensive male and female rats as well as the contribution of endothelium and its relaxing factors to this action. Baseline coronary perfusion pressure was determined and the vasoactive effects of 17 beta-estradiol (10 microM) were assessed by in bolus administration before and after endothelium denudation by infusion of 0.25 microM sodium deoxycholate or perfusion with 100 microM L-NAME, 2.8 microM indomethacin, 0.75 microM clotrimazole, 100 microM L-NAME plus 2.8 microM indomethacin, and 100 microM L-NAME plus 0.75 microM clotrimazole. Baseline coronary perfusion pressure differed significantly between males (84 +/- 2 mmHg, N = 61) and females (102 +/- 2 mmHg, N = 61). Bolus injection of 10 microM 17 beta-estradiol elicited a transient relaxing response in all groups, which was greater in coronary beds from females. For both sexes, the relaxing response to 17 beta-estradiol was at least in part endothelium-dependent. In the presence of the nitric oxide synthase inhibitor L-NAME, the relaxing response to 17 beta-estradiol was reduced only in females. Nevertheless, in the presence of indomethacin, a cyclooxygenase inhibitor, or clotrimazole, a cytochrome P450 inhibitor, the 17 beta-estradiol response was significantly reduced in both groups. In addition, combined treatment with L-NAME plus indomethacin or L-NAME plus clotrimazole also reduced the 17 beta-estradiol response in both groups. These results indicate the importance of prostacyclin and endothelium-derived hyperpolarizing factor in the relaxing response to 17 beta-estradiol. 17 beta-estradiol-induced relaxation may play an important role in the regulation of coronary tone and this may be one of the reasons why estrogen replacement therapy reduces the risk of coronary heart disease in postmenopausal women.
Collapse
Affiliation(s)
- R L Santos
- Departamento de Ciências Fisiológicas, Centro Biomédico, Universidade Federal do Espírito Santo, Victoria, ES, Brazil
| | | | | | | |
Collapse
|
25
|
Stevenson JC. Hormone replacement therapy: review, update, and remaining questions after the Women's Health Initiative Study. Curr Osteoporos Rep 2004; 2:12-6. [PMID: 16036077 DOI: 10.1007/s11914-004-0009-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Hormone replacement therapy (HRT) is a collective term to include a variety of sex steroids, estrogens, and progestogens, given to postmenopausal women at various doses and administered through various routes. HRT is used for the relief of menopausal symptoms, with many women experiencing considerable improvement in their quality of life. It is also used for the prevention and treatment of osteoporosis, which is as effective as other available therapies. Other potential benefits of HRT are the prevention of cardiovascular disease and dementia. The main risks of HRT are an increased incidence of breast cancer and a transient increase in venous thromboembolism. The Women's Health Initiative is the largest randomized clinical trial of HRT to date, and has demonstrated benefits and risks of one specific HRT regimen. Skeletal benefits have been confirmed in terms of fracture reduction, as has a small risk of breast cancer development. Further studies of other HRT regimens are urgently required to clarify the cardiovascular effects.
Collapse
Affiliation(s)
- John C Stevenson
- Endocrinology & Metabolic Medicine, Faculty of Medicine, Imperial College London, Mint Wing, St Mary's Hospital, Praed Street, London W2 1NY, UK.
| |
Collapse
|
26
|
Stevenson JC, Oladipo A, Manassiev N, Whitehead MI, Guilford S, Proudler AJ. Randomized trial of effect of transdermal continuous combined hormone replacement therapy on cardiovascular risk markers. Br J Haematol 2004; 124:802-8. [PMID: 15009069 DOI: 10.1111/j.1365-2141.2004.04846.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Whether hormone replacement therapy (HRT) is beneficial for coronary heart disease (CHD) is controversial. We hypothesized that continuous combined transdermal HRT may have benefits on CHD risk markers without the potential adverse effects seen with certain other HRT regimens. Sixty apparently healthy postmenopausal women, aged 40-65 years, entered a prospective, double-blind, randomized, placebo-controlled clinical trial; 55 women completed the 6-month study. Women received either transdermal oestradiol 17beta 0.05 mg and norethisterone acetate 0.125 mg daily, or identical placebo. Circulating markers of vascular function and remodelling, forearm blood flow, lipids and lipoproteins, glucose and insulin, and haemostatic safety parameters were measured at baseline and after treatment. Compared with placebo after 6 months, HRT administration resulted in decreased E-selectin (P < 0.01), and angiotensin-converting-enzyme (ACE; P = 0.05). Cholesterol (P < 0.05), low-density lipoproteins (LDL; P < 0.05), high-density lipoprotein3 (HDL3; P < 0.05) and apolipoproteins AII (P < 0.05) and B (P < 0.05), and fasting insulin (P < 0.05) also decreased in the HRT group. Factor VII coagulation activity decreased (P < 0.01) and plasminogen activator inhibitor-1 and fibrin D-dimer increased (P < 0.05) in the HRT group, whilst prothrombin fragment 1 + 2 (P < 0.05) decreased, more so in the placebo group. There were no changes in matrix metalloproteinase (MMP)-2, or in LDL particle size. This transdermal HRT had beneficial effects on vascular function and CHD risk markers.
Collapse
Affiliation(s)
- John C Stevenson
- Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, St Mary's Hospital, UK.
| | | | | | | | | | | |
Collapse
|
27
|
Abstract
Males produce endogenous estrogen from testosterone via the enzyme aromatase. Previous studies have suggested a role for endogenous estrogens in cardiovascular function in men. We examined the effects of endogenous estrogen suppression via aromatase inhibition on endothelial function, systemic arterial compliance, and lipoprotein levels in healthy young men. Using a placebo-controlled double-blind randomized design, 20 healthy men, aged 18 to 32 years, were randomized to receive either the aromatase inhibitor anastrozole (1 mg) or matching placebo. Hormone, lipid levels, C-reactive protein (CRP), and homocysteine were measured. Endothelial function, determined by flow-mediated dilation of the brachial artery, and systemic arterial compliance were assessed at baseline and after 6 weeks of treatment. There was a significant decrease in 17beta-estradiol concentrations with aromatase inhibition, from 85.4+/-4.2 to 64.3+/-8.1 pmol/L (mean+/-SD, P=0.042). Compared with baseline, a significant decrease in flow-mediated dilation was observed in subjects taking anastrozole [median, 6.1% (range, 5.2 to 13.4) to 3.5% (2.0 to 5.7), P=0.034] but not in the placebo group. No changes were observed in nitroglycerin-induced endothelium-independent dilation in either group. There was no change in systemic arterial compliance with either aromatase therapy or placebo. There were no significant changes in lipoproteins, testosterone, DHEA, CRP, or homocysteine levels in either the anastrozole or placebo group. We conclude that suppression of endogenous estrogens with an aromatase inhibitor resulted in impairment of flow-mediated dilation without significant changes in lipoproteins, homocysteine, or CRP. Our results suggest that endogenous estrogens play a direct regulatory role in endothelial function in young healthy men.
Collapse
Affiliation(s)
- Robert Lew
- Baker Medical Research Institute and Alfred Hospital, Prahran, Victoria, Australia
| | | | | | | | | |
Collapse
|
28
|
|
29
|
Abstract
Estrogen has long been observed to endow cardiovascular protective effects, as evidenced by sex-specific differences in the incidence of hypertensive and coronary artery disease, the development of atherosclerosis, and myocardial remodeling after infarction. To exert its tissue-specific effects, the classic estrogen receptor (ER) functions as a ligand-dependent transcription factor. However, there is growing evidence that in response to 17beta-estradiol and heterologous signals, the ER can also mediate signaling cascades at the membrane and in the cytoplasm via various second messengers, such as receptor-mediated protein kinases. This review summarizes the current understanding of nonnuclear ER signaling and discusses the relevance to eliciting the beneficial cardiovascular effects of estrogen. These include vasodilation, inhibition of response to vessel injury, limiting myocardial injury after infarction, and attenuating cardiac hypertrophy. Defining the full repertoire of ER function promises to expose novel, highly specific targets for pharmacological interventions and may ultimately lead to the primary and secondary prevention of cardiovascular diseases.
Collapse
Affiliation(s)
- Karen J Ho
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Mass 02139, USA
| | | |
Collapse
|
30
|
|
31
|
|