Antioxidant supplementation with or without B-group vitamins after acute ischemic stroke: a randomized controlled trial

Nutritional therapy for reducing disability and improving activities of daily living in people after stroke

BACKGROUND

Stroke patients often face disabilities that significantly interfere with their daily lives. Poor nutritional status is a common issue amongst these patients, and malnutrition can severely impact their functional recovery post-stroke. Therefore, nutritional therapy is crucial in managing stroke outcomes. However, its effects on disability, activities of daily living (ADL), and other critical outcomes have not been fully explored.

OBJECTIVES

To evaluate the effects of nutritional therapy on reducing disability and improving ADL in patients after stroke.

SEARCH METHODS

We searched the trial registers of the Cochrane Stroke Group, CENTRAL, MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1982), and AMED (from 1985) to 19 February 2024. We also searched trials and research registries (ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform) and reference lists of articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared nutritional therapy with placebo, usual care, or one type of nutritional therapy in people after stroke. Nutritional therapy was defined as the administration of supplemental nutrients, including energy, protein, amino acids, fatty acids, vitamins, and minerals, through oral, enteral, or parenteral methods. As a comparator, one type of nutritional therapy refers to all forms of nutritional therapies, excluding the specific nutritional therapy defined for use in the intervention group.

DATA COLLECTION AND ANALYSIS

We used Cochrane's Screen4Me workflow to assess the initial search results. Two review authors independently screened references that met the inclusion criteria, extracted data, and assessed the risk of bias and the certainty of the evidence using the GRADE approach. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the odds ratio (OR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I2 statistic. The primary outcomes were disability and ADL. We also assessed gait, nutritional status, all-cause mortality, quality of life, hand and leg muscle strength, cognitive function, physical performance, stroke recurrence, swallowing function, neurological impairment, and the development of complications (adverse events) as secondary outcomes.

MAIN RESULTS

We identified 52 eligible RCTs involving 11,926 participants. Thirty-six studies were conducted in the acute phase, 10 in the subacute phase, three in the acute and subacute phases, and three in the chronic phase. Twenty-three studies included patients with ischaemic stroke, three included patients with haemorrhagic stroke, three included patients with subarachnoid haemorrhage (SAH), and 23 included patients with ischaemic or haemorrhagic stroke including SAH. There were 25 types of nutritional supplements used as an intervention. The number of studies that assessed disability and ADL as outcomes were nine and 17, respectively. For the intervention using oral energy and protein supplements, which was a primary intervention in this review, six studies were included. The results for the seven outcomes focused on (disability, ADL, body weight change, all-cause mortality, gait speed, quality of life, and incidence of complications (adverse events)) were as follows: There was no evidence of a difference in reducing disability when 'good status' was defined as an mRS score of 0 to 2 (for 'good status': OR 0.97, 95% CI 0.86 to 1.10; 1 RCT, 4023 participants; low-certainty evidence). Oral energy and protein supplements may improve ADL as indicated by an increase in the FIM motor score, but the evidence is very uncertain (MD 8.74, 95% CI 5.93 to 11.54; 2 RCTs, 165 participants; very low-certainty evidence). Oral energy and protein supplements may increase body weight, but the evidence is very uncertain (MD 0.90, 95% CI 0.23 to 1.58; 3 RCTs, 205 participants; very low-certainty evidence). There was no evidence of a difference in reducing all-cause mortality (OR 0.57, 95% CI 0.14 to 2.28; 2 RCTs, 4065 participants; low-certainty evidence). For gait speed and quality of life, no study was identified. With regard to incidence of complications (adverse events), there was no evidence of a difference in the incidence of infections, including pneumonia, urinary tract infections, and septicaemia (OR 0.68, 95% CI 0.20 to 2.30; 1 RCT, 42 participants; very low-certainty evidence). The intervention was associated with an increased incidence of diarrhoea compared to usual care (OR 4.29, 95% CI 1.98 to 9.28; 1 RCT, 4023 participants; low-certainty evidence) and the occurrence of hyperglycaemia or hypoglycaemia (OR 15.6, 95% CI 4.84 to 50.23; 1 RCT, 4023 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain about the effect of nutritional therapy, including oral energy and protein supplements and other supplements identified in this review, on reducing disability and improving ADL in people after stroke. Various nutritional interventions were assessed for the outcomes in the included studies, and almost all studies had small sample sizes. This led to challenges in conducting meta-analyses and reduced the precision of the evidence. Moreover, most of the studies had issues with the risk of bias, especially in terms of the absence of blinding and unclear information. Regarding adverse events, the intervention with oral energy and protein supplements was associated with a higher number of adverse events, such as diarrhoea, hyperglycaemia, and hypoglycaemia, compared to usual care. However, the quality of the evidence was low. Given the low certainty of most of the evidence in our review, further research is needed. Future research should focus on targeted nutritional interventions to reduce disability and improve ADL based on a theoretical rationale in people after stroke and there is a need for improved methodology and reporting.

The Protective Effects of Vitamin B Complex on Diclofenac Sodium-Induced Nephrotoxicity: The Role of NOX4/RhoA/ROCK

Diclofenac sodium (DIC) is a widely used non-steroidal anti-inflammatory drug. Unfortunately, its prolonged use is associated with nephrotoxicity due to oxidative stress, inflammation, and fibrosis. We aimed to investigate the nephroprotective effects of vitamin B complex (B1, B6, B12) against DIC-induced nephrotoxicity and its impact on NOX4/RhoA/ROCK, a pathway that plays a vital role in renal pathophysiology. Thirty-two Wistar rats were divided into four groups: (1) normal control; (2) vitamin B complex (16 mg/kg B1, 16 mg/kg B6, 0.16 mg/kg B12, intraperitoneal); (3) DIC (10 mg/kg, intramuscular); and (4) DIC plus vitamin B complex group. After 14 days, the following were assayed: serum renal biomarkers (creatinine, blood urea nitrogen, kidney injury molecule-1), oxidative stress, inflammatory (tumor necrosis factor-α, interleukin-6), and fibrotic (transforming growth factor-β) markers as well as the protein levels of NOX4, RhoA, and ROCK. Structural changes, inflammatory cell infiltration, and fibrosis were detected using hematoxylin and eosin and Masson trichrome stains. Compared to DIC, vitamin B complex significantly decreased the renal function biomarkers, markers of oxidative stress and inflammation, and fibrotic cytokines. Glomerular and tubular damage, inflammatory infiltration, and excessive collagen accumulation were also reduced. Protein levels of NOX4, RhoA, and ROCK were significantly elevated by DIC, and this elevation was ameliorated by vitamin B complex. In conclusion, vitamin B complex administration could be a renoprotective approach during treatment with DIC via, at least in part, suppressing the NOX4/RhoA/ROCK pathway.

Nutrition in chronic inflammatory conditions: Bypassing the mucosal block for micronutrients

Nutritional Immunity is one of the most ancient innate immune responses, during which the body can restrict nutrients availability to pathogens and restricts their uptake by the gut mucosa (mucosal block). Though this can be a beneficial strategy during infection, it also is associated with non-communicable diseases-where the pathogen is missing; leading to increased morbidity and mortality as micronutritional uptake and distribution in the body is hindered. Here, we discuss the acute immune response in respect to nutrients, the opposing nutritional demands of regulatory and inflammatory cells and particularly focus on some nutrients linked with inflammation such as iron, vitamins A, Bs, C, and other antioxidants. We propose that while the absorption of certain micronutrients is hindered during inflammation, the dietary lymph path remains available. As such, several clinical trials investigated the role of the lymphatic system during protein absorption, following a ketogenic diet and an increased intake of antioxidants, vitamins, and minerals, in reducing inflammation and ameliorating disease.

Oxidative stress and early mortality in acute ischemic stroke: A prospective cohort study

BACKGROUND

Malondialdehyde (MDA) is an oxidative stress biomarker, which represents a unifying mechanism of brain injury that occurs throughout the ischemic stroke cascade. The current study aimed to examine whether or not acute ischemic stroke (AIS) patients who had elevated serum MDA levels at admission had an increased risk of mortality and a worse functional outcome three months later.

METHODS

An observational, prospective cohort study that enrolled 90 patients with AIS. The patients were examined in the first 24 hours and then followed up for three months to assess mortality, short-term neurological functional outcome, and neurological disability by the Modified Rankin Scale (MRS).

RESULTS

The mean of serum MDA level among AIS patients was 6.3 ± 3.7 nmol/ml. Non-survivor cases were associated with statistically significantly higher serum MDA levels compared to survivors (9.7 ± 4.3 vs. 5.3 ± 2.8, p < 0.001), respectively. Patients with severe stroke, according to NIHSS score, were associated with significantly (p < 0.05) higher MDA levels compared to moderate and mild cases (7.4 ± 4.3 vs. 5.4 ± 2.6 vs. 3.3 ± .6). At a cutoff point of ≥ 6.7 nmol/ml, the area under the curve (AUC) for serum MDA levels as a predictor of mortality was 0.8 (0.69-0.91; p < 0.05). The sensitivity, specificity, positive predictive value, and negative predictive value were 77%, 80%, 89.5%, and 48.5%, respectively. Multivariate regression demonstrated that MDA level was a significant independent predictor of mortality among patients with AIS (OR = 1.29, 95% CI: 1.01 to 1.65; p = 0.041).

CONCLUSION

MDA serum level was significantly higher in non-survivors than in survivors patients, so MDA could be used as a predictor for early mortality and short-term outcome of cases with AIS.

The Role of Micronutrients in Neurological Disorders

Trace elements and vitamins, collectively known as micronutrients, are essential for basic metabolic reactions in the human body. Their deficiency or, on the contrary, an increased amount can lead to serious disorders. Research in recent years has shown that long-term abnormal levels of micronutrients may be involved in the etiopathogenesis of some neurological diseases. Acute and chronic alterations in micronutrient levels may cause other serious complications in neurological diseases. Our aim was to summarize the knowledge about micronutrients in relation to selected neurological diseases and comment on their importance and the possibilities of therapeutic intervention in clinical practice.

Impact of Nutritional Status on Outcomes of Stroke Survivors: A Post Hoc Analysis of the NHANES

Stroke, a neurological emergency, is a leading cause of death and disability in adults worldwide. In acute or rehabilitative stages, stroke survivors sustain variable neurological recovery with long-term disabilities. The influence of post-stroke nutritional status on long-term survival has not been confirmed. Using the United States National Health and Nutrition Examination Survey data (2001−2010), we conducted a matched-cohort analysis (929 and 1858 participants in stroke and non-stroke groups, respectively) to investigate the influence of nutritional elements on post-stroke survival. With significantly lower nutrient consumption, the mortality risk was 2.2 times higher in stroke patients compared to non-stroke patients (Kaplan−Meier method with Cox proportional hazards model: adjusted hazard ratio, 2.208; 95% confidence interval: 1.887−2.583; p < 0.001). For several nutritional elements, the lower consumption group had significantly shorter survival than the higher consumption stroke subgroup; moreover, stroke patients with the highest 25% nutritional intake for each nutritional element, except moisture and total fat, had significantly shorter survival than non-stroke patients with the lowest 25% nutrition. Malnutrition is highly prevalent in stroke patients and is associated with high mortality rates. The dynamic change in energy requirements throughout the disease course necessitates dietary adjustment to ensure adequate nutritional intake.

Crocins for Ischemic Stroke: A Review of Current Evidence

Crocins (CRs) and the related active constituents derived from Crocus sativus L. (Saffron) have demonstrated protective effects against cerebral ischemia and ischemic stroke, with various bioactivities including neuroprotection, anti-neuroinflammation, antioxidant, and cardiovascular protection. Among CRs, crocin (CR) has been shown to act on multiple mechanisms and signaling pathways involved in ischemic stroke, including mitochondrial apoptosis, nuclear factor kappa light chain enhancer of B cells pathway, S100 calcium-binding protein B, interleukin-6 and vascular endothelial growth factor-A. CR is generally safe and well-tolerated. Pharmacokinetic studies indicate that CR has poor bioavailability and needs to convert to crocetin (CC) in order to cross the blood-brain barrier. Clinical studies have shown the efficacy of saffron and CR in treating various conditions, including metabolic syndrome, depression, Alzheimer’s disease, and coronary artery disease. There is evidence supporting CR as a treatment for ischemic stroke, although further studies are needed to confirm their efficacy and safety in clinical settings.

Folic acid effect on homocysteine, sortilin levels and glycemic control in type 2 diabetes mellitus patients

Aim

The present study aimed to determine the folic acid supplement (FAS) effects on serum homocysteine and sortilin levels, glycemic indices, and lipid profile in type II diabetic patients.

Method

A double-blind randomized controlled clinical trial have been performed on 100 patients with T2DM randomly divided into two groups that received either placebo or folic acid 5 mg/d for 12 weeks.

Results

FAS caused a significant decrease in homocysteine and sortilin serum levels (28.2% and 33.7%, P < 0.0001, respectively). After 3 months of intervention, 8.7% decrease in fasting blood glucose (P = 0.0005), 8.2% in HbA1c (P = 0.0002), 13.7% in serum insulin (P < 0.0001) and 21.7% in insulin resistance (P < 0.0001) were found in the folic acid group, however no significant difference was observed in the placebo group. Serum hs-CRP level showed significant positive associations with sortilin (r = 0.237, P = 0.018), homocysteine (r = 0.308, P = 0.002) and fasting blood glucose (r = 0.342, P = 0.000). There were no significant changes in lipid profile in both groups after 12 weeks.

Conclusion

FAS might be beneficial for reducing homocysteine and sortilin levels, enhancing glycemic control, and improved insulin resistance in patients with T2DM.

Effects of folate supplementation on recurrence and metabolic status of cervical intraepithelial neoplasia grade 2/3 in overweight and obese women: a randomized double-blind placebo-controlled trial

BACKGROUND AND OBJECTIVE

Inconsistent evidence showed that folate supplementation may be associated with reduced risk of cancer due to improved metabolic profiles and reduced markers of oxidative stress and inflammation. The aim of this investigation was to quantify the effects of folate supplementation on the recurrence and other metabolic factors of women with cervical intraepithelial neoplasia grade 2/3 (CIN2/3).

METHODS

This randomized, double-blind, placebo-controlled clinical trial was performed among 60 overweight/obese women with CIN2/3. Definitive CIN2/3 confirmation was done via biopsy, pathological diagnosis, as well as colposcopy. Participants were randomly assigned to the intervention group to take 5 mg/day folate supplements or placebo group (n = 30 in each group) for 12 weeks.

RESULTS

The results of the current study showed a non-significant decrease in recurrence of CIN2/3 in the folate group in comparison with the placebo group (3.3% vs. 16.7%, P = 0.08). Compared with the placebo, folate supplementation significantly decreased plasma homocysteine (Hcy) levels (P < 0.001), serum insulin values (in the crude model) (P = 0.01), and homeostasis model assessment of insulin resistance (P = 0.01). Also, folate supplementation resulted in a significant improvement in the quantitative insulin sensitivity check index (P = 0.002) and total antioxidant capacity (P = 0.04) and a significant reduction in high-sensitivity C-reactive protein (P = 0.015) in comparison with the placebo group.

CONCLUSIONS

In conclusion, folate supplementation for 12 weeks among overweight/obese women with CIN2/3 showed a non-significant decrease in its recurrence and had beneficial effects on insulin sensitivity, inflammation, and oxidative stress markers.

Association between dietary antioxidant vitamins intake and homocysteine levels in middle-aged and older adults with hypertension: a cross-sectional study

OBJECTIVES

Plasma total homocysteine (tHcy) has been implicated in the development of cardiovascular disease. This study aimed to assess the relationship of dietary antioxidant vitamins intake with tHcy levels in middle-aged and older adults with hypertension.

DESIGN

A cross-sectional study.

SETTING

The survey was conducted in the Nanshan district of Shenzhen.

PARTICIPANTS

A total of 1465 middle-aged and older adults with hypertension were included between July and September of 2013.

MEASUREMENTS

Hyperhomocysteinaemia (HHcy) was defined as tHcy ≥15 µmol/L. Some dietary antioxidant vitamins (vitamin C (VC) and vitamin E (VE), carotenes, retinol, lutein) intake was estimated using the Food Frequency Questionnaire. Sociodemographic and potential covariates were evaluated through questionnaires, anthropometric measurements and blood tests. The association between dietary intakes of antioxidant vitamins and tHcy concentration were evaluated by multiple linear regression analyses after napierian logarithm transformed. Multiple logistic regression models were further used to determine ORs and 95% CIs.

RESULTS

The β (95% CIs) of VC intake and tHcy was -0.050 (-0.084 to -0.016). Compared with the lowest quartile in the fully adjusted model, the ORs (95% CIs) for HHcy levels across quartiles of dietary VC intake were 0.82 (0.57 to 1.16), 0.49 (0.33 to 0.74) and 0.40 (0.22 to 0.74) (p for trend=0.001). The β (95% CIs) of retinol intake and tHcy was -0.021 (-0.041 to -0.002) and the ORs (95% CIs) in the third quartile of retinol intake was 0.61 (0.42 to 0.86), while the effect for the highest quartile was not significant (p for trend=0.951). No significant association was observed between dietary VE, carotenes and lutein intake and HHcy.

CONCLUSIONS

A linear inverse association between dietary VC intake and HHcy prevalence, and an L-shaped association between dietary retinol intake and HHcy prevalence were found in Chinese middle-aged and older adults with hypertension.

Neuroprotective Properties of Vitamin C: A Scoping Review of Pre-Clinical and Clinical Studies

There is a need for novel neuroprotective therapies. We aimed to review the evidence for exogenous vitamin C as a neuroprotective agent. MEDLINE, Embase, and Cochrane library databases were searched from inception to May 2020. Pre-clinical and clinical reports evaluating vitamin C for acute neurological injury were included. Twenty-two pre-clinical and 11 clinical studies were eligible for inclusion. Pre-clinical studies included models of traumatic and hypoxic brain injury, subarachnoid and intracerebral hemorrhage, and ischemic stroke. The median [IQR] maximum daily dose of vitamin C in animal studies was 120 [50-500] mg/kg. Twenty-one animal studies reported improvements in biomarkers, functional outcome, or both. Clinical studies included single reports in neonatal hypoxic encephalopathy, traumatic brain injury, and subarachnoid hemorrhage and eight studies in ischemic stroke. The median maximum daily dose of vitamin C was 750 [500-1000] mg, or ∼10 mg/kg for an average-size adult male. Apart from one case series of intracisternal vitamin C administration in subarachnoid hemorrhage, clinical studies reported no patient-centered benefit. Although pre-clinical trials suggest that exogenous vitamin C improves biomarkers of neuroprotection, functional outcome, and mortality, these results have not translated to humans. However, clinical trials used approximately one tenth of the vitamin C dose of animal studies.

Therapeutic potential of nutraceuticals to protect brain after stroke

Stroke leads to significant neuronal death and long-term neurological disability due to synergistic pathogenic mechanisms. Stroke induces a change in eating habits and in many cases, leads to undernutrition that aggravates the post-stroke pathology. Proper nutritional regimen remains a major strategy to control the modifiable risk factors for cardiovascular and cerebrovascular diseases including stroke. Studies indicate that nutraceuticals (isolated and concentrated form of high-potency natural bioactive substances present in dietary nutritional components) can act as prophylactic as well as adjuvant therapeutic agents to prevent stroke risk, to promote ischemic tolerance and to reduce post-stroke consequences. Nutraceuticals are also thought to regulate blood pressure, delay neurodegeneration and improve overall vascular health. Nutraceuticals potentially mediate these effects by their powerful antioxidant and anti-inflammatory properties. This review discusses the studies that have highlighted the translational potential of nutraceuticals as stroke therapies.

Non-survivor patients with malignant middle cerebral artery infarction showed persistently high serum malondialdehyde levels

Objective

Previously there have been found higher circulating malondialdehyde levels during the first week of ischemic stroke in patients with worst neurological functional outcome, and at moment of ischemic stroke in non-survivor patients. Thus, the aim of our study was to determine the potential role of serum malondialdehyde levels during the first week of a severe cerebral infarction to mortality prediction.

Methods

This study was observational, prospective, and multicenter. We included patients with a severe malignant middle cerebral artery infarction (MMCAI) defined as patients with computed tomography showing acute infarction in more than of 50% of the territory and Glasgow Coma Scale (GCS) lower than 9. We determined serum concentrations of malondialdehyde on days 1, 4 and 8 of MMCAI.

Results

Serum malondialdehyde concentrations at days 1 (p < 0.001), 4 (p < 0.001), and 8 (p = 0.001) of MMCAI in non-survivor patients (n = 34) were higher than in survivor patients (n = 34). ROC curve analyses showed that serum malondialdehyde concentrations at days 1, 4, and 8 of MMCAI had an AUC (95% CI) to predict 30-day mortality of 0.77 (0.65–0.86; p < 0.001), 0.82 (0.69–0.91; p < 0.001) and 0.84 (0.70–0.93; p < 0.001) respectively.

Conclusions

The new findings of our study were that serum malondialdehyde levels during the first week of MMCAI could be used as biomarkers to mortality prediction.

Effects of folic acid supplementation on C-reactive protein: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIM

Given the contradictory results of previous randomized controlled trials (RCTs), we performed a systematic review and meta-analysis to quantify and summarize the effects of folic acid supplementation on C-reactive protein (CRP).

METHODS AND RESULTS

We performed a systematic search of all available RCTs conducted up to October 2018 in the following databases: PubMed, Scopus, and Cochrane. RCTs that investigated the effect of folate on CRP were included in the present study. Data were combined with the use of generic inverse-variance random-effects models. Statistical heterogeneity between studies was evaluated using Cochran's Q-test. Ten RCTs (1179 subjects) were included in the present meta-analysis. Pooled analysis results showed that folate supplementation significantly lowered the serum CRP level (weighted mean difference (WMD): -0.685 mg/l, 95% CI: -1.053, -0.318, p < 0.001). However, heterogeneity was significant (I² = 96.7%, p = 0.000). Stratified analyses indicated that sex, intervention period, and type of study population were sources of heterogeneity. Following analysis, results revealed that the greatest impact was observed in women (WMD: -0.967 mg/l, 95% CI: -1.101, -0.833, p = 0.000), patients with type 2 diabetes mellitus (WMD: -1.764 mg/l, 95% CI: -2.002, -1.526, p = 0.000), and intervention period less than 12 weeks (WMD: -0.742 mg/l, 95% CI: -0.834, -0.650, p = 0.000).

CONCLUSION

This meta-analysis suggested that folic acid supplementation could significantly lower the serum CRP level. Folic acid leads to greater CRP lowering effect in women, patients with T2DM, and those with less than 12-week intervention.

Riboflavin - properties, occurrence and its use in medicine

Riboflavin is built on an isoalloxazin ring, which contains three sixcarbon rings: benzoic, pyrazine and pyrimidine. Riboflavin is synthesized by some bacteria, but among humans and animals, the only source of flavin coenzymes (FAD, FMN) is exogenous riboflavin. Riboflavin transport in enterocytes takes place via three translocators encoded by the SLC52 gene. Deficiency of dietary riboflavin has wide ranging implications for the efficacy of other vitamins, the mechanism of cellular respiration, lactic acid metabolism, hemoglobin, nucleotides and amino acid synthesis. In studies it was found that, pharmacologic daily doses (100 mg) have the potential to react with light, which can have adverse cellular effects. Extrene caution should be exercised when using riboflavin as phototherapy in premature newborns. At the cellular level, riboflavin deficiency leads to increased oxidative stress and causes disorders in the glutathione recycling process. Risk factors for developing riboflavin deficinecy include pregnancy, malnutrition (including anorexia and other eating disorders, vegitarianism, veganism and alcoholism. Furthermore, elderly people and atheletes are also at risk of developing this deficiency. Widespread use of riboflavin in medicine, cancer therapy, treatment of neurodegenerative diseases, corneal ectasia and viral infections has resulted in the recent increased interest in this flavina.

Effects of Folate Supplementation on Carotid Intima-Media Thickness, Biomarkers of Inflammation, and Oxidative Stress in Carbamazepine-Treated Epileptic Children

Background:

This study was conducted to assess the effects of folate supplementation on carotid intima-media thickness (CIMT), biomarkers of inflammation, and oxidative stress in carbamazepine-treated epileptic children.

Methods:

This randomized, double-blind, placebo-controlled trial was carried out in 54 epileptic children aged 2–12 years old receiving carbamazepine monotherapy. Participants were randomly allocated into two groups to receive either 5 mg folate supplements or placebo (n = 27 in each group) for 12 weeks.

Results:

After the 12-week intervention, compared with the placebo, folate supplementation resulted in a significant reduction in plasma homocysteine (Hcy) (changes from baseline − 2.1 ± 2.5 vs. +0.1 ± 0.4 μmol/L, P < 0.001), serum high-sensitivity C-reactive protein (hs-CRP) (changes from baseline − 1.5 ± 3.5 vs. +0.4 ± 1.4 mg/L, P = 0.01), a significant increase in plasma nitric oxide (NO) (changes from baseline + 1.9 ± 5.8 vs. −2.0 ± 6.4 μmol/L, P = 0.02), and total antioxidant capacity (TAC) concentrations (changes from baseline + 88.6 ± 116.0 vs. +1.8 ± 77.4 mmol/L, P = 0.002). We did not observe any significant effects in mean levels of left and right CIMT, maximum levels of left and right CIMT, and total glutathione (GSH) and malondialdehyde (MDA) levels following the supplementation of folate compared with the placebo.

Conclusions:

Overall, folate supplementation at a dosage of 5 mg/day for 12 weeks among epileptic children receiving carbamazepine had beneficial effects on Hcy, hs-CRP, NO, and TAC levels, but did not affect CIMT, and GSH and MDA levels.

Dietary vitamin B intake and the risk of esophageal cancer: a meta-analysis

BACKGROUND

Several epidemiology studies have explored the association between dietary B vitamins' intake and the risk of esophageal cancer (EC). However, the results remain inconclusive. Thus, we conducted a systematic review with meta-analysis to evaluate such association.

METHODS

Literature retrieval was performed using PubMed (Medline), ScienceDirect, and Cochrane Library electronic databases for all studies published from database inception to December 2017.

RESULTS

The meta-analysis included 19 studies and showed an overall decreased risk of EC (OR=0.77, 95% CI: 0.68-0.87) in association with multivitamin B (ie, B1, B2, B3, B5, B6, B9, and B12) dietary intake. In a subgroup analysis based on vitamin B subclass, B1, B3, B6, and B9 vitamins were associated with decreased EC risk (vitamin B1: OR=0.68, 95% CI: 0.56-0.82; vitamin B3: OR=0.70, 95% CI: 0.53-0.94; vitamin B6: OR=0.64, 95% CI: 0.49-0.83; and vitamin B9: OR=0.69, 95% CI: 0.55-0.86). By contrast, no association was detected between dietary vitamin B2 and vitamin B5 intake and EC risk (vitamin B2: OR=0.86, 95% CI: 0.64-1.16; vitamin B5: OR=0.49, 95% CI: 0.20-1.20), whereas a potential non-linear dose-response association was found between dietary vitamin B12 intake and EC risk. A statistically significant, inverse association was observed for an increase of 100 µg/day in supplemental vitamin B6 and B9 and EC risk (vitamin B6: OR=0.98, 95% CI: 0.98-0.99; vitamin B9: OR= 0.89; 95% CI: 0.86-0.94).

CONCLUSION

These findings support that vitamin B may have an influence on carcinogenesis of the esophagus. Vitamin B1, B3, B6, B9 showed a decreased risk of EC, and vitamin B12 showed an increased risk of EC.

Adjunctive Therapy Approaches for Ischemic Stroke: Innovations to Expand Time Window of Treatment

Tissue plasminogen activator (tPA) thrombolysis remains the gold standard treatment for ischemic stroke. A time-constrained therapeutic window, with the drug to be given within 4.5 h after stroke onset, and lethal side effects associated with delayed treatment, most notably hemorrhagic transformation (HT), limit the clinical use of tPA. Co-administering tPA with other agents, including drug or non-drug interventions, has been proposed as a practical strategy to address the limitations of tPA. Here, we discuss the pharmacological and non-drug approaches that were examined to mitigate the complications-especially HT-associated with delayed tPA treatment. The pharmacological treatments include those that preserve the blood-brain barrier (e.g., atovarstatin, batimastat, candesartan, cilostazol, fasudil, minocycline, etc.), enhance vascularization and protect the cerebrovasculature (e.g., coumarin derivate IMM-H004 and granulocyte-colony stimulating factor (G-CSF)), and exert their effects through other modes of action (e.g., oxygen transporters, ascorbic acid, etc.). The non-drug approaches include stem cell treatments and gas therapy with multi-pronged biological effects. Co-administering tPA with the abovementioned therapies showed promise in attenuating delayed tPA-induced side effects and stroke-induced neurological and behavioral deficits. Thus, adjunctive treatment approach is an innovative therapeutic modality that can address the limitations of tPA treatment and potentially expand the time window for ischemic stroke therapy.

Strategies to Extend Thrombolytic Time Window for Ischemic Stroke Treatment: An Unmet Clinical Need

To date, reperfusion with tissue plasminogen activator (tPA) remains the gold standard treatment for ischemic stroke. However, when tPA is given beyond 4.5 hours of stroke onset, deleterious effects of the drug ensue, especially, hemorrhagic transformation (HT), which causes the most significant morbidity and mortality in stroke patients. An important clinical problem at hand is to develop strategies that will enhance the therapeutic time window for tPA therapy and reduce the adverse effects (especially HT) of delayed tPA treatment. We reviewed the pharmacological agents which reduced the risk of HT associated with delayed (beyond 4.5 hours post-stroke) tPA treatment in preclinical studies, which we classified into those that putatively preserve the blood-brain barrier (e.g., minocycline, cilostazol, fasudil, candesartan, and bryostatin) and/or enhance vascularization and protect the cerebrovasculature (e.g., coumarin derivate IMM-H004 and granulocyte colony-stimulating factor). Recently, other new therapeutic modalities (e.g., oxygen transporters) have been reported which improved delayed tPA-associated outcomes by acting through other mechanisms. While the above-mentioned interventions unequivocally reduced delayed tPA-induced HT in stroke models, the long-term efficacy of these drugs are not yet established. Further optimization is required to expedite their future clinical application. The findings from this review indicate the need to explore the most ideal adjunctive interventions that will not only reduce delayed tPA–induced HT, but also preserve neurovascular functions. While waiting for the next breakthrough drug in acute stroke treatment, it is equally important to allocate considerable effort to find approaches to address the limitations of the only FDA-approved stroke therapy.

Intake of antioxidants and B vitamins is inversely associated with ischemic stroke and cerebral atherosclerosis

BACKGROUND/OBJECTIVES

This study was conducted to examine relationships between dietary habits and intakes of antioxidants and B vitamins and the risk of ischemic stroke, and to compare dietary factors according to the presence of cerebral artery atherosclerosis and stroke subtypes.

SUBJECTS/METHODS

A total of 147 patients and 144 control subjects were recruited consecutively in the metropolitan area of Seoul, Korea. Sixty participants each in the case and control groups were included in analyses after 1:1 frequency matching. In addition, 117 acute ischemic stroke patients were classified into subtypes according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) guidelines. Dietary intake was measured using a semi-quantitative food frequency questionnaire composed of 111 food items and plasma lipid and homocysteine levels were analyzed.

RESULTS

When compared with control subjects, stroke patients had unfavorable dietary behaviors and lower intakes of fruits (73.1 ± 83.2 g vs. 230.9 ± 202.1 g, P < 0.001), vegetables (221.1 ± 209.0 g vs. 561.7 ± 306.6 g, P < 0.001), and antioxidants, including vitamins C, E, B₆, β-carotene, and folate. The intakes of fruits, vegetables, vitamin C, and folate were inversely associated with the risk of ischemic stroke after adjusting for confounding factors. Intakes of vegetables, vitamins C, B₆, B₁₂, and folate per 1,000 kcal were lower in ischemic stroke with cerebral atherosclerosis than in those without. Overall vitamin B₁₂ intake per 1,000 kcal differed according to the TOAST classification (P = 0.004), but no differences among groups existed based on the post-hoc test.

CONCLUSIONS

When compared with control subjects, ischemic stroke patients, particularly those with cerebral atherosclerosis, had unfavorable dietary intake, which may have contributed to the development of ischemic stroke. These results indicate that proper dietary recommendations are important for the prevention of ischemic stroke.

The Effects of Folate Supplementation on Carotid Intima-Media Thickness and Metabolic Status in Patients with Metabolic Syndrome

BACKGROUND

This study was carried out to evaluate the effects of folate supplementation on carotid intima-media thickness (CIMT) and metabolic status among patients with metabolic syndrome (MetS).

METHODS

This randomized, double-blind, placebo-controlled trial was conducted among 60 patients with type 2 diabetes mellitus and coronary heart disease. They were all overweight in the age range 40-85 years. Participants were randomly divided into 2 groups: group A (n = 30) received 5 mg folate supplements and group B (n = 30) received placebo for 12 weeks.

RESULTS

Folate supplementation resulted in a significant reduction in maximum levels of left CIMT (-0.05 ± 0.13 vs. +0.02 ± 0.11 mm, p = 0.01) compared with the placebo. Changes in fasting plasma glucose (-2.2 ± 37.5 vs. +30.2 ± 65.8 mg/dl, p = 0.02), serum insulin concentration (-2.0 ± 10.7 vs. +3.0 ± 7.6 µIU/ml, p = 0.04) and homeostasis of assessment-estimated insulin resistance (-0.6 ± 2.3 vs. +0.9 ± 2.3, p = 0.01) in supplemented patients were significantly different from those of patients in the placebo group. Changes in serum triglycerides (p = 0.04), high-density lipoprotein-cholesterol (p = 0.001), high sensitivity C-reactive protein (p = 0.01) and plasma nitric oxide concentrations (p < 0.001) were significantly different between the supplemented patients and placebo group.

CONCLUSIONS

Overall, 5 mg/day folate supplementation for 12 weeks among patients with MetS had beneficial effects on CIMT and the metabolic status.

Association between total antioxidant capacity and mortality in ischemic stroke patients

Objective

Data on circulating total antioxidant capacity (TAC) levels in ischemic stroke patients compared with healthy controls are limited and provided conflicting findings. There are not data about the association between circulating TAC levels, peroxidation state and outcome in patients with severe ischemic stroke. The objective of this study was to examine the relationship of TAC with 30-day mortality after severe ischemic stroke.

Methods

This multicenter study included 58 patients with coma (Glasgow Coma Scale < 9) following severe malignant middle cerebral artery infarction (MMCAI). We measured circulating levels of TAC and malondialdehyde (MDA, a biomarker of lipid peroxidation) on day 1 of severe MMCAI diagnosis. The study endpoint was 30-day mortality.

Results

Non-survivors (n = 29) showed higher serum TAC levels (p < 0.001) and higher serum MDA levels (p = 0.004) than survivors (n = 29). Multiple binomial logistic regression analysis showed that serum TAC levels were associated with 30-day mortality, after controlling for Glasgow Coma Scale and age (odds ratio 1.92; 95 % confidence interval 1.201–3.072; p = 0.006). There was a correlation between serum TAC and MDA levels (rho = 0.35; p = 0.008).

Conclusions

This single-center study in severe MMCAI patients found an association between higher serum TAC levels and 30-day mortality and further identified a relationship between serum TAC levels, lipid peroxidation state and mortality after severe ischemic stroke.

Association between Pre-Transplant Serum Malondialdehyde Levels and Survival One Year after Liver Transplantation for Hepatocellular Carcinoma

Previous studies have found higher levels of serum malondialdehyde (MDA) in hepatocellular carcinoma (HCC) patients compared to healthy controls and higher MDA concentrations in tumoral tissue of HCC patients than in non-tumoral tissue. However, the association between pre-transplant serum levels of MDA and survival in HCC patients after liver transplantation (LT) has not been described, and the aim of the present study was to determine whether such an association exists. In this observational study we measured serum MDA levels in 127 patients before LT. We found higher pre-LT serum MDA levels in 15 non-surviving than in 112 surviving patients one year after LT (p = 0.02). Exact binary logistic regression analysis revealed that pre-LT serum levels of MDA over 3.37 nmol/mL were associated with mortality after one year of LT (Odds ratio = 5.38; 95% confidence interval (CI) = from 1.580 to infinite; p = 0.007) adjusting for age of the deceased donor. The main finding of our study was that there is an association between serum MDA levels before LT for HCC and 1-year survival after LT.

Effects of long-term folate supplementation on metabolic status and regression of cervical intraepithelial neoplasia: A randomized, double-blind, placebo-controlled trial

OBJECTIVE

This study was conducted to determine the effects of long-term folate supplementation on regression and metabolic status of patients with cervical intraepithelial neoplasia grade 1 (CIN1).

METHODS

This randomized, double-blind, placebo-controlled trial was performed among 58 women diagnosed with CIN1, ages 18 to 55 y old. Participants were randomly divided into two groups to receive 5 mg/d folate supplements (n = 29) or placebo (n = 29) for 6 mo. Fasting blood samples were taken at baseline and 6 mo after intervention to quantify related markers.

RESULTS

A greater percentage of women in the folate group had regressed CIN1 (83.3 versus 52.0%, P = 0.019) than those in the placebo group. Long-term folate supplementation resulted in a significant decrease in serum insulin levels (-1.6 ± 6.2 versus +2.6 ± 6.9 μIU/mL, P = 0.018) and homeostatic model assessment-beta cell function (HOMA-B) (-13.0 ± 39.0 versus +11.2 ± 42.3, P = 0.028) compared with the placebo. Additionally, plasma glutathione (GSH) levels were significantly increased (+81.5 ± 264.1 versus -220.9 ± 342.5 μmol/L, P < 0.001) and malondialdehyde (MDA) levels were significantly reduced (-1.0 ± 1.1 versus +0.1 ± 1.6 μmol/L, P = 0.004) in the folate group compared to the placebo.

CONCLUSIONS

Taken together, folate supplementation (5 mg/d) for 6 mo among women with CIN1 resulted in its regression as well as led to decreased serum insulin, HOMA-B, plasma MDA and increased plasma GSH levels; however, it did not affect other metabolic profiles.

Vitamin C Deficiency of Korean Homeless Patients Visiting to Emergency Department with Acute Alcohol Intoxication

Vitamins are essential micronutrients for maintenance of tissue functions. Vitamin deficiency is one of the most serious and common health problems among both chronic alcoholics and the homeless. However, the vitamin-level statuses of such people have been little studied. We evaluated the actual vitamin statuses of alcoholic homeless patients who visited an emergency department (ED). In this study the blood levels of vitamins B1, B12, B6, and C of 217 alcoholic homeless patients were evaluated retrospectively in a single urban teaching hospital ED. Vitamin C deficiency was observed in 84.3% of the patients. The vitamin B1, B12, and B6 deficiency rates, meanwhile, were 2.3%, 2.3%, and 23.5%, respectively. Comparing the admitted patients with those who were discharged, only the vitamin C level was lower. (P=0.003) In fact, the patients' vitamin C levels were markedly diminished, vitamin C replacement therapy for homeless patients should be considered in EDs.

A dose-response meta-analysis reveals an association between vitamin B12 and colorectal cancer risk

OBJECTIVE

The current meta-analysis evaluated the association between vitamin B12 intake and blood vitamin B12 level and colorectal cancer (CRC) risk.

DESIGN

The PubMed and EMBASE databases were searched. A dose-response analysis was performed with generalized least squares regression, with the relative risk (RR) and 95 % CI as effect values.

SETTING

The meta-analysis included seventeen studies.

SUBJECTS

A total of 10 601 patients.

RESULTS

The non-linear dose-response relationship between total vitamin B12 intake and CRC risk was insignificant (P=0·690), but the relationship between dietary vitamin B12 intake and CRC risk was significant (P<0·001). Every 4·5 μg/d increment in total and dietary vitamin B12 intake was inversely associated with CRC risk (total intake: RR=0·963; 95 % CI 0·928, 0·999; dietary intake: RR=0·914; 95 % CI 0·856, 0·977). The inverse association between vitamin B12 intake and CRC risk was also significant when vitamin B12 intake was over a dosage threshold, enhancing the non-linear relationship. The non-linear dose-response relationship between blood vitamin B12 level and CRC risk was insignificant (P=0·219). There was an insignificant association between every 150 pmol/l increment in blood vitamin B12 level and CRC risk (RR=1·023; 95 % CI 0·881, 1·187).

CONCLUSIONS

Our meta-analysis indicates that evidence supports the use of vitamin B12 for cancer prevention, especially among populations with high-dose vitamin B12 intake, and that the association between CRC risk and total vitamin B12 intake is stronger than between CRC risk and dietary vitamin B12 intake only.

Meta-analysis reveals protective effects of vitamin B on stroke patients

Stroke is the loss of brain function due to a disturbance in the blood supply to the brain resulting from either ischemia or hemorrhage. Previous studies have evaluated the clinical importance of nutritional interventions such as vitamin B supplementation in the management of acute strokes. However, it is still inconclusive whether or not vitamin B supplementation will benefit patients with acute strokes. Therefore, a meta-analysis was performed to assess the efficacy of vitamin B supplementation in the treatment of stroke patients. Medline, Embase, Scopus, and Cochrane Library databases were searched (from 1960 to June 2015) and forest plots were generated to illustrate the treatment effects. A systemic review of the electronic databases yielded 12 eligible studies consisting of 7474 patients. Forest plots from the meta-analyses of the included studies illustrated that vitamin B supplementation significantly lowered the plasma concentration of total homocysteine (SMD = −0.82; 95% CI: −0.77; Z = −29.06, p < 0.0001) and resulted in significant reduction in stroke recurrence (OR = 0.86%; 95% CI: 0.76, 0.97; Z = −2.41; p = 0.016) as well as a combined incidence of vascular events, including recurrent strokes, myocardial infarctions and vascular deaths (OR = 0.87%; 95% CI: 0.79, 0.96; Z= −2.73; p = 0.0063).

Additionally, the nearly-symmetrical funnel plot (Egger’s test, t = −1.705, p = 0.1224) indicated the absence of publication bias regarding the meta-analysis that examined the effect of vitamin B supplementation on the plasma levels of homocysteine in acute stroke patients. These findings suggested that vitamin B supplementation presents a potential addition to the armamentarium for the management of acute stroke patients.

Ascorbic Acid Reduces the Adverse Effects of Delayed Administration of Tissue Plasminogen Activator in a Rat Stroke Model

Delayed treatment of stroke with recombinant tissue plasminogen activator (r-tPA) induces overexpression of matrix metalloproteinase 9 (MMP-9) which leads to breakdown of the blood-brain barrier (BBB) and causes more injuries to the brain parenchyma. In this study, the effect of ascorbic acid (AA), an antioxidant agent, on the delayed administration of r-tPA in a rat model of permanent middle cerebral artery occlusion (MCAO) was investigated. Forty male rats were randomly divided into four groups: untreated control rats (ischaemic animals), AA-treated (500 mg/kg; 5 hr after stroke) rats, r-tPA-treated (5 hr after stroke 1 mg/kg) rats and rats treated with the combination of AA and r-tPA. Middle cerebral artery occlusion was induced by occluding the right middle cerebral artery (MCA). Infarct size, BBB, brain oedema and the levels of MMP-9 were measured at the end of study. Neurological deficits were evaluated at 24 and 48 hr after stroke. Compared to the control or r-tPA-treated animals, AA alone (p < 0.001) or in combination with r-tPA (p < 0.05) significantly decreased infarct volume. Ascorbic acid alone or r-tPA + AA significantly reduced BBB permeability (p < 0.05), levels of MMP-9 (p < 0.05 versus control; p < 0.01 versus r-tPA) and brain oedema (p < 0.001) when compared to either the control or the r-tPA-treated animals. Latency to the removal of sticky labels from the forepaw was also significantly decreased after the administration of AA + r-tPA (p < 0.05) at 24 or 48 hr after stroke. Based on our data, acute treatment with AA may be considered as a useful candidate to reduce the side effects of delayed application of r-tPA in stroke therapy.

Serum malondialdehyde levels in patients with malignant middle cerebral artery infarction are associated with mortality

Objective

Malondialdehyde (MDA) is an end-product formed during lipid peroxidation, due to degradation of cellular membrane phospholipids. MDA is released into extracellular space and finally into the blood; it has been used as an effective biomarker of lipid oxidation. High circulating levels of MDA have been previously described in patients with ischemic stoke than in controls, and an association between circulating MDA levels and neurological functional outcome in patients with ischemic stoke. However, an association between serum MDA levels and mortality in patients with ischemic stroke has not been previously reported, and that was the objective of this study.

Methods

Observational, prospective and multicenter study performed in six Intensive Care Units. We included patients with severe malignant middle cerebral artery infarction (MMCAI) defined as Glasgow Coma Scale (GCS) lower than 9. We measured serum MDA levels in 50 patients with severe MMCAI at the time of diagnosis and in 100 healthy subjects. Mortality at 30 days was the end point of the study.

Results

We found that patients with severe MMCAI showed higher serum MDA levels than healthy subjects (p<0.001). We found higher serum MDA levels (p<0.001) in non-surviving MMCAI patients (n=26) than in survivors (n=24). The area under the curve for prediction of 30-day mortality for serum MDA levels was 0.77 (95% CI = 0.63-0.88; p<0.001). Serum MDA levels >2.27 nmol/mL were associated with 30-day mortality (OR=7.23; 95% CI=1.84-28.73; p=0.005) controlling for GCS and age on multiple binomial logistic regression analysis.

Conclusions

To our knowledge, this is the first study showing that serum malondialdehyde levels in patients with MMCAI are associated with early mortality.

The effects of folate supplementation on inflammatory factors and biomarkers of oxidative stress in overweight and obese women with polycystic ovary syndrome: a randomized, double-blind, placebo-controlled clinical trial

OBJECTIVE

This study was conducted to determine the effects of folate supplementation on inflammatory factors and biomarkers of oxidative stress among women with polycystic ovary syndrome (PCOS).

DESIGN, PATIENTS AND MEASUREMENTS

This randomized, double-blind, placebo-controlled clinical trial was conducted among 69 women diagnosed with PCOS and aged 18-40 year old. Participants were randomly assigned to three groups receiving the following: (1) folate-1: 1 mg/d folate supplements (N = 23); (2) folate-5: 5 mg/d folate supplements (N = 23) and (3) placebo (N = 23) for 8 weeks. Fasting blood samples were taken at the beginning of the study and after 8 weeks to measure homocysteine (Hcy), inflammatory factors including high-sensitivity C-reactive protein (hs-CRP), nitric oxide (NO), biomarkers of oxidative stress including total antioxidant capacity (TAC), glutathione (GSH), malondialdehyde (MDA) and homoeostatic model assessment-beta cell function (HOMA-B).

RESULTS

Supplementation with 5 mg/d folate resulted in reduced plasma Hcy (-2·23 vs -1·86 and 1·16 μm, respectively, P < 0·05), HOMA-B (-7·63 vs 1·43 and 13·66, respectively, P < 0·05), serum hs-CRP (-212·2 vs -262·4 and 729·8 μg/l, respectively, P < 0·05) and plasma MDA concentrations (-0·48 vs -0·24 and 0·69 μm, respectively, P < 0·01) compared with folate-1 and placebo groups. Furthermore, a significant rise in plasma TAC (0·64 vs -3·53 and -215·47 mm, respectively, P < 0·01) and GSH levels (162·1 vs 195·8 and -158·2 μm, respectively, P < 0·01) was also observed following the administration of 5 mg/d folate supplements compared with folate-1 and placebo groups.

CONCLUSIONS

In conclusion, folate supplementation (5 mg/d) in women with PCOS had beneficial effects on inflammatory factors and biomarkers of oxidative stress.

Effectiveness of B vitamins on the control of hypertension and stroke events of SHRSP rats

The spontaneously hypertensive stroke-prone rat (SHRSP) is a recognized animal model for the study of severe hypertension and stroke, being characterized by presenting an elevated tissue levels of free radicals. Therefore, this study has the main goal to identify the effect of B vitamins, closely associated to the control of oxidative stress, on SHRSP rats. After 10 days (baseline period), the animals, 18 SHRSP rats at 18 weeks of age, were divided into three groups with six rats treated with riboflavin (B2), six treated with pyridoxine (B6) plus folic acid (B9), and control. Body weight, water and food intake, diuresis, sensory-motor responses, and systolic blood pressure of all the rats were determined daily. Physical aspects of whole body (i.e., distribution and coloring of hair, skin and mucosa, and an eventual presence of bleeding, stains, cracks, or opacification) and behavior were equally monitored. The data were evaluated by ANOVA two-way and p < .05 was considered significant. The supraphysiologic doses did not cause toxic effects. There was a significant decrease of systolic blood pressure, homocysteine, and malondialdehyde (MDA) blood levels in animals under B vitamin supplementation. The treatment also inhibited the neurological signs of an ischemic attack (unbalance, ataxia, and convulsions). The findings reported here suggest that B vitamin therapy was effective for the control of systolic blood pressure and oxidative stress. Hence, it could be thought as one of the alternative therapies to prevent the occurrence of stroke.

Methoxistasis: integrating the roles of homocysteine and folic acid in cardiovascular pathobiology

Over the last four decades, abnormalities in the methionine-homocysteine cycle and associated folate metabolism have garnered great interest due to the reported link between hyperhomocysteinemia and human pathology, especially atherothrombotic cardiovascular disease. However, clinical trials of B-vitamin supplementation including high doses of folic acid have not demonstrated any benefit in preventing or treating cardiovascular disease. In addition to the fact that these clinical trials may have been shorter in duration than appropriate for modulating chronic disease states, it is likely that reduction of the blood homocysteine level may be an oversimplified approach to a complex biologic perturbation. The methionine-homocysteine cycle and folate metabolism regulate redox and methylation reactions and are, in turn, regulated by redox and methylation status. Under normal conditions, a normal redox-methylation balance, or “methoxistasis”, exists, coordinated by the methionine-homocysteine cycle. An abnormal homocysteine level seen in pathologic states may reflect a disturbance of methoxistasis. We propose that future research should be targeted at estimating the deviation from methoxistasis and how best to restore it. This approach could lead to significant advances in preventing and treating cardiovascular diseases, including heart failure.

Oxidative damage and inflammation in obese diabetic Emirati subjects supplemented with antioxidants and B-vitamins: a randomized placebo-controlled trail

BACKGROUND

Obesity and related morbidities are reaching epidemic proportions in the Arab populations. Possible mechanisms that link obesity/visceral fat to diabetes and cardiovascular (CVD) complications include inflammation and increased oxidative stress. The aim of this study is to test whether supplementary antioxidants with B-group vitamins enhance antioxidant capacity and/or mitigate oxidative damage and subclinical inflammation in obese diabetic patients.

METHODS

Hundred diabetic patients were randomly assigned to receive either oral dose of daily B-group vitamins (1.67 mg folic acid, 1.67 mg vitamin B-2, 20 mg vitamin B-6, 0.134 mg vitamin B-12) and antioxidant vitamins (221 mg of α-tocopherol and 167 mg of vitamin C) [n = 50], or an identical placebo [n = 50] daily for 90 days. Blood was obtained before treatment, and after 90 days for measurements of plasma antioxidant vitamins status, markers of oxidative damage [malondialdehyde (MDA) and protein carbonyls] and inflammation (C-Reactive Proteins [CRP], IL6 & TNFα).

RESULTS

Supplementation with antioxidant and B-group vitamins increased plasma concentration of vitamin E and folate and reduced homocysteine in the intervention groups compared with the placebo group. Vitamin B12 improved in the supplement group compared with the decline seen in the placebo group however, this did not reach statistical significance. Vitamin C declined in both groups but more so in the intervention group. Both MDA and Protein carbonyls increased in both the supplement and the placebo group. IL6 concentration increased in both groups but less so in the supplement group (p = 0.023). TNF showed more pronounced decline in the supplement group compared with the placebo group but the difference between cumulative changes did not reach statistical significance (p = 0.204). CRP concentrations declined in the supplement group in contrast to the rise seen in the placebo group however, the difference between cumulative changes was not statistically significant (p = 0.205).

CONCLUSIONS

Antioxidants supplementation with B-group vitamins enhances antioxidant capacity, and may have an anti-inflammatory effect in obese diabetic patients.

Antioxidant micronutrients in the critically ill: a systematic review and meta-analysis

INTRODUCTION

Critical illness is characterized by oxidative stress, which is a major promoter of systemic inflammation and organ failure due to excessive free radical production, depletion of antioxidant defenses, or both. We hypothesized that exogenous supplementation of trace elements and vitamins could restore antioxidant status, improving clinical outcomes.

METHODS

We searched computerized databases, reference lists of pertinent articles and personal files from 1980 to 2011. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated relevant clinical outcomes with antioxidant micronutrients (vitamins and trace elements) supplementation versus placebo.

RESULTS

A total of 21 RCTs met inclusion criteria. When the results of these studies were statistically aggregated (n = 20), combined antioxidants were associated with a significant reduction in mortality (risk ratio (RR) = 0.82, 95% confidence interval (CI) 0.72 to 0.93, P = 0.002); a significant reduction in duration of mechanical ventilation (weighed mean difference in days = -0.67, 95% CI -1.22 to -0.13, P = 0.02); a trend towards a reduction in infections (RR= 0.88, 95% CI 0.76 to 1.02, P = 0.08); and no overall effect on ICU or hospital length of stay (LOS). Furthermore, antioxidants were associated with a significant reduction in overall mortality among patients with higher risk of death (>10% mortality in control group) (RR 0.79, 95% CI 0.68 to 0.92, P = 0.003) whereas there was no significant effect observed for trials of patients with a lower mortality in the control group (RR = 1.14, 95% 0.72 to 1.82, P = 0.57). Trials using more than 500 μg per day of selenium showed a trend towards a lower mortality (RR = 0.80, 95% CI 0.63 to 1.02, P = 0.07) whereas trials using doses lower than 500 μg had no effect on mortality (RR 0.94, 95% CI 0.67 to 1.33, P = 0.75).

CONCLUSIONS

Supplementation with high dose trace elements and vitamins may improve outcomes of critically ill patients, particularly those at high risk of death.

Red blood cell distribution width is associated with poor clinical outcome in acute cerebral infarction

Increased red blood cell distribution width (RDW), which is a marker of anisocytosis, is associated with mortality and cardiovascular events in the general population and in patients with heart failure or coronary heart disease. We investigated whether RDW in acute cerebral infarction is predictive of functional outcome and mortality. A total of 847 consecutive patients with first-ever acute cerebral infarction who presented to the emergency department within seven days of symptom onset were enrolled in this study. We investigated the association of RDW with poor functional outcome (modified Rankin Scale >2) and all-cause mortality at three months, as well as survival time for one year after stroke onset. Multivariate logistic regression revealed that higher RDW was independently associated with poor functional outcome (adjusted odds ratio [OR], 1.222 per 1% increment in RDW, 95% confidence interval [CI] 1.059-1.409, p=0.006) and all-cause death (adjusted OR, 1.395 per 1% increment in RDW, 95% CI 1.168-1.665, p<0.001) at three months after stroke onset. RDW was an independent predictor of survival in multivariate Cox-proportional regression model (adjusted hazard ratio, 1.328 per 1% increment in RDW, 95%CI 1.178-1.498, p<0.001). The addition of RDW to a survival model significantly increased predictability for survival across the entire follow-up period (weighted average of the area-under the curves, 0.858 vs. 0.841, p<0.05). In conclusion, higher RDW measured in cases of acute stage cerebral infarction was associated with poor functional outcome and mortality. RDW may be used as a biomarker for the prediction of long-term outcomes in patients with acute cerebral infarction.

Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases

BACKGROUND

Our systematic review has demonstrated that antioxidant supplements may increase mortality. We have now updated this review.

OBJECTIVES

To assess the beneficial and harmful effects of antioxidant supplements for prevention of mortality in adults.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, LILACS, the Science Citation Index Expanded, and Conference Proceedings Citation Index-Science to February 2011. We scanned bibliographies of relevant publications and asked pharmaceutical companies for additional trials.

SELECTION CRITERIA

We included all primary and secondary prevention randomised clinical trials on antioxidant supplements (beta-carotene, vitamin A, vitamin C, vitamin E, and selenium) versus placebo or no intervention.

DATA COLLECTION AND ANALYSIS

Three authors extracted data. Random-effects and fixed-effect model meta-analyses were conducted. Risk of bias was considered in order to minimise the risk of systematic errors. Trial sequential analyses were conducted to minimise the risk of random errors. Random-effects model meta-regression analyses were performed to assess sources of intertrial heterogeneity.

MAIN RESULTS

Seventy-eight randomised trials with 296,707 participants were included. Fifty-six trials including 244,056 participants had low risk of bias. Twenty-six trials included 215,900 healthy participants. Fifty-two trials included 80,807 participants with various diseases in a stable phase. The mean age was 63 years (range 18 to 103 years). The mean proportion of women was 46%. Of the 78 trials, 46 used the parallel-group design, 30 the factorial design, and 2 the cross-over design. All antioxidants were administered orally, either alone or in combination with vitamins, minerals, or other interventions. The duration of supplementation varied from 28 days to 12 years (mean duration 3 years; median duration 2 years). Overall, the antioxidant supplements had no significant effect on mortality in a random-effects model meta-analysis (21,484 dead/183,749 (11.7%) versus 11,479 dead/112,958 (10.2%); 78 trials, relative risk (RR) 1.02, 95% confidence interval (CI) 0.98 to 1.05) but significantly increased mortality in a fixed-effect model (RR 1.03, 95% CI 1.01 to 1.05). Heterogeneity was low with an I(2)- of 12%. In meta-regression analysis, the risk of bias and type of antioxidant supplement were the only significant predictors of intertrial heterogeneity. Meta-regression analysis did not find a significant difference in the estimated intervention effect in the primary prevention and the secondary prevention trials. In the 56 trials with a low risk of bias, the antioxidant supplements significantly increased mortality (18,833 dead/146,320 (12.9%) versus 10,320 dead/97,736 (10.6%); RR 1.04, 95% CI 1.01 to 1.07). This effect was confirmed by trial sequential analysis. Excluding factorial trials with potential confounding showed that 38 trials with low risk of bias demonstrated a significant increase in mortality (2822 dead/26,903 (10.5%) versus 2473 dead/26,052 (9.5%); RR 1.10, 95% CI 1.05 to 1.15). In trials with low risk of bias, beta-carotene (13,202 dead/96,003 (13.8%) versus 8556 dead/77,003 (11.1%); 26 trials, RR 1.05, 95% CI 1.01 to 1.09) and vitamin E (11,689 dead/97,523 (12.0%) versus 7561 dead/73,721 (10.3%); 46 trials, RR 1.03, 95% CI 1.00 to 1.05) significantly increased mortality, whereas vitamin A (3444 dead/24,596 (14.0%) versus 2249 dead/16,548 (13.6%); 12 trials, RR 1.07, 95% CI 0.97 to 1.18), vitamin C (3637 dead/36,659 (9.9%) versus 2717 dead/29,283 (9.3%); 29 trials, RR 1.02, 95% CI 0.98 to 1.07), and selenium (2670 dead/39,779 (6.7%) versus 1468 dead/22,961 (6.4%); 17 trials, RR 0.97, 95% CI 0.91 to 1.03) did not significantly affect mortality. In univariate meta-regression analysis, the dose of vitamin A was significantly associated with increased mortality (RR 1.0006, 95% CI 1.0002 to 1.001, P = 0.002).

AUTHORS' CONCLUSIONS

We found no evidence to support antioxidant supplements for primary or secondary prevention. Beta-carotene and vitamin E seem to increase mortality, and so may higher doses of vitamin A. Antioxidant supplements need to be considered as medicinal products and should undergo sufficient evaluation before marketing.

Nutrition for brain recovery after ischemic stroke: an added value to rehabilitation

In patients who undergo rehabilitation after ischemic stroke, nutrition strategies are adopted to provide tube-fed individuals with adequate nutrition and/or to avoid the body wasting responsible for poor functional outcome and prolonged stay in the hospital. Investigations have documented that nutrition interventions can enhance the recovery of neurocognitive function in individuals with ischemic stroke. Experimental studies have shown that protein synthesis is suppressed in the ischemic penumbra. In clinical studies on rehabilitation patients designed to study the effects of counteracting or limiting this reduction of protein synthesis by providing protein supplementation, patients receiving such supplementation had enhanced recovery of neurocognitive function. Cellular damage in cerebral ischemia is also partly caused by oxidative damage secondary to free radical formation and lipid peroxidation. Increased oxidative stress negatively affects a patient's life and functional prognosis. Some studies have documented that nutrition supplementation with B-group vitamins may mitigate oxidative damage after acute ischemic stroke. Experimental investigations have also shown that cerebral ischemia changes synaptic zinc release and that acute ischemia increases zinc release, aggravating neuronal injury. In clinical practice, patients with ischemic stroke were found to have a lower than recommended dietary intake of zinc. Patients in whom daily zinc intake was normalized had better recovery of neurological deficits than subjects given a placebo. The aim of this review is to highlight those brain metabolic alterations susceptible to nutrition correction in clinical practice. The mechanisms underlying the relationship between cerebral ischemia and nutrition metabolic conditions are discussed.

Vitamin E and risk of cardiovascular diseases: a review of epidemiologic and clinical trial studies

Cardiovascular diseases are the leading cause of worldwide mortality. There is strong epidemiologic evidence for a beneficial effect of vitamin E on cardiovascular disease risk. However, conflicting results have been reported by intervention studies. To assess the potential benefit of vitamin E intake on the risk of cardiovascular diseases, fifty-nine published reports from observational studies, retrospective and prospective, randomised clinical trials, meta-analyses as well as pooling analyses were reviewed. The paper provides a detailed discussion about design, quality and limitations of these studies with regard to the evidence of the hypothesized relationship between vitamin E and cardiovascular diseases.

Inflammation, vitamin deficiencies and organ failure in critically ill patients

It is unknown whether biochemical vitamin deficiencies in critical illness are associated with severity of illness, organ dysfunction, inflammation or mortality. This nested cohort study recruited 98 patients admitted as emergencies to the intensive care unit, who had a stay of greater than 48 hours. Patient data were prospectively collected. Within the first 48 hours of admission, concentrations of C-reactive protein, vitamins A, E, B1, B12 and folate were measured on arterial blood. These measures were then repeated at least once during the later (> 48 hours) period of their stay. Seventy patients (71%) had completed vitamin studies eligible for inclusion in the analysis. Ten patients died (14.3%) during their hospital stay and mortality was associated with age, admission source and severity of illness scores. Vitamin B12 concentration was weakly associated with C-reactive protein concentrations on admission to the intensive care unit (r on days one and two = 0.4 [P = 0.002], 0.36 [P = 0.04], respectively) and with the Sequential Organ Failure Assessment score between days two and four (Spearman's r = 0.361 [P = 0.04], 0.42 [P = 0.02] and 0.48 [P = 0.02], respectively). Vitamin A concentration was weakly associated with the C-reactive protein concentrations on days one and five (Spearman's r = -0.5 [P = 0.001], -0.4 [P = 0.03], respectively). Change in deficiency status of any of the vitamins over time in the first week of intensive care admission did not appear to influence mortality. We conclude that while weak correlations were identified between vitamins A and B12 and C-reactive protein and Sequential Organ Failure Assessment scores, the importance of these associations and their relationship to hospital mortality remain to be determined.

Abnormal transmethylation/transsulfuration metabolism and DNA hypomethylation among parents of children with autism

An integrated metabolic profile reflects the combined influence of genetic, epigenetic, and environmental factors that affect the candidate pathway of interest. Recent evidence suggests that some autistic children may have reduced detoxification capacity and may be under chronic oxidative stress. Based on reports of abnormal methionine and glutathione metabolism in autistic children, it was of interest to examine the same metabolic profile in the parents. The results indicated that parents share similar metabolic deficits in methylation capacity and glutathione-dependent antioxidant/detoxification capacity observed in many autistic children. Studies are underway to determine whether the abnormal profile in parents reflects linked genetic polymorphisms in these pathways or whether it simply reflects the chronic stress of coping with an autistic child.

Discrepancy between improvement of insulin sensitivity and that of arterial endothelial function in patients receiving antihypertensive medication

OBJECTIVES

We evaluated whether the changes in the insulin sensitivity observed in hypertensive patients following treatment with an angiotensin II receptor blocker (candesartan) or calcium-channel antagonist (amlodipine) might be related to improvement of the endothelial function (END) and/or plasma level of high-sensitive C-reactive protein (CRP) following such treatment.

METHODS AND RESULTS

Seventy-one hypertensive patients (age: 58 +/- 10 years) without obvious target organ damage were allocated randomly to treatment with either candesartan at the dose of 8 mg/day or amlodipine at the dose of 5 mg/day. At the start and end of the 8-month treatment period, the homeostasis model assessment index of insulin resistance (HOMA-IR index), plasma CRP and END, as assessed by changes in the forearm blood flow in reactive hyperemia, were determined. While significant improvement of END was observed in patients receiving either drug, only candesartan, but not amlodipine, also reduced the plasma CRP and HOMA-IR index (2.13 +/- 1.92 --> 1.53 +/- 1.47, P < 0.05). In the patients receiving treatment with candesartan, stepwise multivariate linear regression analysis revealed that the percent change in the HOMA-IR index was significantly and independently correlated with that in the plasma CRP (beta = 0.38, P < 0.05), but not with that in END:

CONCLUSION

Improvement of the END alone by the antihypertensive medication might not entirely explain the improvement of the insulin sensitivity observed in these patients. Additional mechanisms may be involved, and the anti-inflammatory effects of the medication observed in patients treated with candesartan may also be related, at least in part, to the observed improvement of insulin sensitivity.

Riboflavin status in acute ischaemic stroke

BACKGROUND

There is experimental evidence that riboflavin (vitamin B2) supplementation reduces oxidative damage and cerebral oedema following acute stroke.

OBJECTIVE

To measure riboflavin levels in acute stroke before and after supplementation with this vitamin.

DESIGN

Ninety-six acute ischaemic stroke patients had their riboflavin status measured at baseline and then randomly assigned to receive 5 mg of oral riboflavin and other B-group vitamins within 12 h of the stroke onset and then daily or no B-vitamins for 14 days. Non-fasting venous blood was obtained at baseline, days 7 and 14 post-randomization for measurement of riboflavin status using erythrocyte glutathione reductase activity coefficient (EGRAC). EGRAC is a measure of riboflavin tissue saturation. This assay has the advantage of being extremely stable and sensitive. EGRAC values are inversely proportional to riboflavin status, so that values greater than 1.3 indicate biochemical deficiency.

RESULTS

Fifty-one per cent of patients studied were riboflavin deficient at baseline. Fourteen days of riboflavin supplementation significantly improved the measure of B2 status compared with the control group. Seven out of 37 patients in the supplement group (19%) were riboflavin deficient compared with 22 out of 39 patients (56%) in the control group at the end of the treatment period (P=0.035 for the differences in cumulative changes between groups over 2 weeks).

CONCLUSIONS

A high proportion of acute stroke patients were biochemically deficient of riboflavin immediately post-infarct. Supplementation with 5 mg of riboflavin for 2 weeks significantly improved riboflavin status; however, the clinical significance of these findings is not yet known.