Effects of Ginkgo biloba in dementia: systematic review and meta-analysis

Novel Energy Drink Improves Cognitive Function and Mood, without Influencing Myocardial Oxygen Demand or Ventricular Repolarization in Adult Gamers: A Randomized, Double-Blind, Placebo-Controlled, Crossover Trial

OBJECTIVES

To examine the efficacy of acute consumption of a novel energy drink (C4S) versus placebo for improving cognitive and gaming performance and mood. Secondarily, we examined the cardiovascular safety profile of acute C4S consumption.

METHODS

Forty-five healthy, young adult video gamers completed two experimental visits in randomized order where they consumed either C4S or a placebo and then completed a validated battery of neurocognitive tests, played five video games, and completed a mood state survey. Blood pressure (BP), heart rate (HR), oxygen saturation, and electrocardiogram measurements were taken at baseline and repeated throughout each visit.

RESULTS

Acute consumption of C4S improved cognitive flexibility (absolute mean or median difference [95% CI] = +4.3 [2.2-6.4]; p < 0.001; d = 0.63), executive function (+4.3 [2.3-6.3]; p < 0.001; d = 0.63), sustained attention (+2.1 [0.6-3.6]; p = 0.01; d = 0.44), motor speed (+2.9 [0.8-4.9]; p < 0.001; d = 0.44), psychomotor speed (+3.9 [0.1-7.7]; p = 0.04; d = 0.32) working memory (+1.0 [0.1-1.9]; p = 0.02; d = 0.35), and performance in the two-dimensional visuospatial game Tetris (+463 [-419-2,065] pts; p = 0.049; d = 0.30) compared to placebo. C4S also improved Fatigue-Inertia (-1 [-3-0]; p = 0.004; d = 0.45), Vigor-Activity (+2.4 [1.3-3.6]; p < 0.001; d = 0.64), Friendliness (+0 [0-1]; p = 0.04; d = 0.32), and Total Mood Disturbance (-3 [-6-0]; p = 0.002; d = 0.44). BP increased slightly in C4S versus placebo, while HR decreased from baseline to post-drink in the C4S condition. Rate-pressure-product was higher in C4S versus placebo independent of time but did not increase from baseline. There was no effect on corrected QT interval.

CONCLUSION

Acute consumption of C4S was efficacious for cognitive performance, visuospatial gaming performance, and mood enhancement, and had no effect on myocardial oxygen demand or ventricular repolarization, despite being associated with increases in BP.

Cross-Regional Data Initiative for the Assessment and Development of Treatment for Neurological and Mental Disorders

Purpose

To describe and categorize detailed components of databases in the Neurological and Mental Health Global Epidemiology Network (NeuroGEN).

Methods

An online 132-item questionnaire was sent to key researchers and data custodians of NeuroGEN in North America, Europe, Asia and Oceania. From the responses, we assessed data characteristics including population coverage, data follow-up, clinical information, validity of diagnoses, medication use and data latency. We also evaluated the possibility of conversion into a common data model (CDM) to implement a federated network approach. Moreover, we used radar charts to visualize the data capacity assessments, based on different perspectives.

Results

The results indicated that the 15 databases covered approximately 320 million individuals, included in 7 nationwide claims databases from Australia, Finland, South Korea, Taiwan and the US, 6 population-based electronic health record databases from Hong Kong, Scotland, Taiwan, the Netherlands and the UK, and 2 biomedical databases from Taiwan and the UK.

Conclusion

The 15 databases showed good potential for a federated network approach using a common data model. Our study provided publicly accessible information on these databases for those seeking to employ real-world data to facilitate current assessment and future development of treatments for neurological and mental disorders.

Early intervention and adding effective doses of EGb761 like Ginkgo extract slow down dementia progression: insights to the neurovascular unit

Background

Dementia is a progressive neurodegenerative disorder characterized by cognitive decline, memory impairment, and functional deterioration. Pharmacological interventions play a crucial role in managing dementia symptoms and potentially slowing down disease progression.

Objectives

This study aimed to investigate the impact of pharmacological interventions, including acetylcholinesterase inhibitors (AChEIs), memantine, and Gingko extract, on the progression of dementia, with a specific focus on mild cognitive impairment (MCI), Alzheimer's disease (AD), and non-Alzheimer dementias.

Methods

A total of 547 participants out of 3,547 cases in a specific dataset followed by the same author, including healthy controls, individuals with MCI, AD, and non-Alzheimer dementias, were included in this study. The follow-up duration was up to 211 months, allowing for a minimum 3 visits comprehensive assessment of disease progression. The treatment approaches included AChEIs, memantine, and combination therapy, with variations in the starting time for these treatments based on the dementia type.

Results

The use of AChEIs and memantine showed efficacy in improving cognitive function and overall function in individuals with MCI, AD, and non-AD dementias. Combination therapy EGb761 like Gingko extract with AChEIs and/or Memantine demonstrated a slower progression compared to AChEIs alone in individuals with prodromal dementia (MCI) and AD. The starting time for memantine and combination therapy was earlier in non-AD dementia cases compared to AD dementia cases and prodromal dementia.

Conclusion

Pharmacological interventions, particularly the use of AChEIs and memantine, can have a positive impact on cognitive function and overall function in individuals with dementia. The combination of AChEIs with EGb761 like Gingko extract may provide additional benefits in slowing down disease progression in AD cases. Early recognition and accurate classification of MCI subtypes are crucial, and the use of EGb761 like Gingko extract is recommended for symptomatic treatment. Future personalized risk predictions based on biomarker constellations may further enhance the multi-target treatment approaches of MCI and different dementia types.

A bibliometric and thematic analysis of the trends in the research on ginkgo biloba extract from 1985 to 2022

Background

Ginkgo biloba extract (GBE), a complementary and alternative medicine, has been widely used for disorders such as brain infarction, dementia, and coronary heart disease, in recent decades. Given its widespread clinical use, GBE has always been a vital research topic. However, there are no bibliometric analyses on this topic; furthermore, published reviews of GBE focus only on a specific research field or lack scientific and systematic evaluation. This study combined bibliometrics with thematic reviews by visual analysis to identify the current status of GBE research and to better identify research hotspots and trends in the past 40 years to understand future developments in basic and clinical research.

Methods

Articles and reviews on GBE were retrieved by topic from the Web of Science Core Collection from inception to 2022.12.01. Countries, institutions, authors, journals, references, and keywords in the field were visually analyzed using CiteSpace, Scimago Graphica, and VOSviewer software; then, these visualization results for references and keywords were clarified in detail by thematic reviews in subdivisions of the fields.

Results

In total, 2015 publications were included. The GBE-related literature has high volumes of publications and citations. The majority of literature is from China, and the USA cooperates most closely with other countries. In GBE research, Christen Yves is the most cited author, Phytotherapy Research is the most prolific journal, and the Journal of Ethnopharmacology is the most co-cited journal. Through a comprehensive analysis of keywords, references, and reviews, the quality of the meta-analysis of randomized controlled clinical trials of GBE in treating dementia was evaluated by the Risk of Bias in Systematic Reviews scale (ROBIS). Current research on GBE focuses on its pharmacological mechanisms, and neuroprotective application in diseases such as Alzheimer's disease, and glaucoma. Randomized controlled trials are the current research hotspot.

Conclusion

Research on GBE is flourishing; using bibliometric and thematic analysis, we identified its hotspots and trends. The pharmacological mechanisms and clinical applications of GBE are the focus of present and likely future research.

Oxidative stress: A target to treat Alzheimer's disease and stroke

Oxidative stress has been established as a well-known pathological condition in several neurovascular diseases. It starts with increased production of highly oxidizing free-radicals (e.g. reactive oxygen species; ROS and reactive nitrogen species; RNS) and becomes too high for the endogenous antioxidant system to neutralize them, which results in a significantly disturbed balance between free-radicals and antioxidants levels and causes cellular damage. A number of studies have evidently shown that oxidative stress plays a critical role in activating multiple cell signaling pathways implicated in both progression as well as initiation of neurological diseases. Therefore, oxidative stress continues to remain a key therapeutic target for neurological diseases. This review discusses the mechanisms involved in reactive oxygen species (ROS) generation in the brain, oxidative stress, and pathogenesis of neurological disorders such as stroke and Alzheimer's disease (AD) and the scope of antioxidant therapies for these disorders.

Efficacy and safety of herbal medicine on dementia and cognitive function: An umbrella review of systematic reviews and meta-analysis

This study aims to summarize the effects of herbs on dementia and assess the strength of evidence. Six international and local databases were searched from inception to October 2021 for systematic reviews and meta-analyses of clinical trials investigated the effects of herbal medicine on dementia or cognitive function. Two researchers independently extracted data, assessed the methodological quality, and rated the credibility of evidence according to established criteria. Thirty-seven articles evaluating 13 herbal medicines were included. Of these, 65% were rated critically low using AMSTAR2. Of 90 unique outcomes, 41 (45.6%) were statistically significant based on random effects model (p ≤ .05). Only 3 herbs were supported by suggestive evidence whereas the others were supported by weak evidence. The suggestive evidence supported benefits of Chinese herbal medicine (CHM) plus pharmacotherapy (WMD:1.84; 95% CI: 1.34, 2.35) and Vinpocetine (WMD: -0.94; 95%CI: -1.50, -0.38) on improving cognitive function assessing by Montreal Cognitive Assessment and Syndrom-Kurz-Test, respectively. Moreover, suggestive evidence supported benefit of Huperzia serrata on improving Activities of Daily Living (WMD:-7.18; 95%CI: -9.12, -5.23). No SAE was reported. In conclusion, several herbs were used for improving dementia and cognitive function but recent evidence were limited by the small sample size and poor methodological quality. Therefore, further large and well-designed studies are needed to support the evidence.

A pilot randomized controlled trial of WeiNaoKang (SaiLuoTong) in treating vascular dementia

Objective

WeiNaoKang (or SaiLuoTong) is an herbal formula consisting of ginkgo, ginseng, and saffron. Our objective was to investigate if WeiNaoKang could improve cognitive function and cerebral perfusion in patients suffering from vascular dementia.

Methods

A 16-week randomized double-blind, placebo-controlled trial was carried out in the setting of a memory disorder clinic at a single center. Patients with vascular dementia diagnosed clinically but supported by imaging and other investigations were invited to participate. The diagnoses were based on the National Institute of Neurological Disorders and Stroke/Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) criteria. An independent blinded assessor evaluated the effects of the formula. Intervention group was compared to the control group. A subgroup of participants was randomly chosen for further evaluation of cerebral perfusion by single photon emission computed tomography scans post-treatment.

Results

Both groups were comparable in age (mean = 74 ± 7.2 years in the placebo group and 75 ± 7.4 in the intervention group) and in other demographics. Sixty-two participants were included in final analysis. Alzheimer's Disease Assessment Scale - Cognitive Portion (ADAS-cog) was the primary outcome. By week 16, the mean ADAS-cog reduced from 24.48 to 20.30 (mean reduction = 4.18) for those in the treatment group, and from 18.98 to 17.81 (mean reduction = 1.18) for those in the placebo group. The difference in mean reduction of ADAS-cog was -3.00 (95% confidence interval [CI] = -4.910 to -1.100) in favor of the treatment group. Secondary outcomes of activities of daily living and quality of life measures also showed significant difference. In the perfusion scan analysis, the difference in the change in cerebral blood flow (t-scores) pre- and post-treatment between the intervention group (n = 7) and the placebo group (n = 11) was statistically significant (P < 0.001).

Conclusion

In this randomized, double-blind placebo-controlled trial, we demonstrated significant differences in improvement in cognitive function and activities of daily living. The clinical improvement is corroborated with improvement in cerebral perfusion in a subset of participants.

Dietary Flavonoids and Human Cognition: A Meta-Analysis

Improving cognition is important in all age groups, from performance in school examinations to prevention of cognitive decline in later life. Dietary polyphenols, in particular flavonoids, have been examined for their benefits to cognitive outcomes. This meta-analysis evaluates the effects of dietary flavonoids on cognition across the lifespan. In January 2020 databases were searched for randomized controlled trials investigating flavonoid effects on human cognition. Eighty studies, comprising 5519 participants, were included in the final meta-analysis. The global analysis indicates dietary flavonoids induced significant benefit to cognitive performance (g = 0.148, p < 0.001), with subgroup analyses revealing that cocoa (g = 0.224, p = 0.036), ginkgo (g = 0.187, p ≤ 0.001), and berries (g = 0.149, p = 0.009) yielded the most notable improvements. Significant benefits were observed from chronic studies, in middle-aged and older adults, and with low and medium doses. The domains of long-term memory, processing speed, and mood showed sensitivity to flavonoid intervention. This meta-analysis provides evidence for the positive effects of flavonoids on cognition and highlights several moderating factors. Flavonoid-based dietary interventions therefore potentially offer a highly accessible, safe, and cost-effective treatment to help tackle the burden of cognitive decline.

Magnetic Molecularly Imprinted Polymers: An Update on Their Use in the Separation of Active Compounds from Natural Products

During the last few years, separation techniques using molecularly imprinted polymers (MIPs) have been developed, making breakthroughs using magnetic properties. Compared to conventional MIPs, magnetic molecularly imprinted polymers (MMIPs) have advantages in sample pretreatment due to their high specificity and selectivity towards analytes as a result of their larger specific surface areas and highly accessible specific binding sites. The techniques of isolation of active compounds from natural products usually require very long process times and low compound yields. When MMIPs are used in sample separation as Solid Phase Extraction (SPE) sorbents, the MMIPs are introduced into the dissolved sample and spread evenly, and they form bonds between the analyte and the MMIPs, which are then separated from the sample matrix using an external magnetic field. This process of separating analytes from the sample matrix makes the separation technique with MMIPs very simple and easy. This review discusses how to synthesize MMIPs, which factors must be considered in their synthesis, and their application in the separation of active compounds from natural products. MMIPs with magnetic core-shells made by co-precipitation can be a good choice for further development due to the high synthesis yield. Further optimization of the factors affecting the size and distribution of magnetic core-shell particles can obtain higher synthesis yields of MMIPs with higher adsorption capacity and selectivity. Thus, they can isolate target compounds from natural plants in high yields and purity.

Ginkgo biloba: A Treasure of Functional Phytochemicals with Multimedicinal Applications

Ginkgo biloba is an ancient plant species that is thought to provide a variety of health benefits to living organisms and contains plenty of bioactive components, making it a chemically diversified plant. G. biloba has been shown to have a variety of medicinal and pharmacological properties, including anticancer, antidementia, antidiabetic, antiobesity, antilipidemic, antimicrobial, antioxidant, antilipid peroxidation, antiplatelet, anti-inflammatory, hepatoprotective, antidepressant, antiaging, immunomodulatory, antihypertensive, and neuroprotective effects and is frequently used to treat neurological, cardiovascular, and respiratory diseases, such as tardive dyskinesia. Therefore, this review described the therapeutic applications of G. biloba. In addition to describing the therapeutic potential, this review also evaluates the chemical constituents, toxicity, adverse effect, synergistic effect, and the clinical studies of this plant which have been utilized for therapeutic benefits but have demonstrated other consequences. The capacity of G. biloba components to act as free radical scavengers is critical, and combining its extract with other plant extracts has been shown to synergistically boost antioxidant properties. G. biloba used long-term or at high doses that resulted in some adverse effects. Severe drug interactions have also been reported in both animals and humans when combined with other medications. The available data established from both preclinical and clinical studies confirm the potential of G. biloba plant extract in various diseases. Besides, the safety and efficacy of G. biloba continue to require verification through additional experimentation to guide medicinal use.

Ginkgo biloba in the Aging Process: A Narrative Review

Neurodegenerative diseases, cardiovascular disease (CVD), hypertension, insulin resistance, cancer, and other degenerative processes commonly appear with aging. Ginkgo biloba (GB) is associated with several health benefits, including memory and cognitive improvement, in Alzheimer’s disease (AD), Parkinson’s disease (PD), and cancer. Its antiapoptotic, antioxidant, and anti-inflammatory actions have effects on cognition and other conditions associated with aging-related processes, such as insulin resistance, hypertension, and cardiovascular conditions. The aim of this study was to perform a narrative review of the effects of GB in some age-related conditions, such as neurodegenerative diseases, CVD, and cancer. PubMed, Cochrane, and Embase databases were searched, and the PRISMA guidelines were applied. Fourteen clinical trials were selected; the studies showed that GB can improve memory, cognition, memory scores, psychopathology, and the quality of life of patients. Moreover, it can improve cerebral blood flow supply, executive function, attention/concentration, non-verbal memory, and mood, and decrease stress, fasting serum glucose, glycated hemoglobin, insulin levels, body mass index, waist circumference, biomarkers of oxidative stress, the stability and progression of atherosclerotic plaques, and inflammation. Therefore, it is possible to conclude that the use of GB can provide benefits in the prevention and treatment of aging-related conditions.

Nutrition, Physical Activity, and Other Lifestyle Factors in the Prevention of Cognitive Decline and Dementia

Multiple factors combined are currently recognized as contributors to cognitive decline. The main independent risk factor for cognitive impairment and dementia is advanced age followed by other determinants such as genetic, socioeconomic, and environmental factors, including nutrition and physical activity. In the next decades, a rise in dementia cases is expected due largely to the aging of the world population. There are no hitherto effective pharmaceutical therapies to treat age-associated cognitive impairment and dementia, which underscores the crucial role of prevention. A relationship among diet, physical activity, and other lifestyle factors with cognitive function has been intensively studied with mounting evidence supporting the role of these determinants in the development of cognitive decline and dementia, which is a chief cause of disability globally. Several dietary patterns, foods, and nutrients have been investigated in this regard, with some encouraging and other disappointing results. This review presents the current evidence for the effects of dietary patterns, dietary components, some supplements, physical activity, sleep patterns, and social engagement on the prevention or delay of the onset of age-related cognitive decline and dementia.

Early intervention for young children with autism spectrum disorder: protocol for a scoping review of economic evaluations

BACKGROUND

In many countries, children who are diagnosed with autism during the first 5 years of life are offered a range of early intervention options. These options vary considerably in the theoretical approaches and techniques applied, their intensity and duration, settings, the person/s delivering supports and the training they require. Early interventions are a significant contributor to total autism-related costs in Western countries, but only in the last 10-20 years has there been adequate outcome data to enable the comparison of different interventions' cost-effectiveness. This protocol describes a scoping review to better understand what economic evaluations have been completed in this field, and the methods used to date.

METHODS

We will systematically search the following databases from their inception to 2021 for eligible studies: MEDLINE, EMBASE, PsycINFO, Econlit, PEDE, NHS EED and HTA. Full economic evaluations of any types of early intervention for children with autism prior to school entry will be included. Two reviewers will screen the studies, extract the data and assess the study quality using established checklists. The risk of bias will be assessed using the extended CHEC-list for all studies and, additionally, the Philips checklist for modelled studies. Quality of reporting will be assessed using the CHEERS checklist. A narrative synthesis will be completed to collate the findings, describe the methods used and identify which interventions have been researched from an economic perspective.

DISCUSSION

This review will provide researchers, policymakers and service providers with current information about the economic evidence for early interventions for young children with autism and point to priorities for further research. It will inform future economic evaluations by highlighting the gaps or inconsistencies in the methods used to date. Limitations of the review will be acknowledged and discussed.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework:  https://osf.io/sj7kt.

Medicinal herbs and nutritional supplements for dementia therapy: potential therapeutic targets and clinical evidence

Spices and herbs have been used for medicinal purposes for centuries. Also, in the last decades, the use of different nutritional supplements has been implemented to treat all kinds of diseases, including those that present an alteration in cognitive functioning. Dementia is a clinical syndrome in which a person's mental and cognitive capacities gradually decline. As the disease progresses, the person's autonomy diminishes. As there is not an effective treatment to prevent progressive deterioration in many of these pathologies, nutritional interventions have been, and still are, one of the most widely explored therapeutic possibilities. In this review, we have discussed a great number of potentially interesting plants, nutritional derivatives and probiotics for the treatment of dementia around the world. Their action mechanisms generally involve neuroprotective effects via anti-inflammatory, antioxidant, anti-apoptotic, b-amyloid and tau anti-aggregate actions; brain blood flow improvement, and effects on synaptic cholinergic and dopaminergic neurotransmission, which may optimize cognitive performance in patients with cognitive impairment. As for their efficacy in patients with cognitive impairment and/or dementias, evidence is still scarce and/or their outcomes are controversial. We consider that many of these substances have promising therapeutic properties. Therefore, the scientific community has to continue with a more complete research focused on both identifying possible action mechanisms and carrying out clinical trials, preferably randomized double-blind ones, with a greater number of patients, a long-term follow-up, dose standardization and the use of current diagnosis criteria.

Herb-drug interactions and toxicity: Underscoring potential mechanisms and forecasting clinically relevant interactions induced by common phytoconstituents via data mining and computational approaches

Herbals in the form of medicine are employed extensively around the world. Herbal and conventional medicine combination is a potentially dangerous practice mainly in comorbid, hepato insufficient and frail patients leading to perilous herb-drug interactions (HDI) and toxicity. This study features potential HDI of 15 globally famous plant species through data mining and computational methods. Several plant species were found to mimic warfarin. Phytochemicals from M. charantia induced hypoglycemica. M. chamomila and G. biloba possessed anticoagulant activities. S. hispanica reduces postprandial glycemia. R. officinalis has been reported to inhibit the efflux of anticancer substrates while A. sativum can boost the clearance of anticancer agents. P. ginseng can alter blood coagulation. A cross link of the biological and in silico data revealed that a plethora of herbal metabolites such as ursolic and rosmarinic acid among others are possible/probable inhibitors of specific CYP450 enzymes. Consequently, plant species/metabolites with a given pharmacological property/metabolizing enzyme should not be mixed with drugs having the same pharmacological property/metabolizing enzyme. Even if combined with drugs, herbal medicines must be used at low doses for a short period of time and under the supervision of a healthcare professional to avoid potential adverse and toxic effects.

Strategies for the use of Ginkgo biloba extract, EGb 761® , in the treatment and management of mild cognitive impairment in Asia: Expert consensus

BACKGROUND

Mild cognitive impairment (MCI) is a neurocognitive state between normal cognitive aging and dementia, with evidence of neuropsychological changes but insufficient functional decline to warrant a diagnosis of dementia. Individuals with MCI are at increased risk for progression to dementia; and an appreciable proportion display neuropsychiatric symptoms (NPS), also a known risk factor for dementia. Cerebrovascular disease (CVD) is thought to be an underdiagnosed contributor to MCI/dementia. The Ginkgo biloba extract, EGb 761® , is increasingly being used for the symptomatic treatment of cognitive disorders with/without CVD, due to its known neuroprotective effects and cerebrovascular benefits.

AIMS

To present consensus opinion from the ASian Clinical Expert group on Neurocognitive Disorders (ASCEND) regarding the role of EGb 761® in MCI.

MATERIALS & METHODS

The ASCEND Group reconvened in September 2019 to present and critically assess the current evidence on the general management of MCI, including the efficacy and safety of EGb 761® as a treatment option.

RESULTS

EGb 761® has demonstrated symptomatic improvement in at least four randomized trials, in terms of cognitive performance, memory, recall and recognition, attention and concentration, anxiety, and NPS. There is also evidence that EGb 761® may help delay progression from MCI to dementia in some individuals.

DISCUSSION

EGb 761® is currently recommended in multiple guidelines for the symptomatic treatment of MCI. Due to its beneficial effects on cerebrovascular blood flow, it is reasonable to expect that EGb 761® may benefit MCI patients with underlying CVD.

CONCLUSION

As an expert group, we suggest it is clinically appropriate to incorporate EGb 761® as part of the multidomain intervention for MCI.

Preventing dementia? Interventional approaches in mild cognitive impairment

Mild cognitive impairment (MCI) is defined as an intermediate state between normal cognitive aging and dementia. It describes a status of the subjective impression of cognitive decline and objectively detectible memory impairment beyond normal age-related changes. Activities of daily living are not affected. As the population ages, there is a growing need for early, proactive programs that can delay the consequences of dementia and improve the well-being of people with MCI and their caregivers. Various forms and approaches of intervention for older people with MCI have been suggested to delay cognitive decline. Pharmacological as well as non-pharmacological approaches (cognitive, physiological, nutritional supplementation, electric stimulation, psychosocial therapeutic) and multicomponent interventions have been proposed. Interventional approaches in MCI from 2009 to April 2019 concerning the cognitive performance are presented in this review.

Ginkgo Biloba affects microvascular morphology: a prospective optical coherence tomography angiography pilot study

PURPOSE

To analyze the vascular morphology changes after consumption of Ginkgo biloba in healthy volunteers by optical coherence tomography angiography (OCTA).

METHODS

Sixty healthy volunteers without systemic and ocular disease were included in this prospective pilot study. After receiving the informed consent of the volunteers, Ginkgo biloba extract (120 mg oral capsule) was administered to sixty volunteers for 4 weeks, once a day in the morning. The main outcome measures were the difference between before and after four-week of consumption in best-corrected visual acuity (BCVA), retinal nerve fiber layer (RNFL) and subfoveal choroidal thickness (sfCT) with optical coherence tomography; whole, foveal, parafoveal and perifoveal regions' superior and deep macular vascular plexus vessel density, foveal avascular zone area (FAZ), FAZ perimeter (PERIM), vessel density in a 300 µm wide region around FAZ (FD-300), choroidal and outer retinal flow area, radial peripapillary capillary (RPC) vascular density of whole, inside the disc, peripapillary and four quadrants with OCTA.

RESULTS

The study group consisted of sixty eyes of 32 women and 28 men with a mean age of 20.57 ± 1.16 years. In post-consumption measurements, peripapillary and superior, inferior, temporal quadrant RPC vascular density (%) was statistically significantly higher than pre-consumption measurements (p 0.020, p 0.021, p 0.008 and p 0.014, respectively). No significant difference was observed for BCVA, sfCT, other macular or RPC vascular density and flow area OCTA parameters between measurements.

CONCLUSION

Four-week consumption of Ginkgo biloba leads to vascular morphological changes in RPC. Further clinical studies are needed to demonstrate its use and effects/benefits in glaucoma, optic neuropathy and other diseases affecting the optic nerve.

Different Doses of Pharmacological Treatments for Mild to Moderate Alzheimer's Disease: A Bayesian Network Meta-Analysis

Background

Pharmacological treatments play a significant role in treating mild to moderate Alzheimer's disease (AD), but the optimal doses of various drugs used for these treatments are unknown. Our study compared the efficacy, acceptability, and safety of different doses of pharmacological treatments for mild to moderate AD.

Methods

Randomized controlled trials (RCTs) were identified by searching the PubMed, EMBASE, and Cochrane Library databases (all RCTs published from the date of inception of the databases until September 19, 2019). Trials comparing the efficacy, acceptability, and safety of pharmacological interventions involving donepezil, galantamine, rivastigmine, memantine, huperzine A, and Ginkgo biloba extract EGb761, alone or in combination, were identified. The primary outcomes were efficacy, acceptability, and safety.

Results

Our meta-analysis included 37 studies involving 14,705 participants. In terms of improving cognitive function, galantamine 32 mg, galantamine 24 mg, donepezil 5 mg, and donepezil 10 mg were more effective than other interventions, with the surface under the cumulative ranking curve (SUCRA) values of 93.2, 75.5, 73.3, and 65.6%, respectively. According to the SUCRA values, EGb761 240 mg was considered to be the optimal intervention in terms of both acceptability and safety. With regard to clinical global impression, rivastigmine 12 mg had the highest probability of being ranked first (83.7%). The rivastigmine 15 cm² patch (SUCRA = 93.7%) may be the best choice for daily living. However, there were no interventions that could significantly improve neuropsychiatric symptoms, compared with the placebo.

Conclusions

Different doses of the tested pharmacological interventions yielded benefits with regard to cognition, acceptability, safety, function, and clinical global impressions, but not effective behaviors.

Ginkgo Biloba Extract in Ophthalmic and Systemic Disease, With a Focus on Normal-Tension Glaucoma

Glaucoma is a neurodegenerative eye disease that results in retinal ganglion cell loss and ultimately loss of vision. Elevated intraocular pressure (IOP) is the most common known risk factor for retinal ganglion cell damage and visual field loss, and the only modifiable risk factor proven to reduce the development and progression of glaucoma. This has greatly influenced our approach and assessment in terms of diagnosis and treatment. However, as many as ≥50% of patients with progressive vision loss from primary open angle glaucoma without IOP elevation (≤22 mm Hg) have been reported in the United States and Canada; 90% in Japan and 80% in Korea. Extensive research is currently underway to identify the etiology of risk factors for glaucoma other than or in addition to elevated IOP (so-called "normal-tension" glaucoma; NTG) and use this knowledge to expand available treatment options. Currently, Food and Drug Administration-approved medications for glaucoma exclusively target elevated IOP, suggesting the need for additional approaches to treatment options beyond the current scope as the definition of glaucoma changes to encompass cellular and molecular mechanisms. This review focuses on alternative medical approaches, specifically Ginkgo Biloba extract, as a potential treatment option for normal-tension glaucoma.

Efficacy and Safety of Ginkgo biloba in Patients with Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Ginkgo biloba and its extract have been suggested to have a neuroprotective role in patients with acute ischemic stroke. We aimed to examine the efficacy and safety of Ginkgo biloba use in patients with acute ischemic stroke. We searched seven databases for randomized controlled studies examining the use of Ginkgo biloba in patients with acute ischemic stroke. Relevant studies were retrieved, screened, and data were extracted independently by two reviewers. Random effects meta-analyses were performed to evaluate the efficacy and safety outcomes of Ginkgo biloba. We subsequently assessed the certainty of evidence using the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology. We found 12 randomized controlled studies enrolling 1466 patients. Pooled results suggest that Ginkgo biloba use was associated with an improvement in neurological function among individuals with AIS with a reduction of 2.87 points on the National Institute of Health Stroke Scale score (95% CI: -4.01--1.74, p<0.001). Ginkgo biloba use was also associated with an improvement in activities of daily living and functional outcome (Mean Difference: 9.52; 4.66-14.33, p<0.001). Subgroup analysis suggest that the impact was larger when using an injectable formulation of Ginkgo biloba compared to the oral formulation. There was no apparent impact of Ginkgo biloba use on all-cause mortality (Risk ratio (RR): 1.21; 0.29-5.09, p=0.80) or cerebrovascular bleeding (RR: 0.82; 0.43-1.57, p=0.55). There was limited evidence on to support the use of gingko biloba in terms of improving quality of life and other stroke events. As such, more studies are needed before it can be recommended for routine use in improving neurological and cognitive function in patients with acute ischemic stroke.

Treatment of dementia and mild cognitive impairment with or without cerebrovascular disease: Expert consensus on the use of Ginkgo biloba extract, EGb 761®

Background

The Ginkgo biloba special extract, EGb 761^® has been widely used in the treatment of neuropsychiatric disorders, including Alzheimer’s disease (AD).

Methods

To guide clinical practice in the Asian region, the Asian Clinical Expert Group on Neurocognitive Disorders compiled evidence‐based consensus recommendations regarding the use of EGb 761^® in neurocognitive disorders with/without cerebrovascular disease.

Results

Key randomized trials and robust meta‐analyses have demonstrated significant improvement in cognitive function, neuropsychiatric symptoms, activities of daily living (ADL) and quality of life with EGb 761^®versus placebo in patients with mild‐to‐moderate dementia. In those with mild cognitive impairment (MCI), EGb 761^® has also demonstrated significant symptomatic improvement versus placebo. World Federation of Societies of Biological Psychiatry guidelines list EGb 761^® with the same strength of evidence as acetylcholinesterase inhibitors and N‐methyl‐D‐aspartate (NMDA) antagonists e.g. memantine (Grade 3 recommendation; Level B evidence). Only EGb 761^® had Level B evidence in improving cognition, behaviour, and ADL in both AD and vascular dementia patients. Safety analyses show EGb 761^® to have a positive risk‐benefit profile. While concerns have been raised regarding a possible increased bleeding risk, several randomized trials and two meta‐analyses have not supported this association.

Conclusions

The Expert Group foresee an important role for EGb 761^®, used alone or as an add‐on therapy, in the treatment of MCI and dementias, particularly when patients do not derive benefit from acetylcholinesterase inhibitors or NMDA antagonists. EGb 761^® should be used in alignment with local clinical practice guidelines.

Herbal Medicine for Cardiovascular Diseases: Efficacy, Mechanisms, and Safety

Cardiovascular diseases (CVDs) are a significant health burden with an ever-increasing prevalence. They remain the leading causes of morbidity and mortality worldwide. The use of medicinal herbs continues to be an alternative treatment approach for several diseases including CVDs. Currently, there is an unprecedented drive for the use of herbal preparations in modern medicinal systems. This drive is powered by several aspects, prime among which are their cost-effective therapeutic promise compared to standard modern therapies and the general belief that they are safe. Nonetheless, the claimed safety of herbal preparations yet remains to be properly tested. Consequently, public awareness should be raised regarding medicinal herbs safety, toxicity, potentially life-threatening adverse effects, and possible herb–drug interactions. Over the years, laboratory data have shown that medicinal herbs may have therapeutic value in CVDs as they can interfere with several CVD risk factors. Accordingly, there have been many attempts to move studies on medicinal herbs from the bench to the bedside, in order to effectively employ herbs in CVD treatments. In this review, we introduce CVDs and their risk factors. Then we overview the use of herbs for disease treatment in general and CVDs in particular. Further, data on the ethnopharmacological therapeutic potentials and medicinal properties against CVDs of four widely used plants, namely Ginseng, Ginkgo biloba, Ganoderma lucidum, and Gynostemma pentaphyllum, are gathered and reviewed. In particular, the employment of these four plants in the context of CVDs, such as myocardial infarction, hypertension, peripheral vascular diseases, coronary heart disease, cardiomyopathies, and dyslipidemias has been reviewed, analyzed, and critically discussed. We also endeavor to document the recent studies aimed to dissect the cellular and molecular cardio-protective mechanisms of the four plants, using recently reported in vitro and in vivo studies. Finally, we reviewed and reported the results of the recent clinical trials that have been conducted using these four medicinal herbs with special emphasis on their efficacy, safety, and toxicity.

Thin layer drying behavior of Ginkgo biloba L. leaves with respect to Ginkgolide A and Bilobalide content and microbial load

Influence of drying temperature (30-50 °C) and relative humidity (RH: 30-80%) on moisture content, energy requirement and quality of Ginkgo biloba leaves with respect to chemical markers namely Ginkgolide A (GA) and Bilobalide (BB), and microbial load of dried materials has been analyzed. Leaves were dried in climate control chamber with varying temperature and relative humidity (RH). Total time required for attaining equilibrium was higher for low temperature at all the RH levels as well as for high RH at all the temperatures. Energy requirement was found to increase at high RH and low temperature. GA and BB concentration increased during drying in comparison to that in fresh material. Microbial load analyzed for dried samples was also found within the limit as prescribed in European Pharmacopeia under the category 3B. 40 °C temperature and 50 % RH with less drying duration was observed as suitable conditions for better recovery of BB and GA content, less microbial load and less energy consumption, during drying of G. biloba leaves.

Evidence and gap map of studies assessing the effectiveness of interventions for people with disabilities in low-and middle-income countries

Background

There are approximately 1 billion people in the world with some form of disability. This corresponds to approximately 15% of the world's population (World Report on Disability, 2011). The majority of people with disabilities (80%) live in low- and middle-income countries (LMICs), where disability has been shown to disproportionately affect the most disadvantaged sector of the population. Decision makers need to know what works, and what does not, to best invest limited resources aimed at improving the well-being of people with disabilities in LMICs. Systematic reviews and impact evaluations help answer this question. Improving the availability of existing evidence will help stakeholders to draw on current knowledge and to understand where new research investments can guide decision-making on appropriate use of resources. Evidence and gap maps (EGMs) contribute by showing what evidence there is, and supporting the prioritization of global evidence synthesis needs and primary data collection.

Objectives

The aim of this EGM is to identify, map and describe existing evidence of effectiveness studies and highlight gaps in evidence base for people with disabilities in LMICs. The map helps identify priority evidence gaps for systematic reviews and impact evaluations.

Methods

The EGM included impact evaluation and systematic reviews assessing the effect of interventions for people with disabilities and their families/carers. These interventions were categorized across the five components of community-based rehabilitation matrix; health, education, livelihood, social and empowerment. Included studies looked at outcomes such as, health, education, livelihoods, social inclusion and empowerment, and were published for LMICs from 2000 onwards until January 2018. The searches were conducted between February and March 2018. The EGM is presented as a matrix in which the rows are intervention categories (e.g., health) and subcategories (e.g., rehabilitation) and the column outcome domains (e.g., health) and subdomains (e.g., immunization). Each cell lists the studies for that intervention for those outcomes, with links to the available studies. Included studies were therefore mapped according to intervention and outcomes assessed and additional filters as region, population and study design were also coded. Critical appraisal of included systematic review was done using A Measurement Tool to Assess Systematic Reviews' rating scale. We also quality-rated the impact evaluation using a quality assessment tool based on various approaches to risk of bias assessment.

Results

The map includes 166 studies, of which 59 are systematic reviews and 107 impact evaluation. The included impact evaluation are predominantly quasiexperimental studies (47%). The numbers of studies published each year have increased steadily from the year 2000, with the largest number published in 2017.The studies are unevenly distributed across intervention areas. Health is the most heavily populated area of the map. A total of 118 studies of the 166 studies concern health interventions. Education is next most heavily populated with 40 studies in the education intervention/outcome sector. There are relatively few studies for livelihoods and social, and virtually none for empowerment. The most frequent outcome measures are health-related, including mental health and cognitive development (n = 93), rehabilitation (n = 32), mortality and morbidity (n = 23) and health check-up (n = 15). Very few studies measured access to assistive devices, nutrition and immunization. Over half (n = 49) the impact evaluation come from upper-middle income countries. There are also geographic gaps, most notably for low income countries (n = 9) and lower-middle income countries (n = 34). There is a fair amount of evidence from South Asia (n = 73) and Sub-Saharan Africa (n = 51). There is a significant gap with respect to study quality, especially with respect to impact evaluation. There appears to be a gap between the framing of the research, which is mostly within the medical model and not using the social model of disability.

Conclusion

Investing in interventions to improve well-being of people with disabilities will be critical to achieving the 2030 agenda for sustainable development goals. The EGM summarized here provides a starting point for researchers, decision makers and programme managers to access the available research evidence on the effectiveness of interventions for people with disabilities in LMICs in order to guide policy and programme activity, and encourage a more strategic, policy-oriented approach to setting the future research agenda.

Ginkgo biloba Induces Thrombomodulin Expression and Tissue-Type Plasminogen Activator Secretion via the Activation of Krüppel-Like Factor 2 within Endothelial Cells

The effects of thrombo-prevention, such as antiplatelet and anticoagulant activity, have been reported with the usage of Ginkgo biloba extract (GbE); however, the detailed mechanism has not yet been fully investigated, especially the role of Krüppel-like factor 2 (KLF2). This study aimed to investigate whether GbE can activate KLF2 and then induce thrombomodulin (TM) and tissue-type plasminogen activator (t-PA) secretion to enhance the effects of thrombo-prevention. Different concentrations of GbE were incubated with human umbilical vein endothelial cells (HUVECs) to evaluate its effect on endothelial cells. We found that KLF2 expression is correlated to the risk of atherosclerosis and venous thromboembolism in clinical practice. In the HUVEC cell model, GbE stimulated the expression of KLF2 in a dose-dependent manner. Moreover, TM and t-PA secretion increased when the cells were cultured with GbE. Both the expressions and activities of TM and t-PA in the GbE-treated cells declined after KLF2 was blocked by shKLF2. In sum, with GbE treatment, KLF2 expression in human endothelial cells was significantly activated, which in turn induced an increase in the protein expression and activity of TM and t-PA. After shRNA inhibited the KLF2 expression, GbE stopped inducing the expression and activity of TM and t-PA. These findings suggest that GbE exerts an antithrombotic effect on endothelial cells by increasing the TM expression and t-PA secretion; further, KLF2 is a key factor in this mechanism.

Herbal Medicine of the 21st Century: A Focus on the Chemistry, Pharmacokinetics and Toxicity of Five Widely Advocated Phytotherapies

Widely advocated for their health benefits worldwide, herbal medicines (HMs) have evolved into a billion dollar generating industry. Much is known regarding their wellness inducing properties, prophylactic and therapeutic benefits for the relief of both minor to chronic ailment conditions given their long-standing use among various cultures worldwide. On the other hand, their equally meaningful chemistry, pharmacokinetic profile in humans, interaction and toxicity profile have been poorly researched and documented. Consequently, this review is an attempt to highlight the health benefits, pharmacokinetics, interaction, and toxicity profile of five globally famous HMs. A systematic literature search was conducted by browsing major scientific databases such as Bentham Science, SciFinder, ScienceDirect, PubMed, Google Scholar and EBSCO to include 196 articles. In general, ginsenosides, glycyrrhizin and curcumin demonstrate low bioavailability when orally administered. Ginkgo biloba L. induces both CYP3A4 and CYP2C9 and alters the AUC and Cmax of conventional medications including midazolam, tolbutamide, lopinavir and nifedipine. Ginsenosides Re stimulates CYP2C9, decreasing the anticoagulant activity of warfarin. Camellia sinensis (L.) Kuntze increases the bioavailability of buspirone and is rich in vitamin K thereby inhibiting the activity of anticoagulant agents. Glycyrrhiza glabra L. displaces serum bound cardiovascular drugs such as diltiazem, nifedipine and verapamil. Herbal medicine can directly affect hepatocytes leading to hepatoxicity based on both intrinsic and extrinsic factors. The potentiation of the activity of concurrently administered conventional agents is potentially lethal especially if the drugs bear dangerous side effects and have a low therapeutic window.

Modulatory Effects of Ginkgo biloba Against Amyloid Aggregation Through Induction of Heat Shock Proteins in Aluminium Induced Neurotoxicity

Protein misfolding and aggregation of amyloid beta (Aβ) peptide, as well as formation of neurofibrillary tangles (NFTs) are the signature hallmarks of Alzheimer's disease (AD) pathology. To prevent this, molecular chaperones come into play as they facilitate the refolding of the misfolded proteins and cell protection under stress. Here, we have evaluated the possible effects of Ginkgo biloba (GBE) against aggregation of the Aβ through activation of heat shock proteins (HSPs) in the Aluminium (Al) induced AD based model. GBE (100 mg/kg body weight) was administered per oral to the female SD rats in conjunction with intraperitoneal (i.p.) injection of Al lactate (10 mg/kg body weight) for six weeks. Pretreated animals were administered GBE for additional two weeks prior to any exposure of Al. GBE administration resulted in decrease in Aβ aggregation, ubiquitin deposition, accompanying a significant decline in APP & Tau protein hyperphosphorylation which can be attributed to activation of Heat shock factor (HSF-1) and upregulation in the protein expression of HSPs. Histopathological investigation studies have also shown the decrease in aggregation of Aβ peptide by GBE administration. Additionally, the decrease in ROS levels and Aβ aggregation by GBE administration prohibited the decline in the neurotransmitter levels and monoamine oxidase levels in hippocampus and cortex. This further caused improvement in learning and memory of the animals. In conclusion, our results indicate that GBE prevents the symptoms of Al induced AD like pathophysiology by upregulating the HSPs levels and decreasing the aggregation load.

7-Deoxy-trans-dihydronarciclasine Isolated from Lycoris chejuensis Inhibits Neuroinflammation in Experimental Models

Overactivated microglia and persistent neuroinflammation hold an important role in the pathophysiology of neurodegenerative diseases. The extract of Lycoris chejuensis (CJ) and its active compound, 7-deoxy-trans-dihydronarciclasine (named E144), attenuated expressions of pro-inflammatory factors, including nitric oxide, prostaglandin E₂, inducible nitric oxide synthase, cyclooxygenase-2 (COX-2), tumor necrosis factor α (TNF-α), and interleukin 6, secreted by lipopolysaccharide-activated BV-2 microglial cells, as measured by an enzyme-linked immunosorbent assay or western blotting. In contrast, CJ extract and E144 promoted the secretion of the anti-inflammatory cytokine, interleukin 10. Moreover, we found that E144 attenuated the expression of TNF-α and COX-2 in the cerebral cortex of lipopolysaccharide-treated mice and/or T2576 transgenic mice as well as reduced the reactive immune cells visualized by ionized calcium-binding adaptor molecule 1. Our results suggest the possibility of E144 to serve as a potential anti-neuroinflammatory agent by preventing excess production of pro-inflammatory factors.

Chinese herbal medicine Qinggongshoutao for the treatment of amnestic mild cognitive impairment: A 52-week randomized controlled trial

Introduction

This randomized, double-blind trial aimed to test effect of a Chinese herbal medicine, Qinggongshoutao (QGST) pill, on the cognition and progression of amnestic mild cognitive impairment (aMCI).

Methods

Patients with aMCI were randomly assigned to receive QGST, Ginkgo biloba extract, or placebo for 52 weeks. The primary outcome measures were progression to possible or probable Alzheimer's disease (AD) and change in Alzheimer's Disease Assessment Scale-cognitive subscale scores; secondary outcome measures included assessments for cognition and function.

Results

Total 350 patients were enrolled, possible or probable AD developed in 10. There were significant differences in the probability of progression to AD in the QGST group (1.15%) compared with placebo group (10%). There was significant difference in Alzheimer's Disease Assessment Scale-cognitive subscale scores in favor of QGST over the placebo group. Secondary outcome measure (Mini-Mental State Examination) also showed benefit in QGST at end point.

Discussion

In patients with aMCI, QGST showed lower AD progression rate than placebo at 8.85%, and may have benefit on global cognition.

Mitochondria- and Oxidative Stress-Targeting Substances in Cognitive Decline-Related Disorders: From Molecular Mechanisms to Clinical Evidence

Alzheimer's disease (AD) is the most common form of dementia affecting people mainly in their sixth decade of life and at a higher age. It is an extensively studied neurodegenerative disorder yet incurable to date. While its main postmortem brain hallmarks are the presence of amyloid-β plaques and hyperphosphorylated tau tangles, the onset of the disease seems to be largely correlated to mitochondrial dysfunction, an early event in the disease pathogenesis. AD is characterized by flawed energy metabolism in the brain and excessive oxidative stress, processes that involve less adenosine triphosphate (ATP) and more reactive oxygen species (ROS) production respectively. Mitochondria are at the center of both these processes as they are responsible for energy and ROS generation through mainly oxidative phosphorylation. Standardized Ginkgo biloba extract (GBE), resveratrol, and phytoestrogens as well as the neurosteroid allopregnanolone have shown not only some mitochondria-modulating properties but also significant antioxidant potential in in vitro and in vivo studies. According to our review of the literature, GBE, resveratrol, allopregnanolone, and phytoestrogens showed promising effects on mitochondria in a descending evidence order and, notably, this order pattern is in line with the existing clinical evidence level for each entity. In this review, the effects of these four entities are discussed with special focus on their mitochondria-modulating effects and their mitochondria-improving and antioxidant properties across the spectrum of cognitive decline-related disorders. Evidence from preclinical and clinical studies on their mechanisms of action are summarized and highlighted.

Beliefs, practices and knowledge of community pharmacists regarding complementary and alternative medicine: national cross-sectional study in Lebanon

INTRODUCTION

Pharmacists are uniquely positioned to provide patients with evidence-based information in order to ensure effective and safe use of Complementary and alternative medicine (CAM) products.

OBJECTIVE

Assess beliefs, practices and knowledge related to CAM products among community pharmacists in Lebanon.

DESIGN, METHODS AND SETTING

Using stratified random sampling, a nationally representative survey was conducted among community pharmacists in Lebanon. Through face-to-face interviews, pharmacists completed a multicomponent questionnaire consisting of four sections: (1) sociodemographic characteristics; (2) beliefs related to regulation of CAM products, role of media in promoting their safe use, availability of resources and continuing education; (3) practices including selling CAM products, providing advice for patients and reporting adverse effects and (4) knowledge about specific CAM products, their uses, side effects and interactions.

RESULTS

A total of 341 pharmacists agreed to participate (response rate: 86%). Only pharmacists with complete data were included in this study (n=310). Pharmacists agreed that CAM products are effective (63.8%) and that they should be exclusively sold in pharmacies (80.3%), but disagreed that commercially marketed CAM products are well regulated (63.5%) and that media plays a positive role in educating users about these products (55.8%). As for practices, 64.5% of pharmacists were always or often advising patients on safe use; however, 74.2% of participants rarely or never reported adverse effects. Regarding knowledge, although the majority of pharmacists were aware of the uses of CAM products, fewer knew about their side effects and their interactions with drugs. After adjustment for covariates, receiving education/training on CAM products during university was the sole predictor of higher knowledge score (ß=0.68, 95% CI 0.29 to 1.07).

CONCLUSIONS

This study revealed positive beliefs of pharmacists in Lebanon towards CAM products and indicated important gaps in their practice and knowledge. Deliberate efforts to enhance the education of pharmacists are warranted to ensure the safe integration and use of CAM products in Lebanon.

Health-Promoting Strategies for the Aging Brain

As the world's population ages and people live longer, the changes in the aging brain present substantial challenges to our health and society. With greater longevity come age-related diseases, many of which have direct and indirect influences on the health of the brain. Although there is some degree of predictable decline in brain functioning with aging, meaningful cognitive decline is not inevitable and is perhaps preventable. In this review, we present the case that the course of aging-related brain disease and dysfunction can be modified. We present the evidence for conditions and risk factors that may contribute to cognitive decline and dementia and for interventions that may mitigate their impact on cognitive functioning later in life, or even prevent them and their cognitive sequelae from developing. Although much work remains to be done to meet the challenges of the aging brain, strategies to promote its health have been demonstrated and offer much promise, which can only be realized if we mount a vigorous public health effort to implement these strategies.

Therapeutic efficacy of the Ginkgo special extract EGb761® within the framework of the mitochondrial cascade hypothesis of Alzheimer's disease

OBJECTIVES

The mitochondrial cascade hypothesis of dementia assumes mitochondrial dysfunction as an important common pathomechanism for the whole spectrum of age-associated memory disorders from cognitive symptoms in the elderly over mild cognitive impairment to Alzheimer's dementia. Thus, a drug such as the Ginkgo special extract EGb 761^® which improves mitochondrial function should be able to ameliorate cognitive deficits over the whole aging spectrum.

METHODS

We review the most relevant publications about effects of EGb 761^® on cognition and synaptic deficits in preclinical studies as well as on cognitive deficits in man from aging to dementia.

RESULTS

EGb 761^® improves mitochondrial dysfunction and cognitive impairment over the whole spectrum of age-associated cognitive disorders in relevant animal models and in vitro experiments, and also shows clinical efficacy in improving cognition over the whole range from aging to Alzheimer's or even vascular dementia.

CONCLUSIONS

EGb 761^® shows clinical efficacy in the treatment of cognitive deficits over the whole spectrum of age-associated memory disorders. Thus, EGb 761^® can serve as an important pharmacological argument for the mitochondrial cascade hypothesis of dementia.

Phytochemicals for Improving Aspects of Cognitive Function and Psychological State Potentially Relevant to Sports Performance

Subjective alertness and optimal cognitive function, including in terms of attention, spatial/working memory and executive function, are intrinsic to peak performance in many sports. Consumption of a number of plant-derived 'secondary metabolite' phytochemicals can modulate these psychological parameters, although there is a paucity of evidence collected in a sporting context. The structural groups into which these phytochemicals fall-phenolics, terpenes and alkaloids-vary in terms of the ecological roles they play for the plant, their toxicity and the extent to which they exert direct effects on brain function. The phenolics, including polyphenols, play protective roles in the plant, and represent a natural, benign component of the human diet. Increased consumption has been shown to improve cardiovascular function and is associated with long-term brain health. However, whilst short-term supplementation with polyphenols has been shown to consistently modulate cerebral blood-flow parameters, evidence of direct effects on cognitive function and alertness/arousal is currently comparatively weak. Terpenes play both attractant and deterrent roles in the plant, and typically occur less frequently in the diet. Single doses of volatile monoterpenes derived from edible herbs such as sage (Salvia officinalis/lavandulaefolia) and peppermint (Mentha piperita), diterpene-rich Ginkgo biloba extracts and triterpene-containing extracts from plants such as ginseng (Panax ginseng/quinquefolius) and Bacopa monnieri have all been shown to enhance relevant aspects of cognitive function and alertness. The alkaloids play toxic defensive roles in the plant, including via interference with herbivore brain function. Whilst most alkaloids are inappropriate in a sporting context due to toxicity and legal status, evidence suggests that single doses of nicotine and caffeine may be able to enhance relevant aspects of cognitive function and/or alertness. However, their benefits may be confounded by habituation and withdrawal effects in the longer term. The efficacy of volatile terpenes, triterpene-rich extracts and products combining low doses of caffeine with other phytochemicals deserves more research attention.

Acute ingestion of rosemary water: Evidence of cognitive and cerebrovascular effects in healthy adults

BACKGROUND

The use of herbal extracts and supplements to enhance health and wellbeing is increasing in western society.

AIMS

This study investigated the impact of the acute ingestion of a commercially available water containing an extract and hydrolat of rosemary ( Rosmarinus officinalis L. syn. Salvia rosmarinus Schleid.). Aspects of cognitive functioning, mood and cerebrovascular response measured by near-infrared spectroscopy provided the dependent variables.

METHODS

Eighty healthy adults were randomly allocated to consume either 250 mL of rosemary water or plain mineral water. They then completed a series of computerised cognitive tasks, followed by subjective measures of alertness and fatigue. Near-infrared spectroscopy monitored levels of total, oxygenated and deoxygenated haemoglobin at baseline and throughout the cognitive testing procedure.

RESULTS

Analysis of the data revealed a number of statistically significant, small, beneficial effects of rosemary water on cognition, consistent with those found previously for the inhalation of the aroma of rosemary essential oil. Of particular interest here are the cerebrovascular effects noted for deoxygenated haemoglobin levels during cognitive task performance that were significantly higher in the rosemary water condition. This represents a novel finding in this area, and may indicate a facilitation of oxygen extraction at times of cognitive demand.

CONCLUSION

Taken together the data suggest potential beneficial properties of acute consumption of rosemary water. The findings are discussed in terms of putative metabolic and cholinergic mechanisms.

Similar treatment outcomes with Ginkgo biloba extract EGb 761 and donepezil in Alzheimer's dementia in very old age: A retrospective observational study

Objective: To provide pilot data for the safety and efficacy of EGb 761 in the oldest-old patients (aged 80 or older). Materials and methods: In a retrospective analysis, we compared treatment outcomes with EGb 761 or donepezil over 12 months in 189 patients aged 80 years or older suffering from Alzheimer’s disease (AD). Results: Over 12 months, there was no significant difference in cognitive decline, measured with the mini-mental state examination (MMSE) score, between donepezil and EGb 761 (p = 0.31). We found more adverse events in the donepezil group. Conclusion: Results suggest similar effects on cognitive symptoms from the use of EGb 761 in the treatment of dementia in AD together with favorable safety compared to donepezil.

Treatment effects of Ginkgo biloba extract EGb 761® on the spectrum of behavioral and psychological symptoms of dementia: meta-analysis of randomized controlled trials

ABSTRACTBackground:In randomized controlled trials, Ginkgo biloba extract EGb 761® has been found to be effective in the treatment of behavioral and psychological symptoms of dementia (BPSD).

METHODS

To assess the effects of EGb 761® on specific BPSD, we analyzed data from all randomized, placebo-controlled, at least 20-week, trials of EGb 761® enrolling patients with dementia (probable Alzheimer's disease (AD), probable vascular dementia or probable AD with cerebrovascular disease) who had clinically significant BPSD (Neuropsychiatric Inventory (NPI) total score at least 6). Data were pooled and joint analyses of NPI single item composite and caregiver distress scores were performed by meta-analysis with a fixed effects model.

RESULTS

Four trials involving 1628 patients (EGb 761®, 814; placebo, 814) were identified; treatment duration was 22 or 24 weeks; the daily dose of EGb 761® was 240 mg in all trials. Pooled analyses including data from the full analysis sets of all trials (EGb 761®, 796 patients; placebo, 802 patients) revealed significant superiority of EGb 761® over placebo in total scores and 10 single symptom scores. Regarding caregiver distress scores, EGb 761®-treated patients improved significantly more than those receiving placebo in all symptoms except delusions, hallucinations, and elation/euphoria. The benefit of EGb 761® mainly consists of improvement in symptoms present at baseline, but the incidence of some symptoms was also decreased.

CONCLUSIONS

Twenty two- to twenty four-week treatment with Ginkgo biloba extract EGb 761® improved BPSD (except psychotic-like features) and caregiver distress caused by such symptoms.

Effect of long-term nutraceutical and dietary supplement use on cognition in the elderly: a 10-year systematic review of randomised controlled trials

Nutraceuticals have generated interest as a way to mitigate the cognitive decline in older adults. The aim of this systematic review was to determine the evidence for these claims from the scientific literature in randomised, double-blinded, controlled trials (duration: ≥1 year; participants: n≥100; age(mean): ≥65 years). Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched four electronic databases (PubMed, Scopus, CINAHL and Web of Science) and identified twenty-five studies published between the 15·June·2006 and 14·June·2016. Interventions included B-vitamins, n-3 fatty acids, antioxidant vitamins and herbs. Of the B-vitamin studies, four found benefits to cognition with supplementation. The first of these B-vitamin studies, in individuals with mild cognitive impairment (n 266; duration=2 years), included benefit to executive function (P=0·015) and improvements in the Mini-Mental State Examination (MMSE) among participants with baseline homocysteine above 11·3 µmol/l (P<0·001). In the same sample, the second study found cognitive benefits of B-vitamins dependent on the higher baseline plasma n-3 fatty acid status. The third B-vitamin study (n 900; duration=2 years) reported improved performance in immediate (P=0·046) and delayed recall (P=0·013), whereas the fourth study (n 856; duration=2 years) reported slower rate of cognitive decline in the MMSE (P=0·05). One study investigating DHA treatment (n 402; duration=1·5 years) revealed the slower rate of cognitive change in apoE e4 non-carriers (P=0·03). As only five included studies revealed notable benefits, presently based on the specific compounds explored here, there is not compelling evidence to support the use nutraceuticals to improve cognition in the elderly. Future long-term trials of nutraceuticals should investigate interactions with lifestyle, blood biomarkers and genetic risk factors.

Popular Herbal and Natural Remedies Used in Psychiatry

Natural and herbal remedies, also known as "alternative" or "complementary" medicines, have grown tremendously in popularity over the past two decades, becoming a major component of health care and general wellness in the United States and worldwide. The ready availability of these remedies over the counter and their generally good tolerability and safety contribute to this popularity, and many people have benefited from them, often in cases when conventional treatments have failed or caused intolerable side effects. Despite many Food and Drug Administration (FDA)-approved psychotropic medications on the market, efficacy has been inconsistent for some, and many treatment responders will eventually relapse. Continued research on the efficacy and safety of these alternative therapies is, therefore, important. This article reviews six of the most commonly used natural remedies for psychiatric conditions, including the antidepressants St. John's wort, omega-3 fatty acids, and S-adenosyl methionine (SAMe); the sedative-hypnotics valerian and melatonin; and the nootropic ginkgo biloba. We outline the general indications for use, suggested doses, possible mechanisms, and adverse effects to give clinicians a good summary of the benefits and liabilities of each. Although there is growing evidence of efficacy and safety to support the use of these remedies, clinicians must be aware of the limitations of the evidence base and take that into account with all the other factors that contribute to clinical decision making.

Cocoa and Dark Chocolate Polyphenols: From Biology to Clinical Applications

It is well known that cocoa and dark chocolate possess polyphenols as major constituents whose dietary consumption has been associated to beneficial effects. In fact, cocoa and dark chocolate polyphenols exert antioxidant and anti-inflammatory activities switching on some important signaling pathways such as toll-like receptor 4/nuclear factor κB/signal transducer and activator of transcription. In particular, cocoa polyphenols induce release of nitric oxide (NO) through activation of endothelial NO synthase which, in turn, accounts for vasodilation and cardioprotective effects. In the light of the above described properties, a number of clinical trials based on the consumption of cocoa and dark chocolate have been conducted in healthy subjects as well as in different categories of patients, such as those affected by cardiovascular, neurological, intestinal, and metabolic pathologies. Even if data are not always concordant, modifications of biomarkers of disease are frequently associated to improvement of clinical manifestations. Quite interestingly, following cocoa and dark chocolate ingestion, cocoa polyphenols also modulate intestinal microbiota, thus leading to the growth of bacteria that trigger a tolerogenic anti-inflammatory pathway in the host. Finally, many evidences encourage the consumption of cocoa and dark chocolate by aged people for the recovery of the neurovascular unit.

Towards the concept of disease-modifier in post-stroke or vascular cognitive impairment: a consensus report

BACKGROUND

Vascular cognitive impairment (VCI) is a complex spectrum encompassing post-stroke cognitive impairment (PSCI) and small vessel disease-related cognitive impairment. Despite the growing health, social, and economic burden of VCI, to date, no specific treatment is available, prompting the introduction of the concept of a disease modifier.

CONSENSUS AND SUGGESTIONS

Within this clinical spectrum, VCI and PSCI remain advancing conditions as neurodegenerative diseases with progression of both vascular and degenerative lesions accounting for cognitive decline. Disease-modifying strategies should integrate both pharmacological and non-pharmacological multimodal approaches, with pleiotropic effects targeting (1) endothelial and brain-blood barrier dysfunction; (2) neuronal death and axonal loss; (3) cerebral plasticity and compensatory mechanisms; and (4) degenerative-related protein misfolding. Moreover, pharmacological and non-pharmacological treatment in PSCI or VCI requires valid study designs clearly stating the definition of basic methodological issues, such as the instruments that should be used to measure eventual changes, the biomarker-based stratification of participants to be investigated, and statistical tests, as well as the inclusion and exclusion criteria that should be applied.

CONCLUSION

A consensus emerged to propose the development of a disease-modifying strategy in VCI and PSCI based on pleiotropic pharmacological and non-pharmacological approaches.