Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Natural product-derived therapies for treating drug-resistant epilepsies: From ethnopharmacology to evidence-based medicine

ETHNOPHARMACOLOGICAL RELEVANCE

Epilepsy is one of the most prevalent neurological human diseases, affecting 1% of the population in all age groups. Despite the availability of over 25 anti-seizure medications (ASMs), which are approved in most industrialized countries, approximately 30% of epilepsy patients still experience seizures that are resistant to these drugs. Since ASMs target only limited number of neurochemical mechanisms, drug-resistant epilepsy (DRE) is not only an unmet medical need, but also a formidable challenge in drug discovery.

AIM

In this review, we examine recently approved epilepsy drugs based on natural product (NP) such as cannabidiol (CBD) and rapamycin, as well as NP-based epilepsy drug candidates still in clinical development, such as huperzine A. We also critically evaluate the therapeutic potential of botanical drugs as polytherapy or adjunct therapy specifically for DRE.

METHODS

Articles related to ethnopharmacological anti-epileptic medicines and NPs in treating all forms of epilepsy were collected from PubMed and Scopus using keywords related to epilepsy, DRE, herbal medicines, and NPs. The database clinicaltrials.gov was used to find ongoing, terminated and planned clinical trials using herbal medicines or NPs in epilepsy treatment.

RESULTS

A comprehensive review on anti-epileptic herbal drugs and natural products from the ethnomedical literature is provided. We discuss the ethnomedical context of recently approved drugs and drug candidates derived from NPs, including CBD, rapamycin, and huperzine A. Recently published studies on natural products with preclinical efficacy in animal models of DRE are summarized. Moreover, we highlight that natural products capable of pharmacologically activating the vagus nerve (VN), such as CBD, may be therapeutically useful to treat DRE.

CONCLUSIONS

The review highlights that herbal drugs utilized in traditional medicine offer a valuable source of potential anti-epileptic drug candidates with novel mechanisms of action, and with clinical promise for the treatment of drug-resistant epilepsy (DRE). Moreover, recently developed NP-based anti-seizure medications (ASMs) indicate the translational potential of metabolites of plant, microbial, fungal and animal origin.

Infection of the Ex Vivo Tonsil Model by HTLV-1 Envelope-Pseudotyped Viruses

Human T-cell leukemia virus type 1 (HTLV-1) is the causal agent of adult T-cell leukemia/lymphoma and HTLV-1-associated myelopathy/tropical spastic paraparesis. Its tropism is known to be broad in cultured cell lines, while in vivo data support a more selective transmission toward CD4+ T cells and the limited targeting of other hematopoietic cell types. An essential condition for HTLV-1 infection is cell-to-cell contact, to which both virological synapse and viral biofilm have been suggested to strongly contribute. As cell lines and animal models each present their own limitations in studying HTLV-1 replication, we have explored the use of an ex vivo model based on the secondary lymphoid tonsillar tissue. HIV-1 luciferase-expressing pseudotyped viruses bearing the HTLV-1 envelope protein at their surface were first shown to recapitulate the wide spectrum of infectivity of HTLV-1 toward various cell lines. Tonsil fragments were next exposed to pseudotyped viruses and shown to be reproducibly infected. Infection by HTLV-1 Env-pseudotyped viruses was blocked by different anti-gp46 antibodies, unlike infection by HIV-1 virions. The dose-dependent infection revealed a gradual increase in luciferase activity, which was again sensitive to anti-gp46 antibodies. Overall, these results suggest that the ex vivo tonsil model represents a reliable alternative for studying HTLV-1 replication and potentially viral latency, as well as early clonal formation.

Widespread alterations in microRNA biogenesis in human Huntington’s disease putamen

Altered microRNA (miRNA) expression is a common feature of Huntington’s disease (HD) and could participate in disease onset and progression. However, little is known about the underlying causes of miRNA disruption in HD. We and others have previously shown that mutant Huntingtin binds to Ago2, a central component of miRNA biogenesis, and disrupts mature miRNA levels. In this study, we sought to determine if miRNA maturation per se was compromised in HD. Towards this end, we characterized major miRNA biogenesis pathway components and miRNA maturation products (pri-miRNA, pre-miRNA, and mature) in human HD (N = 41, Vonsattel grades HD2-4) and healthy control (N = 25) subjects. Notably, the striatum (putamen) and cortex (BA39) from the same individuals were analyzed in parallel. We show that Ago2, Drosha, and Dicer were strongly downregulated in human HD at the early stages of the disease. Using a panel of HD-related miRNAs (miR-10b, miR-196b, miR-132, miR-212, miR-127, miR-128), we uncovered various types of maturation defects in the HD brain, the most prominent occurring at the pre-miRNA to mature miRNA maturation step. Consistent with earlier findings, we provide evidence that alterations in autophagy could participate in miRNA maturation defects. Notably, most changes occurred in the striatum, which is more prone to HTT aggregation and neurodegeneration. Likewise, we observed no significant alterations in miRNA biogenesis in human HD cortex and blood, strengthening tissue-specific effects. Overall, these data provide important clues into the underlying mechanisms behind miRNA alterations in HD-susceptible tissues. Further investigations are now required to understand the biological, diagnostic, and therapeutic implications of miRNA/RNAi biogenesis defects in HD and related neurodegenerative disorders.

Goal management training and psychoeducation / mindfulness for treatment of executive dysfunction in Parkinson’s disease: A feasibility pilot trial

Introduction

As there is currently no pharmacological treatment for Parkinson’s Disease Mild Cognitive Impairment (PD-MCI) with executive dysfunctions, specific cognitive interventions must be investigated. Most previous studies have tested bottom-up cognitive training programs but have not shown very good results.

Objectives

The aim of this study was to test ease of implementation, differential safety and preliminary efficacy of two top-down (strategy-learning) home-based, individualized, cognitive interventions: Goal Management Training (GMT), adapted for PD-MCI (Adapted-GMT), and a psychoeducation program combined with mindfulness exercises (PSYCH-Mind).

Methods

This was a single-blind block-randomized between-group comparative study. Twelve PD-MCI with mild executive dysfunctions were divided in four blocks and randomly assigned to any of the two interventions. The participants were included if they had PD-MCI diagnosis (no dementia), with stabilized medication. Both groups (Adapted-GMT and PSYCH-mind) received five intervention sessions each lasting 60–90 minutes for five weeks. Measures were collected at baseline, mid-point, one-week, four-week and 12-week follow-ups. Executive functions were assessed with the Dysexecutive questionnaire (DEX) and the Zoo Map Test (ZMT). Quality of life (QoL) and psychiatric symptoms were also evaluated. Repeated measures ANCOVAs (mixed linear analysis) were applied to all outcomes.

Results

There was one drop out, and both interventions were feasible and acceptable. Despite the small sample size limiting statistical power, patients of both groups significantly improved executive functions per the DEX-patient (Time: F(4,36) = 2.96, p = 0.033, CI95%: 10.75–15.23) and DEX-caregiver scores (Time: F(4,36) = 6.02, p = 0.017, CI95%: 9.63–17.23). Both groups significantly made fewer errors between measurement times on the ZMT (Time: F(3,36) = 16.66, p = 0.001, CI95%: 1.07–2.93). However, QoL significantly increased only in PSYCH-Mind patients at four-week follow-up (interaction Time*Group: F(4,36) = 5.31, p = 0.002, CI95%: 15.33–25.61).

Conclusion

Both interventions were easily implemented and proved to be safe. Because both interventions are arguably cost-effective, these pilot findings, although promising, need to be replicated in large samples.

ClinicalTrials.gov Identifier

NCT04636541.

[Geriatric pathways and organisation in response to the needs of EDS]

The emergency department remains the main method of admission for older people to hospital. The management of old elderly in these departments is a complex subject. It's particularities and the specificities of the evaluation of their health contribute to the difficulties of the care teams. For the elderly, a visit to the emergency room is a significant medical event in the care process that can have repercussions on their functional decline. The promotion of a geriatric culture in emergency departments is essential and can be done in different ways, but collaboration between emergency physicians and geriatricians remains essential for successful care adapted to the specific characteristics of elderly patients.

The Impact of Clear Speech on the Perceptual and Acoustic Properties of Fricative-Vowel Sequences in Speakers With Dysarthria

Purpose Studies have reported that clear speech has the potential to influence suprasegmental and segmental aspects of speech, in both healthy and dysarthric speakers. While the impact of clear speech has been studied on the articulation of individual segments, few studies have investigated its effects on coarticulation with multisegment sequences such as fricative-vowel. Objectives The goals of this study are to investigate, in healthy and dysarthric speech, the impact of clear speech on (a) the perception of anticipatory vowel coarticulation in fricatives and (b) the acoustic characteristics of this effect. Method Ten speakers with dysarthria secondary to idiopathic Parkinson's disease were recruited as well as 10 age- and sex-matched healthy speakers. A sentence reading task was performed in natural and clear speaking conditions. The sentences contained words with the initial fricatives /s/ and /ʃ/ preceded by /ə/ and followed by the vowels /i/, /y/, /u/, or /a/. For the perceptual measurements, five listeners were recruited and were asked to predict the upcoming word by listening only to the isolated fricative. Acoustic analyses consisted of spectral moment analysis (M1-M4) on averaged time series. Results Perceptual findings report that identification rates were improved with clear speech for the speakers with dysarthria, but only for the fricative-/i/ sequences. Error pattern analysis indicates that this improvement is associated with an increase in the roundness parameter (lip spreading) identification. Acoustic results are unclear for M1 and M3 but suggest that M2 and M4 differentiation between the rounded versus unrounded vowel contexts is increased with clear speech for the speakers with dysarthria. Discussion Taken together, these findings suggest that clear speech may improve lip coordination in dysarthric speakers with Parkinson's disease. However, the impact of clear speech on the acoustic measures of fricative spectral moments is somewhat limited. This suggests that these metrics, when taken individually, do not capture the entire complexity of fricative-vowel coarticulation.

The Quebec Parkinson Network: A Researcher-Patient Matching Platform and Multimodal Biorepository

BACKGROUND

Genetic, biologic and clinical data suggest that Parkinson's disease (PD) is an umbrella for multiple disorders with clinical and pathological overlap, yet with different underlying mechanisms. To better understand these and to move towards neuroprotective treatment, we have established the Quebec Parkinson Network (QPN), an open-access patient registry, and data and bio-samples repository.

OBJECTIVE

To present the QPN and to perform preliminary analysis of the QPN data.

METHODS

A total of 1,070 consecutively recruited PD patients were included in the analysis. Demographic and clinical data were analyzed, including comparisons between males and females, PD patients with and without RBD, and stratified analyses comparing early and late-onset PD and different age groups.

RESULTS

QPN patients exhibit a male:female ratio of 1.8:1, an average age-at-onset of 58.6 years, an age-at-diagnosis of 60.4 years, and average disease duration of 8.9 years. REM-sleep behavior disorder (RBD) was more common among men, and RBD was associated with other motor and non-motor symptoms including dyskinesia, fluctuations, postural hypotension and hallucinations. Older patients had significantly higher rates of constipation and cognitive impairment, and longer disease duration was associated with higher rates of dyskinesia, fluctuations, freezing of gait, falls, hallucinations and cognitive impairment. Since QPN's creation, over 60 studies and 30 publications have included patients and data from the QPN.

CONCLUSIONS

The QPN cohort displays typical PD demographics and clinical features. These data are open-access upon application (http://rpq-qpn.ca/en/), and will soon include genetic, imaging and bio-samples. We encourage clinicians and researchers to perform studies using these resources.

Cellule de coordination des flux sortants des réanimations en période de Covid-19

La pandémie de Covid-19 a inscrit l’hôpital au coeur d’une crise sanitaire de cinétique longue. Le système de santé a dû dans un premier temps accepter cette notion de crise déstructurante et piloter dans l’incertitude. Un des enjeux majeurs était d’éviter la saturation du système, notamment l’accessibilité à la réanimation. À la demande de la cellule de crise du groupe hospitalier AP–HPSorbonne Université, l’équipe Dynamo a dû apporter des propositions permettant de libérer des places en réanimation. C’était la stratégie retenue pour éviter une mise en tension de l’hôpital. La cellule Dynamo, avec l’accord du directeur médical de crise, a ouvert un flux entre les réanimations expertes et des unités créées de novo (publiques et privées). Cette équipe est le fruit d’une préparation conjointe entre le département médico-universitaire DREAM et le service médical du RAID. Elle a permis d’organiser et d’effectuer dans de bonnes conditions sanitaires et sécuritaires le transfert d’une centaine de patients entre les réanimations d’Îlede- France. L’objectif était une répartition cohérente pour maintenir une capacité d’accueil dans les réanimations les plus spécialisées et impactées par l’intensité des soins. Pour cela, la cellule Dynamo a défini des critères médicaux de patients éligibles au transfert. La méthodologie utilisait quatre boucles indépendantes : le service demandeur, l’équipe de transfert, le vecteur de transfert et le service receveur. Cette organisation a offert agilité et autonomie. Nous publions ce retour d’expérience pour partager les bases méthodologiques et humaines de notre organisation afin d’inspirer d’autres cellules innovantes en cas de situations sanitaires exceptionnelles.

Cardinal Motor Features of Parkinson's Disease Coexist with Peak-Dose Choreic-Type Drug-Induced Dyskinesia

Background:

Clinical and anecdotal observations propose that patients with Parkinson’s disease (PD) may show drug-induced dyskinesia (DID) concomitantly with cardinal motor features. However, the extent of the concomitant presence of DID and cardinal features remains to be determined.

Objectives:

This cross-sectional study measured peak-dose choreic-type DID in a quantitative manner in patients diagnosed with PD, and determined whether symptoms such as tremor, bradykinesia, rigidity, postural instability or freezing of gait (FoG) were still detectable in these patients.

Methods:

89 patients diagnosed with PD were recruited and assessed using a combination of quantitative measures using inertial measurement units to capture DID, tremor, bradykinesia, and FoG. Clinical evaluations were also used to assess rigidity and postural instability. Motor symptoms of PD were assessed 3 times during the testing period, and a series of activities of daily living were repeated twice, in between clinical tests, during which the level of DID was quantified. Peak-dose was identified as the period during which patients had the highest levels of DID. Levels of tremor, rigidity, bradykinesia, postural instability, and FoG were used to determine the percentage of patients showing these motor symptoms simultaneously with DID.

Results:

72.4% of patients tested presented with measurable DID during the experiment. Rest, postural and kinetic tremor (12.7% , 38.1% , and 15.9% respectively), bradykinesia (28.6% ), rigidity (55.6% ), postural instability (71.4% ) and FoG (9.5% ) were detected simultaneously with DID.

Conclusions:

PD symptomatology remains present in patients showing peak-dose choreic-type DID, illustrating the challenge facing physicians when trying to avoid dyskinesia while attempting to alleviate motor symptoms.

Goal management training ® home-based approach for mild cognitive impairment in Parkinson's disease: a multiple baseline case report

Approximately 30% of patients with Parkinson's disease experience mild cognitive impairment (PD-MCI), often affecting executive functions. Our objective was to assess tolerability, safety and preliminarily efficacy of Goal Management Training® (GMT) for PD-MCI. GMT was administered at home, for five weeks. Dysexecutive Questionnaire (DEX), Parkinson Disease Questionnaire (PDQ-39), Zoo Map Test and Dementia Rating Scale-II were administered before, one and four weeks after Adapted-GMT. Reliable Change Index (RCI) was calculated. One participant completed GMT with caregiver. Executive complaints decreased (DEX RCIs between -2.10 and -1.68), PDQ-39 was maintained (RCI = -0.18). Adapted-GMT seems safe for PD-MCI, but efficacy remains doubtful.

The influence of vascular risk factors on cognitive function in early Parkinson's disease

OBJECTIVES

Hypertension, dyslipidemia, diabetes, and obesity are well-established risk factors for cognitive impairment and dementia in older adults. In contrast, previous studies that have assessed the impact of vascular risk factors (VRFs) on cognition in Parkinson's disease (PD) have had methodological limitations and reported conflicting findings. We address this question in a large well-characterized cohort of de novo PD patients.

METHODS

A total of 367 untreated and non-demented patients aged 50 years and older with early PD (H&Y = 1.0-2.0) underwent a comprehensive clinical and neuropsychological assessment at baseline and 24 months later. A series of linear mixed models were used to determine the effects of VRFs on cognition while controlling for patient and disease characteristics. The outcomes included norm-referenced Z-scores of global cognition, visuospatial skills, verbal episodic memory, semantic verbal fluency, attention, and working memory tests.

RESULTS

A longer history of hypertension and a higher pulse pressure were significant predictors of lower Z-scores on immediate and delayed free recall, recognition, and verbal fluency tests. On average, every 10 mmHg increase in pulse pressure was associated with a 0.08 reduction on the cognitive Z-scores. The effects were independent of age, education, disease duration, motor impairment, medication, and depressive symptoms. Other VRFs were not associated with cognitive outcomes.

CONCLUSIONS

Our results are consistent with previous studies suggesting that hypertension exerts a detrimental effect on memory and verbal fluency in early PD. Management of blood pressure and cardiovascular health may be important to reduce risk of cognitive decline in PD. Copyright © 2017 John Wiley & Sons, Ltd.

Smoking history is associated to cognitive impairment in Parkinson's disease

INTRODUCTION

Patients with Parkinson's disease (PD) are more likely to suffer from cognitive impairment and dementia than healthy older adults. The aim of this study was to investigate smoking history as a risk factor for cognitive decline in PD.

METHOD

One hundred thirty-nine PD patients aged 50 years and older (Hoehn and Yahr = 1-3) were recruited from a clinical database. Global cognitive function was assessed with the Mini-Mental State Examination (MMSE) and smoking history was investigated as part of a standard clinical interview. A multiple linear regression analysis was used to develop a model for predicting participants' MMSE scores from age, education, Hoehn and Yahr stage, disease duration, the number of vascular risk factors and the number of smoking pack-years.

RESULTS

The regression model significantly accounted for 22.9% of the variance in MMSE scores. Significant predictors were education (β = .312, p < .001), age (β = -.215, p = .013) and total smoking pack-years (β = -.180, p = .029). In former smokers, the number of years since quitting had no effect on global cognition and there were no significant difference between patients who had quit smoking more than 10 years ago and those who had quit less than 10 years ago, F(1, 63) = 1.72, p = .195.

CONCLUSION

Smoking history was associated to global cognitive impairment in PD even in patients who had quit smoking. These results are in line with findings in healthy older adults that have linked smoking to cognitive impairment, global brain atrophy and functional changes. Future studies should consider a broader assessment of cognitive functions.

Herpes Simplex Virus Isolates from an Immunocompromised Patient who Failed to Respond to Acyclovir Treatment Express Thymidine Kinase with Altered Substrate Specificity

Ten sequential post-treatment herpes simplex virus type 1 (HSV-1) isolates were obtained from an immunocompromised patient whose infection, during prolonged treatment, became unresponsive to acyclovir (ACV). Of the ten isolates, eight later isolates were resistant in vitro to ACV and ganciclovir (DHPG), but remained sensitive to 9-β-D-arabinofuranosyladenine (ara-A) and phosphonoformate (PFA). Biochemical characterization of plaque-purified clones of the resistant isolates revealed an altered thymidine kinase (TK) substrate specificity phenotype. The comparative nucleotide sequence analysis of polymerase chain reaction (PCR)-amplified DNA encoding the TK genes of one sensitive and two resistant clones showed a single mutation at nucleotide 527. This change would result in a substitution of arginine by glutamine at residue 176 of the polypeptide, a mutation previously observed in a laboratory isolated variant, SC16 Tr7 (Darby et al., 1986).

Impact of the LSVT on vowel articulation and coarticulation in Parkinson's disease

The purpose of this study was to investigate the impact of the Lee Silverman Voice Treatment (LSVT®) on vowel articulation and consonant-vowel (C-V) coarticulation in dysarthric speakers with Parkinson's disease (PD). Nine Quebec French speakers diagnosed with idiopathic PD underwent the LSVT®. Speech characteristics were compared before and after treatment. Vowel articulation was measured using acoustic vowel space and calculated with the first (F1) and second formant (F2) of the vowels /i/, /u/ and /a/. C-V coarticulation was measured using locus equations, an acoustic metric based on the F2 transitions within vowels in relation to the preceding consonant. The relationship between these variables, speech loudness and vowel duration was also analysed. Results showed that vowel contrast increased in F1/F2 acoustic space after administration of the LSVT®. This improvement was associated with the gain in speech loudness and longer vowel duration. C-V coarticulation patterns between consonant contexts showed greater distinctiveness after the treatment. This improvement was associated with the gain in speech loudness only. These results support the conclusions of previous studies investigating the relationship between the LSVT®, speech loudness and articulation in PD. These results expand clinical understanding of the treatment and indicate that loud speech changes C-V coarticulation patterns. Clinical applications and theoretical considerations are discussed.

The effects of subthalamic deep brain stimulation on metaphor comprehension and language abilities in Parkinson's disease

The effects of subthalamic nucleus (STN) deep brain stimulation (DBS) in Parkinson's disease (PD) on different language abilities are still controversial and its impact on high-level language abilities such as metaphor comprehension has been overlooked. The aim of this study was to determine the effects of STN electrical stimulation on metaphor comprehension and language abilities such as lexical and semantic capacities. Eight PD individuals with bilateral STN-DBS were first evaluated OFF-DBS and, at least seven weeks later, ON-DBS. Performance on metaphor comprehension, lexical decision, word association and verbal fluency tasks were compared ON and OFF-DBS in addition to motor symptoms evaluation. STN stimulation had a significant beneficial effect on motor symptoms in PD. However, this stimulation did not have any effect on metaphor comprehension or any other cognitive ability evaluated in this study. These outcomes suggest that STN stimulation may have dissociable effects on motor and language functions.

Thirty Days without a Bite: Wernicke's Encephalopathy in a Patient with Paranoid Schizophrenia

Wernicke’s Encephalopathy (WE) is a preventable neurologic condition characterized by altered mental status, ophthalmoplegia, and ataxia. Although historically associated with alcoholism, a few authors have described WE in patients with non-alcohol related psychiatric disorders. We report herein the case of a 36-year-old young man with paranoid schizophrenia who was brought to hospital for confusion and difficulties with his vision. His roommate said he had gone about thirty days without eating ‘…because he was on a slimming cure’. History and physical examination suggested WE as a result of isolation and poor diet leading to nutritional deficiency. This was confirmed by brain magnetic resonance imaging showing classic thalamic, mammillary bodies and brainstem lesions. Of note, his cognitive profile was far more heterogeneous than what had classically been described in the literature and involved both cortical and subcortical pathology, generating memory but also significant executive deficits. Intravenous treatment with thiamine was given and our patient showed mild improvements in visual acuity and nystagmus. However, persistent cognitive and physical disabilities consistent with Korsakoff syndrome remained, and he now lives in a supervised home. This case illustrates the tragic consequences of nutritional deficiencies in a patient with paranoid schizophrenia. The threshold to suspect WE in schizophrenic patients should be lowered and in doubt prophylactic parenteral thiamine should be administered.

The role of basal ganglia in language production: evidence from Parkinson's disease

According to the dominant view in the literature, basal ganglia do not play a direct role in language but are involved in cognitive control required by linguistic and non-linguistic processing. In Parkinson's disease, basal ganglia impairment leads to motor symptoms and language deficits; those affecting the production of verbs have been frequently explored. According to a controversial theory, basal ganglia play a specific role in the conjugation of regular verbs as compared to irregular verbs. We report the results of 15 patients with Parkinson's disease in experimental conjugation tasks. They performed below healthy controls but their performance did not differ for regular and irregular verbs. These results confirm that basal ganglia are involved in language processing but do not play a specific role in verb production.

[Are non-literal language comprehension deficits related to a theory of mind deficit in Parkinson's disease?]

Theory of mind (TOM), i.e. the capacity to attribute mental states to oneself and others, would be impaired in Parkinson's disease (PD). Nonliteral language (NLL) comprehension would also be impaired in this disease. The goal of this study was to verify the presence of an association between the TOM and NLL comprehension deficits. We assessed 15 individuals in the early stages of PD and 17 healthy controls (HC), comparable on gender, age and education. Each subject completed a TOM evaluation task and a NLL task (i.e. metaphor comprehension). They also completed executive functioning (mental flexibility, inhibition and working memory) evaluation tasks. Our results showed that patients with PD had significant difficulties in the TOM and NLL comprehension tasks compared to HC participants. A significant relationship was found between TOM and NLL comprehension results. Moreover, NLL scores were associated with a task evaluating mental flexibility. Thus, PD might cause both TOM and NLL comprehension deficit even in the early stages of the disease. Our results showed that there would be a close relationship between TOM and NLL in people with PD.

Clinical validity of the Mattis Dementia Rating Scale-2 in Parkinson disease with MCI and dementia

The utility of the Mattis Dementia Rating Scale 2 (MDRS-2) in screening for dementia in Parkinson disease (PD) is well documented. However, little is known about its sensitivity to mild cognitive impairment in PD (PD-MCI). This study sought to document the validity of the MDRS-2 for diagnoses of PD-MCI and dementia in PD (PDD). Twenty-two healthy controls (HCs), 22 PD-MCI, and 16 PDD were compared on each MDRS-2 subscales and MDRS-2 total standard scores. Patients with PDD performed significantly worse than the other groups (all Ps < .05) on the MDRS-2 total and on all subscales, except attention. PD-MCI had significant lower scores than HCs on the MDRS-2 total and on initiation/perseveration and memory subscales. The optimal cutoff score for PD-MCI diagnosis was ≤ 140/144 and ≤ 132/144 for PDD. These findings suggest that MDRS-2 is a useful tool to identify dementia but that there might be a ceiling effect in the MDRS-2 cutoff score to diagnose MCI in PD.

Mattis Dementia Rating Scale 2: screening for MCI and dementia

Identifying patients at higher risk of developing dementia is important. The usefulness of the Mattis Dementia Rating scale-Second Edition (MDRS-2) to detect and differentiate between patients with amnestic mild cognitive impairment (A-MCI), Parkinson's disease and MCI (PD-MCI), PD with dementia (PDD), and Alzheimer's disease (AD) was investigated. In all, 22 healthy controls (HC), 22 A-MCI, 22 PD-MCI, 16 PDD, and 22 AD patients were evaluated using an extensive neuropsychological battery, including the MDRS-2. The MDRS-2 total standardized score detected all groups of patients. The dementia groups performed worse than HC on the 5 MDRS-2 subscales. Alzheimer's disease patients scored higher than PDD on MDRS-2 conceptualization and lower on memory. Healthy controls were better than PD-MCI on MDRS-2 initiation/perseveration and memory and better than A-MCI on memory. No difference was found between the MCI groups. The MDRS-2 is a suitable short scale for MCI and dementia screening but is not specific enough to differentiate between A-MCI and PD-MCI.

Management of familial hypercholesterolemia in children and young adults: consensus paper developed by a panel of lipidologists, cardiologists, paediatricians, nutritionists, gastroenterologists, general practitioners and a patient organization

Since heterozygous familial hypercholesterolemia (HeFH) is a disease that exposes the individual from birth onwards to severe hypercholesterolemia with the development of early cardiovascular disease, a clear consensus on the management of this disease in young patients is necessary. In Belgium, a panel of paediatricians, specialists in (adult) lipid management, general practitioners and representatives of the FH patient organization agreed on the following common recommendations. 1. Screening for HeFH should be performed only in children older than 2 years when HeFH has been identified or is suspected (based on a genetic test or clinical criteria) in one parent.2. The diagnostic procedure includes, as a first step, the establishment of a clear diagnosis of HeFH in one of the parents. If this precondition is satisfied, a low-density-lipoprotein cholesterol (LDL-C) levelabove 3.5 mmol/L (135 mg/dL) in the suspected child is predictive for differentiating affected from non-affected children. 3. A low saturated fat and low cholesterol diet should be started after 2 years, under the supervision of a dietician or nutritionist.4. The pharmacological treatment, using statins as first line drugs, should usually be started after 10 years if LDL-C levels remain above 5 mmol/L (190 mg/dL), or above 4 mmol/L (160 mg/dL) in the presence of a causative mutation, a family history of early cardiovascular disease or severe risk factors. The objective is to reduce LDL-C by at least 30% between 10 and 14 years and, thereafter, to reach LDL-C levels of less than 3.4 mmol/L (130 mg/dL).

CONCLUSION

The aim of this consensus statement is to achieve more consistent management in the identification and treatment of children with HeFH in Belgium.

Prucalopride and donepezil act synergistically to reverse scopolamine-induced memory deficit in C57Bl/6j mice

It is known that 5-HT(4) receptor agonists increase sAPPalpha levels in the cortex and hippocampus of mice as well as in a model of Alzheimer's disease (AD). As sAPPalpha is thought to have pro-mnesic properties, we assessed whether its increase induces cognitive improvement in a spatial memory task and whether it reverses a scopolamine-induced memory deficit. Mice treated or not treated with scopolamine were trained in the Morris water maze for 3 days. Before the probe test, they received an injection of either a 5-HT(4) receptor agonist (prucalopride or RS 67333), or an acetylcholinesterase inhibitor (donepezil), or both drugs. As expected, scopolamine decreased performance, an effect that was not reversed by the drugs tested when injected alone. However, prucalopride (5 mg kg(-1), s.c.) acted synergistically with donepezil (0.75 mg kg(-1), s.c.) to counteract completely scopolamine-induced amnesia. Western blot analysis of tissue homogenates in the cortex and hippocampus shows that sAPPalpha levels did not differ between saline- and scopolamine-treated mice. Furthermore, a region-dependent drug action was observed since the scopolamine-treated mice display a tendency to increase sAPPalpha levels in the hippocampus after donepezil or in the cortex after prucalopride. Our results suggest that a combined treatment with a 5-HT(4) receptor agonist with an acetylcholinesterase inhibitor has beneficial effects on memory in mice. Moreover, it seems to enhance sAPPalpha levels in two brain regions highly affected in AD. Thus, a drug polytherapy could be interesting not only to enhance cognitive performance and decrease drawbacks but also to get the best action in each brain region.

5-HT4 receptor agonists increase sAPPalpha levels in the cortex and hippocampus of male C57BL/6j mice

BACKGROUND AND PURPOSE

A strategy to treat Alzheimer's disease (AD) is to increase the soluble form of amyloid precursor protein (sAPPalpha), a promnesic protein, in the brain. Because strong evidence supports beneficial effects of 5-hydroxytryptamine 5-HT(4) receptor agonists in memory and learning, we investigated the role of 5-HT(4) receptors on APP processing in 8 weeks-old male C57BL/6j mice.

EXPERIMENTAL APPROACH

Mice were given, subcutaneously, prucalopride or ML 10302 (s.c.), two highly selective 5-HT(4) receptor agonists and, up to 240 min later, the hippocampus and cortex were analysed by Western blot for sAPPalpha determination.

KEY RESULTS

Prucalopride (5 or 10 mg kg(-1)) significantly increased sAPPalpha levels in the hippocampus and cortex, but did not modify the expression level of APP mRNA as detected by quantitative RT-PCR. A selective 5-HT(4) receptor antagonist, GR125487 (1 mg kg(-1), s.c.) inhibited prucalopride induced- increase in sAPPalpha levels. In addition, levels of sAPPalpha were increased by ML10302 only at 20 mg kg(-1) and was limited to the cortex. Also, prucalopride increased sAPPalpha levels in the cortex of a transgenic mouse model of AD, expressing the London mutation of APP. Furthermore, the combined injection of a selective acetylcholinesterase inhibitor, donepezil and prucalopride induced a synergic increase in sAPPalpha levels in the cortex and hippocampus.

CONCLUSIONS AND IMPLICATIONS

Our results demonstrate that the 5-HT(4) receptor plays a key role in the non-amyloidogenic pathway of APP metabolism in vivo and give support to the beneficial use of 5-HT(4) agonists for AD treatment.

Coronary risk factors and inflammation in patients with coronary artery disease and internal cardioverter defibrillator implants

BACKGROUND

The internal cardioverter defibrillator (ICD) is increasingly used to treat ventricular tachyarrhythmias in patients with coronary artery disease (CAD). The burden of coronary risk factors and inflammation is however not well studied in these high risk patients.

STUDY AIMS

The aim of the present study was to describe the prevalence of coronary risk factors (including lipid values) and inflammation (including high sensitive-C-reactive protein, hs-CRP) in patients with CAD and ICD implants.

METHODS

Baseline clinical characteristics and laboratory results of all eligible patients for the Cholesterol Lowering and Arrhythmias Recurrences after Internal Defibrillator Implantation trial (CLARIDI trial) were used. All patients had documented CAD, an ICD implant and were not yet treated with statins. Coronary risk factors, lipid values, glycated haemoglobin (HbA(1c)) and hs-CRP levels were determined.

RESULTS

In the 110 included patients (mean age 68+/-9 years, LVEF 40+/-17%, NYHA class II-III in 47%), a high prevalence of coronary risk factors was documented: current smoking in 18%, body mass index > or =30 kg/m(2) in 16%, blood pressure > or =140/90 mm Hg in 40%, history of diabetes in 12%, and HbA(1c) > or =6% in 16% of patients not known with diabetes. A total cholesterol >175 mg/dl was found in 76% of patients and an LDL cholesterol >100 mg/dl in 83%. Finally, median hs-CRP was 4.8 mg/l (interquartile range 2.5-13.9 mg/l). Hs-CRP values > or =2 mg/l were noted in 83% of all patients and in 68% of patients who had an ICD implant more than 6 months before inclusion.

CONCLUSION

In CAD patients with ICD implants, the burden of coronary risk factors is high, often unrecognized and/or under-treated. Persistent inflammation is found in the majority of these patients.

Evaluation of the pharmacokinetic profile and analgesic efficacy of oral morphine after total hip arthroplasty

BACKGROUND AND OBJECTIVE

Oral morphine may be useful for postoperative pain relief, but few studies have tested its use after in-hospital surgery.

METHODS

We evaluated clinical efficacy and the pharmacokinetic parameters of oral morphine after total hip arthroplasty. We recruited 60 patients who had total hip arthroplasty under general anaesthesia. The patients were randomized to receive placebo, 10 mg morphine sulphate or 20 mg morphine sulphate orally every 4 h for 24 h. The oral administration was started 3 h after the morphine-loading dose in the Post Anaesthesia Care Unit and then patients used intravenous morphine patient-controlled analgesia for 24 h. Pain score at rest (scored by patients on a visual analogue scale), sedation, nausea, vomiting and urinary retention were monitored. In 11 additional total hip arthroplasty patients, we determined the pharmacokinetics of morphine and its metabolites after oral administration of 20 mg morphine sulphate every 4 h for 16 h.

RESULTS

The amount of morphine administered via patient-controlled analgesia over 24 h was reduced in the 20-mg group compared with that in the placebo group (19.0 +/- 2.7 mg vs. 33.0 +/- 5.5 mg; P = 0.03). No significant morphine-sparing effect was observed in the 10-mg group. Pain scores and side-effects were similar in all groups. The pharmacokinetic study revealed a limited and slow absorption of morphine.

CONCLUSION

Despite a limited absorption of oral morphine postoperatively, high doses of oral morphine have a significant analgesic effect after total hip arthroplasty.

Activation of HTLV-I gene transcription by protein tyrosine phosphatase inhibitors

Human T-cell leukemia virus type I (HTLV-I) transcription generally depends on the ability of the viral Tax protein to bind the CREB transcription factor and form an active complex by recruiting CBP/p300 coactivators to the long terminal repeat (LTR). Studies have demonstrated that T-cell activating agents that stimulate CREB are potent inducers of HTLV-I transcription. Herein, we demonstrate that bpV[pic], a protein tyrosine phosphatase (PTP) inhibitor activates the HTLV-I LTR in the presence and absence of Tax expression. Optimal activation occurred at 8 h and was synergistic with forskolin or PGE(2). Infected cell lines and cells transfected with HTLV-I proviral DNA were equally responsive to the synergistic effect of bpV and forskolin on HTLV-I gene expression. Activation of the LTR by bpV[pic] was T-cell receptor-independent, but required ZAP70, calcineurin activity and functional calcium entry. Inhibition of the SHP-1 PTP was suggested to be important. Transfection experiments with a CREB dominant-negative mutant and with isolated TRE1- or CREB-responsive reporter constructs and treatment with the MDL-12,330A adenylate cyclase inhibitor all supported the involvement of a CREB/ATF family member in this bpV-dependent activation of the HTLV-I LTR, although CREB itself did not seem to be involved. Analysis of HTLV-I reporter constructs containing mutated CREB-binding sites also implied the involvement of another element in this activation. These results demonstrate for the first time a powerful effect of PTP inhibitors on HTLV-I LTR activity and suggest participation of both CREB-dependent and -independent pathways in this activation.

Haptoglobin polymorphisms and iron homeostasis in health and in disease

Haptoglobin (Hpt) is a plasma protein with hemoglobin-binding capacity. It is a well-known marker of hemolysis. Hpt is also an acute-phase protein that functions as a bacteriostatic agent, an inhibitor of prostaglandin synthesis and angiogenesis. However, the best-known biological function of Hpt is capture of hemoglobin (Hb). The identification of functional differences in haptoglobin molecules resulting from relatively common polymorphisms has further elucidated the importance of haptoglobin in iron homeostasis and in disease processes influenced by iron metabolism. In this review the effect of Hpt polymorphism on these different disease entities will be discussed.

Multiconjugate adaptive optics: laboratory experience

We present the results from a laboratory multiconjugate adaptive optics experiment. The experiment is differentiated from other published work in that it has a programmable deterministic turbulence generator and an output science camera. The turbulence was generated using a dual layer turbulence emulator, and then corrected using an AO system with 2 wavefront correctors and a Shack-Hartman wavefront sensor, which processed information from five artificial guide stars. We report our results and also describe some of the problems.

Randomized prospective study of the analgesic effect of nefopam after orthopaedic surgery † †Declaration of interest. This work has been sponsored by Biocodex Laboratories, in charge of nefopam (Acupan injectable™) commercialization

BACKGROUND

Balanced postoperative analgesia combines non-narcotic drugs and opioids. We organized a large study to evaluate nefopam analgesia and tolerance in combination with morphine for patient-controlled analgesia (PCA) after orthopaedic surgery.

METHODS

Two hundred and one patients scheduled to undergo hip arthroplasty were included in this multicentre (n=24), double-blind, randomized study comparing nefopam (20 mg every 4 h for 24 h) with placebo, the first dose being infused peroperatively. The primary outcome measure was the cumulative morphine dose received postoperatively by PCA over 24 h. Secondary outcome measures were the amount of morphine received as a loading dose in the postanaesthesia care unit (PACU) and during the 24-h observation period, and pain assessments using a visual analogue scale (VAS) and a verbal pain scale (VPS), patient's satisfaction with analgesia and treatment tolerance.

RESULTS

The two groups were comparable with respect to their characteristics and preoperative pain assessment. PCA-administered morphine over 24 h was significantly less for the nefopam group than the control group (21.2 (15.3) and 27.3 (19.2) mg respectively; P=0.02). This morphine-sparing effect was greater (35.1%) for patients with severe preoperative pain (VAS>30/100). For the entire study period (loading dose and PCA), morphine use was less for the nefopam group (34.5 (19.6) vs 42.7 (23.6) mg; P=0.01). Pain VAS at PACU arrival and during the whole PACU period was significantly lower for the nefopam than for the placebo group (P=0.002 and 0.04 respectively). Patient satisfaction was similar for the nefopam and placebo groups.

CONCLUSION

In combination with PCA morphine, nefopam gives significant morphine-sparing with lower immediate postoperative pain scores without major side-effects. This analgesic effect seems to be particularly notable for patients with intense preoperative pain.

New perspectives on dystonia

Dystonia is a syndrome of sustained muscular contractions with numerous underlying etiologies. This review examines the varied phenomenology of dystonias, its evolving classification including recent genetic data as well as its clinical investigation and treatment. Although age of onset, anatomical distribution and family history are key elements of the investigation of dystonia, classification increasingly relies on etiologic and genetic criteria. Physiological abnormalities in striato-cortical circuits are common in dystonia but the pathophysiology is still unclear. In recent years, a great deal has been learned on the more common primary dystonias such as primary torsion dystonia and on dystonia-plus syndromes such as dopamine responsive dystonia. Treatment of dystonia has also evolved and there are now a number of therapeutic agents with clear beneficial effects including anticholinergics, benzodiazepines, and botulinum toxin and there is growing interest in neurofunctional surgery including deep brain stimulation.

Haptoglobin phenotype 2-2 overrepresentation in Cys282Tyr hemochromatotic patients

BACKGROUND/AIMS

Patients with genotypic Cys282Tyr homozygous hemochromatosis differ largely in phenotypic presentation. The HFE mutation on itself does not explain the different manifestations of hemochromatosis. We hypothesized that the genetic haptoglobin (Hp) polymorphism, because of its effect on iron metabolism, could be a modifying factor that influences the clinical presentation of hereditary hemochromatosis.

METHODS

In 167 Cys282Tyr homozygous hemochromatotic patients, the frequencies of Hp types (1-1, 2-1 and 2-2) and alleles (Hp1, Hp2) were compared with those in 918 healthy subjects. Clinical and laboratory indices of iron overload were incorporated in the analysis.

RESULTS

The Hp 2-2 type was overrepresented in the patient group (P<0.01). Male patients carrying Hp 2-2 had higher serum iron (P=0.003) and ferritin levels (P=0.03) than those with a Hp 1-1 or 2-1 type. The amount of iron removed with phlebotomy was also higher in Hp 2-2 patients (P=0.03).

CONCLUSIONS

The Hp 2-2 type is overrepresented among Cys282Tyr homozygous hemochromatotic patients. At diagnosis, iron overload was more pronounced in male patients carrying Hp 2-2. Our data suggest that Hp polymorphism affects iron metabolism in hereditary hemochromatosis.

Haptoglobin polymorphism as a risk factor for coronary heart disease mortality

OBJECTIVES

the aim of our study was to evaluate the independent role of the haptoglobin (Hp) polymorphism as a risk factor for coronary heart disease (CHD) mortality.

METHODS

within the framework of the longitudinal part of the Belgian Interuniversity Research on Nutrition and Health (BIRNH) survey, a nested case-control study design was performed through matching the 107 deaths from CHD, occurring within a 10-year follow-up period, with three controls for age and gender.

RESULTS

the distribution of the Hp types was found to be in Hardy-Weinberg equilibrium. Conditional logistic regression analysis for matched sets revealed that the Hp polymorphism was significantly associated with CHD death. Rather surprisingly, the finding was that Hp 1-1 individuals were at doubled risk for CHD mortality compared with the others, the odds ratio being 2.09 (95% CI: 1.22-3.60). The association was independent from other classical cardiovascular risk factors and the Hp concentration, and of comparable magnitude between men and women. Moreover, evaluating the interaction term in a multiplicative model showed that the Hp type did not play a synergistic role in the prognostic value of established cardiovascular risk factors.

CONCLUSION

in contrast to the findings from cross-sectionally based studies, the results from this longitudinal study show that Hp 1-1 individuals are at elevated risk for CHD mortality.

Serum vitamin C concentration is low in peripheral arterial disease and is associated with inflammation and severity of atherosclerosis

BACKGROUND

Peripheral arterial disease (PAD) is a severe atherosclerotic condition frequently accompanied by inflammation and oxidative stress. We hypothesized that vitamin C antioxidant levels might be low in PAD and are related to inflammation and disease severity.

METHODS AND RESULTS

We investigated vitamin C (L-ascorbic acid) levels in 85 PAD patients, 106 hypertensives without PAD, and 113 healthy subjects. Serum L-ascorbic acid concentrations were low among PAD patients (median, 27.8 micromol/L) despite comparable smoking status and dietary intake with the other groups (P<0.0001). Subclinical vitamin C deficiency (<11.4 micromol/L), confirmed by low serum alkaline phosphatase activity, was found in 14% of the PAD patients but not in the other groups. Serum C-reactive protein (CRP) concentrations were significantly higher in PAD patients (P<0.0001) and negatively correlated with L-ascorbic acid levels (r=-0.742, P<0.0001). In stepwise multivariate analysis, low L-ascorbic acid concentration in PAD patients was associated with high CRP level (P=0.0001), smoking (P=0.0009), and shorter absolute claudication distance on a standardized graded treadmill test (P=0.029).

CONCLUSIONS

Vitamin C concentrations are lower in intermittent claudicant patients in association with higher CRP levels and severity of PAD. Future studies attempting to relate vitamin C levels to disease occurrence should include in their analysis an inflammatory marker such as CRP.

Synthesis of phenalene and acenaphthene derivatives as new conformationally restricted ligands for melatonin receptors

Conformationally restricted phenalene and acenaphthene derivatives 5 were synthesized from phenalen-1-one and acenaphthen-1-one derivatives using the Horner-Emmons reaction. The amines were prepared through the corresponding isocyanates by the Curtius reaction on the acids or by the reduction of the nitriles. Amido derivatives (R(3) = Me, Et, n-Pr, c-Pr) were prepared by acylation of the amines with the appropriate anhydrides or acid chlorides or by the reductive acylation of the nitriles. The affinities of the compounds for melatonin binding sites were evaluated in vitro in binding assays using chicken brain melatonin and the human mt(1) and MT(2) receptors expressed in HEK-293 cells. The functionality of the compounds was determined by the potency to lighten the skin of Xenopus laevis tadpoles. Highly potent compounds were obtained. The data highlighted the role of the methoxy group located in the ortho position to the ethylamido chain as compounds with picomolar affinities such as 14c were obtained (chicken brain, hmt(1), hMT(2) K(i) values = 0.02, 0.008, 0.069 nM, respectively). Compound 14c was equipotent to the corresponding dimethoxy derivative 15c (chicken brain, hmt(1), hMT(2) K(i) values = 0.07, 0.016, 0.1 nM, respectively). On the other hand, the restricted conformation of the amido chain did not influence selectivity for the cloned hmt(1) and hMT(2) receptors. These compounds were also potent agonists of melanophore aggregation in X. laevis. 15a,c were several hundred fold more potent than melatonin (EC(50) = 0.025, 0.004 nM, respectively). Conformational studies indicated that the minimum energy folded conformation of the ethylamido chain could constitute the putative active form in the receptor site in agreement with previous results.