Public Health and Interprofessional Education as Critical Components in the Evolution of Osteopathic Medical Education

Public health and interprofessional education (IPE) are included among the osteopathic core competencies and Entrustable Professional Activities that should be reflected in osteopathic medical curricula. Cognizant of the importance of these 2 areas, Touro University College of Osteopathic Medicine-CA (TUCOM) has developed initiatives to advance them on campus as well as within its academic curriculum. The authors acknowledge the importance of incorporating public health content into osteopathic medicine as well as expanding IPE in the health professions as part of a larger project to impart a unique identity and relevance to osteopathic medical education at TUCOM. The authors describe TUCOM's public health and IPE initiatives and outcomes in the context of current and future relevance for osteopathic medicine. Future directions to assess the quality and impact of these programs that may be of value for other colleges of osteopathic medicine are also discussed.

Dietary advanced glycation end products and their role in health and disease

Over the past 2 decades there has been increasing evidence supporting an important contribution from food-derived advanced glycation end products (AGEs) to the body pool of AGEs and therefore increased oxidative stress and inflammation, processes that play a major role in the causation of chronic diseases. A 3-d symposium (1st Latin American Symposium of AGEs) to discuss this subject took place in Guanajuato, Mexico, on 1-3 October 2014 with the participation of researchers from several countries. This review is a summary of the different presentations and subjects discussed, and it is divided into 4 sections. The first section deals with current general knowledge about AGEs. The second section dwells on mechanisms of action of AGEs, with special emphasis on the receptor for advanced glycation end products and the potential role of AGEs in neurodegenerative diseases. The third section discusses different approaches to decrease the AGE burden. The last section discusses current methodologic problems with measurement of AGEs in different samples. The subject under discussion is complex and extensive and cannot be completely covered in a short review. Therefore, some areas of interest have been left out because of space. However, we hope this review illustrates currently known facts about dietary AGEs as well as pointing out areas that require further research.

The axis AGE-RAGE-soluble RAGE and oxidative stress in chronic kidney disease

Chronic kidney disease (CKD) has been shown to be associated with high oxidative stress and cardiovascular disease. In this chapter our focus will be on the role of advanced glycation end products (AGE) and their receptor, RAGE in CKD progression and their role on cardiovascular complications. We provide a succinct, yet comprehensive summary of the current knowledge, the challenges and the future therapeutic avenues that are stemming out from novel recent findings. We first briefly review glycation and AGE formation and the role of the kidney in their metabolism. Next, we focus on the RAGE, its signaling and role in oxidative stress. We address the possible role of soluble RAGEs as decoys and the controversy regarding this issue. We then provide the latest information on the specific role of both AGE and RAGE in inflammation and perpetuation of kidney damage in diabetes and in CKD without diabetes, which is the main purpose of the review. Finally, we offer an update on new avenues to target the AGE-RAGE axis in CKD.

Paraoxonase 1 and HDL maturation

Understanding the kinetics and function of paraoxonase 1 (PON1) is becoming an important issue in atherosclerosis. Low PON1 activity has been consistently linked with an increased risk of major cardiovascular events in the setting of secondary prevention of coronary artery disease. Recent studies have shown that there is a specific interaction of myeloperoxidase (MPO)-apoAI-PON1 on HDL surface that seems to be germane to atherogenesis. MPO specifically inhibits PON1 and PON1 mitigates MPO effects. Surprisingly, very little is known about the routes by which PON1 gets integrated into HDL or its fate during HDL remodeling in the intravascular space. We have developed a method that assesses PON1 activity in the individual HDL subclasses with the aid of which we have shown that PON1 is present across the HDL particle range and preferentially in HDL3, confirming data from ultracentrifugation (UC) studies. Upon HDL maturation ex vivo PON1 is activated and it shows a flux to both smaller and larger HDL particles as well as to VLDL and sdLDL. At the same time apoE, AI and AII are shifted across particle sizes. PON1 activation and flux across HDL particles are blocked by CETP and LCAT inhibitors. In a group of particles with such a complex biology as HDL, knowledge of the interaction between apo-lipoproteins, lipids and enzymes is key for an increased understanding of the yet multiple unknown features of its function. Solving the HDL paradox will necessitate the development of techniques to explore HDL function that are practical and well adapted to clinical studies and eventually become useful in patient monitoring. The confluence of proteomic, functional studies, HDL subclasses, PON1 assays and zymogram will yield data to draw a more elaborate and comprehensive picture of the function of HDL. It must be noted that all these studies are static and conducted in the fasting state. The crucial phase will be achieved when human kinetic studies (both in the fasting and post-prandial states) on HDL-PON1, apoA-I and lipid fate in the circulation are carried out.

Circulating soluble RAGE increase after a cerebrovascular event

BACKGROUND

The receptor for AGE (RAGE) is a key mediator in cerebral ischemia. Based on the evidence from animal studies and the presence of increased high mobility group box 1 protein (HMGB1, a RAGE ligand) in the serum of stroke patients, we hypothesized that soluble RAGE (sRAGE) increase in serum after ischemic and hemorrhagic stroke and that the levels decrease with patient improvement.

METHODS

We performed a longitudinal study of the acute changes of sRAGE levels in a series of 15 ischemic and hemorrhagic stroke patients at admission and over a period averaging 1 week and extending for up to more than a month in some of the cases. Serum sRAGE was measured by an enzyme-linked immunosorbent assay (R&D Systems Inc., Minneapolis, MN, USA).

RESULTS

Serum sRAGE at admission were not significantly different between patients and healthy controls, p=0.17. Over the following days after the event, stroke patients displayed an increase of the serum levels of sRAGE, which at peak ranged between 26% and 296%, p>0.001. Similar changes are seen for both types of events, hemorrhagic and ischemic. sRAGE changes paralleled recovery and recurrence or aggravation of the episodes. Biological variability of sRAGE as measured daily in healthy subjects over 21 days showed a CV of only 8.9%.

CONCLUSIONS

Our results provide for the first time a proof of principle that circulating sRAGE increase after ischemic and hemorrhagic stroke and may become candidate biomarkers to consider in larger studies exploring prognostic or follow-up value.

Paraoxonase 1 in neurological disorders

Paroxonase 1 displays multiple physiological activities that position it as a putative player in the pathogenesis of neurological disorders. Here we reviewed the literature focusing on the role of paraoxonase 1 (PON1) as a factor in the risk of stroke and the major neurodegenerative diseases. PON1 activity is reduced in stroke patients, which significantly correlates inversely with carotid and cerebral atherosclerosis. The presence of the R allele of the Q192R PON1 polymorphism seems to potentiate this risk for stroke. PON1 exerts peroxidase activities that may be important in neurodegenerative disorders associated with oxidative stress. PON1 is also a key detoxifier of organophosphates and organophosphate exposure has been linked to the development of neurological disorders in which acetylcholine plays a significant role. In Parkinson's disease most of the studies suggest no participation of either L55M or the Q192R polymorphisms in its pathogenesis. However, many studies suggest that the MM55 PON1 genotype is associated with a higher risk for Parkinson's disease in individuals exposed to organophosphates. In Alzheimer's disease most studies have failed to find any association between PON1 polymorphisms and the development of the disease. Some studies show that PON1 activity is decreased in patients with Alzheimer's disease or other dementias, suggesting a possible protective role of PON1. No links between PON1 polymorphisms or activity have been found in other neurodegenerative diseases such as multiple sclerosis and amyotrophic lateral sclerosis. PON1 is a potential player in the pathogenesis of several neurological disorders. More research is warranted to ascertain the precise pathogenic links and the prognostic value of its measurement in neurological patients.

Recent advances on Ilex paraguariensis research: minireview

Ilex paraguariensis dried and minced leaves are made into a brewed tea, prepared in a sui generis manner by large populations in South America, having evolved from a tea drunk by the Guarani ethnic group to a beverage that has a social and almost ritualistic role in some South American modern societies. It is used both as a source of caffeine, in lieu or in parallel with tea and coffee, but also as a therapeutic agent for its alleged pharmacological properties. Although with some exceptions, research on biomedical properties of this herb has had a late start and strongly lags behind the impressive amount of literature on green tea and coffee. However, in the past 15 years, there was a several-fold increase in the literature studying Ilex paraguariensis properties showing effects such as antioxidant properties in chemical models and ex vivo lipoprotein studies, vaso-dilating and lipid reduction properties, antimutagenic effects, controversial association with oropharyngeal cancer, anti-glycation effects and weight reduction properties. Lately, promising results from human intervention studies have surfaced and the literature offers several developments on this area. The aim of this review is to provide a concise summary of the research published in the past three years, with an emphasis on translational studies, inflammation and lipid metabolism. Ilex paraguariensis reduces LDL-cholesterol levels in humans with Ilex paraguariensis dyslipoproteinemia and the effect is synergic with that of statins. Plasma antioxidant capacity as well as expression of antioxidant enzymes is positively modulated by intervention with Ilex paraguariensis in human cohorts. A review on the evidence implicating Ilex paraguariensis heavy consumption with some neoplasias show data that are inconclusive but indicate that contamination with alkylating agents during the drying process of the leaves should be avoided. On the other hand, several new studies confirm the antimutagenic effects of Ilex paraguariensis in different models, from DNA double breaks in cell culture models to mice studies. Novel interesting work has emerged showing significant effect on weight reduction both in mice and in rat models. Some mechanisms involved are inhibition of pancreatic lipase, activation of AMPK and uncoupling of electron transport. Intervention studies in animals have provided strong evidence of anti-inflammatory effects of Ilex paraguariensis, notably protecting cigarette-induced lung inflammation acting on macrophage migration and inactivating matrix-metalloproteinase. Research on the effects of Ilex paraguariensis in health and disease has confirmed its antioxidant, anti-inflammatory, antimutagenic and lipid-lowering activities. Although we are still waiting for the double-blind, randomized prospective clinical trial, the evidence seems to provide support for beneficial effects of mate drinking on chronic diseases with inflammatory component and lipid metabolism disorders.

Protective action of Ilex paraguariensis extract against free radical inactivation of paraoxonase-1 in high-density lipoprotein

Paraoxonase 1 (PON-1), an antioxidant enzyme carried mainly by HDL, has been shown to display cardioprotective effects. In this study, we investigated whether the polyphenol-rich beverage mate, obtained from extract of Ilex paraguariensis (IP), prevented the loss of PON-1 activity from HDL during oxidant stress. The peroxide radical generator 2,2-azobis(2-amidinopropane) dihydrochloride (AAPH) induced time- and dose-dependent oxidation of HDL, as measured by lipoperoxide content, which is accompanied by a parallel decrease in the activity of PON-1 (p<0.001). IP extract (2-20 microL/mL) afforded time- and concentration-dependent inhibition of the oxidation, with preservation of apoA-I structure and PON-1 activity. Healthy volunteers drank either 0.5 L of IP extract, 0.5 L of coffee and milk or nothing. PON-1 activity increased an average of 10% above the changes seen when the intake was coffee and milk (p<0.05). In conclusion, we demonstrate that IP extract may, to some extent, prevent the loss of the antiatherogenic function of HDL afforded by PON-1 when the particle is under oxidant stress.

Ilex paraguariensis extracts are potent inhibitors of nitrosative stress: A comparative study with green tea and wines using a protein nitration model and mammalian cell cytotoxicity

Due to the increasing importance of nitrosative stress in pathology and the efficacy displayed by flavonoids in cancelling the effects of peroxynitrite, we decided to conduct a comparative study of three commonly used beverages with the highest polyphenol contents and proven antioxidant properties: mate (Ilex paraguariensis); green tea (Camelia sinensis) extracts and white and red wines of the main varietals. We directly evaluated and compared the extracts and wines as protein nitration inhibitors using 3-nitrotyrosine as a biomarker, we studied the extracts as protectors from OONO-induced cytotoxicity in two mammalian cell lines. Both green tea and mate extracts have a high polyphenol content, in the case of Ip, its higher concentration and higher free radical quenching activity on the DPPH assay may be mainly due to the sui generis extraction procedure. When BSA was incubated in the presence of SIN-1, a time and dose dependent nitration of the protein is clearly shown. Co-incubation of BSA with Ip, green tea or red wines led to a dose dependent inhibition of the effect. Ip displayed the highest inhibitory activity, followed by red wines and the green tea. Dilutions as low as 1/1500 produced more than 80% inhibition of albumin nitration. When we studied peroxynitrite-induced cytotoxicity in murine RAW 264.7 macrophages and 31EG4 mammary cells., we found a potent, dose-dependent protective effect that was Ilex paraguariensis > red wines > green tea. Taken together, our results indicate that when the herbal preparations studied here are prepared the way they are usually drunk, Ip displays the highest inhibition of protein nitration, and the highest promotion of cell survival, whereas green tea or red wines display significant but lesser effects at the same concentrations. Further studies aiming at isolation of the active principles and assessment of their bioavailability are warranted.

Antioxidant activity of a botanical extract preparation of Ilex paraguariensis: prevention of DNA double-strand breaks in Saccharomyces cerevisiae and human low-density lipoprotein oxidation

We analyzed the antioxidant properties of Ilex paraguariensis infusion (Ip) popularly known as mate (mä'tā), by using two experimental models: the induction of DNA double-strand breaks (DSB) by hydrogen peroxide (H(2)O(2)) and lethality in Saccharomyces cerevisiae, as well as peroxide and lipoxygenase-induced human low-density lipoprotein (LDL) oxidation. Diploid yeast cells were exposed to different concentrations of H(2)O(2) (5-10 mmol/L) in the absence or presence of Ip infusion (10(-1) v/v) or alpha-tocopherol (10(-2) mol/L). Both mate infusion and alpha-tocopherol significantly decreased the dose dependent DSB number, and the lethality induced by H(2)O(2). Peroxynitrite and lipoxygenase-induced human LDL oxidation are inhibited by Ip extracts in a potent, dose-dependent fashion. Dilutions of 5 x 10(-3) v/v provide 50% +/- 10% inhibition. Finally, Ip extracts are potent direct quenchers of the free radical 1,1-diphenyl-2-picrylhydrazyl. Dilutions of 2 x 10(-2) v/v produced quenching of more than 30%, which was comparable to that obtained with 0.5-1 mmol/L alpha-tocopherol or the quercetin aglycone, respectively. For comparison, total polyphenol content of Ip, green, and black tea (Camelia sinensis) were 6.5 +/- 0.8; 1.8 +/- 0.5; and 1.13 +/- 0.3 mmol of quercetin equivalents per liter, respectively. Their respective free radical quenching activities at dilutions of 1 x 10(-1) v/v were 75% +/- 5%; 35% +/- 5%; and 2% +/- 5%. Ip is thus a rich source of polyphenols and has antioxidant properties comparable to those of green tea which merit further in vivo intervention and cross-sectional studies.

The polyamines spermine and spermidine protect proteins from structural and functional damage by AGE precursors: a new role for old molecules?

Due to the importance of glycation in the genesis of diabetic complications, an intense search for synthetic new antiglycation agents is ongoing. However, a somewhat neglected avenue is the search for endogenous compounds that may inhibit the process and be a source of protodrugs. Based on their ubiquity, their polycationic nature, their essential role in growth, their relatively high concentrations in tissues, and their high concentrations in sperm, we hypothesized that polyamines inhibit glycation and that might be one of their so far elusive functions. In this study we demonstrate a potent antiglycation effect of physiological concentrations of the polyamines spermine and spermidine. We employed two approaches: in the first, we monitored structural changes on histones and ubiquitin in which polyamines inhibit glycation-induced dimer and polymer formation. In the second we monitored functional impairment of catalytic activity of antithrombin III and plasminogen. Protection is afforded against glycation by hexoses, trioses and dicarbonyls AGE precursors and is comparable to those of aminoguanidine and carnosine.

The botanical extracts of Achyrocline satureoides and Ilex paraguariensis prevent methylglyoxal-induced inhibition of plasminogen and antithrombin III

Endogenously produced dicarbonyls, such as methylglyoxal (MG), are involved in advanced glycation end-product formation and thus linked to the pathophysiology of diabetic chronic complications. While the search for synthetic new antiglycation agents continues, little attention has been paid to putative antiglycation agents in natural compounds. Given the link between glycation and oxidation, in this work, we study the effects of methylglyoxal on two model systems; plasminogen and antithrombin III (AT III), then we set out to unravel a possible antiglycation effect for extracts of the flavonoid-rich common herbal species Achyrocline satureoides (AS) and Ilex paraguariensis (IP). Using SAR-PRO-ARG-pNA as a specific thrombin substrate, we show that incubation of plasma with MG decreases heparin activation of AT III by up to a 70%, in a dose-dependent manner. A parallel dose-dependent decrease in plasminogen activity reaching more than 50% was shown using D-BUT-CHT-lys-pNA as a plasmin-specific substrate. Extracts of AS and IP display a dose dependent inhibition of the action of the dicarbonyl, already significant at a 1/100 dilution of the herbal infusions. The inhibition was comparable to that obtained by using millimolar concentrations of known AGE inhibitors such as aminoguanidine and carnosine as well as micromolar concentrations of the antioxidant ascorbic acid. We believe our system of whole plasma glycation over 16 h with micromolar concentrations of MG, coupled with the measurement of activities of plasminogen and AT III by specific substrates provides a straightforward, practical method for monitoring the action of putative antiglycation agents. If predictably milder glycated forms of AT III and plasminogen were to be secreted in vivo, the loss of activities shown here could act synergistically to generate hyperthrombicity.

Three different pathways for human LDL oxidation are inhibited in vitro by water extracts of the medicinal herb Achyrocline satureoides

In this study we investigated the antioxidant properties of one herbal preparation widely used in complementary and alternative medicine in large areas of the world: Achyrocline satureoides (AS), popularly known as "marcela". Although rich in flavonoids, the ethnopharmacological uses of this plant do not include atherosclerosis prevention. Furthermore, no study had been conducted so far exploring the antioxidant activity of Achyrocline satureoides vis-à-vis human LDL oxidation, which is the compelling issue in pinpointing potential cardioprotective new uses for a traditional remedy. We explored the effects of AS extracts on human LDL oxidation, employing 3 different systems which are thought to play a role in oxidation of LDL in the arterial wall: copper, peroxynitrite, and lipoxygenase. Oxidation was monitored by conjugate dienes, TBARS formation and aggregation of apoB using SDS-PAGE. In copper-initiated oxidation a dose dependent inhibition of the initiation and propagation of lipid oxidation is shown by an increase in the lag phase for conjugate diene production which was 60 +/- 15 min in the absence and 120 +/- 20 min in the presence of 4 microg/ml AS extracts (p < 0.001). TBARS production was reduced by 95% after 3 h incubation at 5 microg/ml. Aggregation of apoB was abolished at the same concentrations. SIN-1 (3-morpholinosydnonimine) produces peroxynitrite via generation of NO and O2-. When LDL was incubated in its presence, a milder oxidation was observed as compared with Cu2+, and AS produced over 70% inhibition. Finally, we show a striking dose-dependent inhibitory effect of lipoxygenase conjugate diene production, which is over 95% at AS concentrations of 5 microg/ml. When compared with other antioxidants, AS effect is greater but in the same order of magnitude than that of ascorbic acid and similar to the popular herbal tea Ilex paraguariensis. In all three systems employed an effect is already substantiated at a concentration of the AS extract of 4 microg/ml, which corresponds to a 1/100 dilution of the preparations usually drunk.

Circulating advanced glycation peptides in streptozotocin-induced diabetic rats: evidence for preferential modification of IgG light chains

As the glycation/glycoxidation hypothesis for the genesis of diabetic complications is achieving widespread acceptance, much attention is being paid to the role of low molecular weight advanced glycation (AGE) adducts, as second generation glycating agents. We set out a study with the objective of attesting the presence of increased amounts of AGE-peptides in the circulation of streptozotocin-induced diabetic rats and to determine the nature of the plasma proteins which are main targets for advanced glycation. AGE (Ex 370/Em 440 nm) and pentosidine fluorescence (Ex 335/Em 385 nm) were significantly higher in plasma from diabetic rats after only one month of hyperglycemia as compared to controls (35 +/- 7 vs 25 +/- 2 AU, p< 0.05 and 54 +/- 14 vs 27 +/- 3 AU, p< 0.01 respectively). AGE-peptides (<10 kDa) were more than two-fold higher in diabetic animals. Immunoblots after SDS-PAGE of plasma proteins showed that AGE-IgG displayed a selective predominant increment in the same animals. When native rat IgG was incubated in the presence of AGE-peptides isolated from diabetic animals, AGE modification was already apparent after only 24 h of incubation, and was particularly important for light chains. AGE-immunoreactive light chains displayed an apparent increase in molecular weight. Aminoguanidine prevented, while copper enhanced AGE binding to IgG light chains. Our data validate the streptozotocin-induced diabetic rat as a model reproducing the presence of circulating AGE-peptides, give evidence that IgG are preferential targets for advanced glycation in plasma and suggest that this modification, mediated by AGE-peptides, can be prevented by aminoguanidine.

Susceptibility to copper-enhanced autoxidation of VLDL+LDL fractions from diabetic patients

We describe a simplified method for studying the susceptibility to in vitro autoxidation of lipoproteins containing apolipoprotein B. It comprises copper induced autoxidation of VLDL+LDL plasma fractions and an assay for thiobarbituric acid reactive soluble substances. We studied autoxidation of VLDL+LDL in a population of 30 healthy subjects and a population of 30 diabetic patients. No significant difference in susceptibility to autoxidation could be detected. Protection afforded by ascorbic acid amounted to more than 95% at concentrations easily attainable in vivo by oral supplementation. Thiobarbituric acid reactive substances were higher in plasma from diabetic patients: 0.51 +/- 0.25 mumol/l vs 0.35 +/- 0.07 mumol/l for control subjects (p < 0.001). Our data confirm the presence of higher levels of lipid peroxides in diabetic patients, but fail to demonstrate any difference in susceptibility to oxidation of apolipoprotein B containing particles between control and diabetic subjects.

Polyclonal immunoglobulin M: location of glycation sites

A four step purification procedure for polyclonal human serum IgM was elaborated, including ultracentrifugation, ammonium sulfate and polyethyleneglycol precipitations and diffusion-exclusion gel chromatography. IgM was glycated in vitro both in the presence of [14C]glucose and with unlabeled glucose. Influence of incubation time up to 10 days and of glucose concentration between 10 and 60 mmol/l were studied. With 10 mmol/l glucose, a molar ratio glucose/IgM of 5.7 was attained in 10 days. Increase of glucose concentration up to 60 mmol/l led to a molar ratio of 16.0. Both basal and in vitro glycation were evaluated by 3H-labeling by gel filtration and Concanavalin A-Sepharose chromatographies. Glycation occurs mainly on the heavy chains (> 85%), particularly on the Fd region.