Dietary intake and nutritional status of people with epilepsy: A systematic review

PURPOSE

In people with epilepsy achieving optimal dietary intake may be hampered by psychological and physical comorbidities associated with seizures, medication use, socioeconomic disadvantage and the use of therapeutic diets. This systematic review aimed to evaluate the reported dietary intake and nutritional status of children and adults with epilepsy.

METHODS

A systematic literature search was completed across Ovid MEDLINE, EMBASE and CINAHL (all from inception to 4 November 2021). We included studies that reported dietary intake in adults and children diagnosed with epilepsy compared with local reference ranges, control groups or general populations. Studies using interventions and therapeutic diets were excluded. Risk of bias was assessed using the Study Quality Assessment Tools by the National Heart, Lung and Blood Institute. A descriptive analysis was performed due to the heterogenous nature of the data.

RESULTS

The initial search returned 1214 articles. Full-text screening was completed for 98 studies and 19 studies met eligibility criteria and were included for extraction. These comprised of seven paediatric studies, eight adult studies and four studies that included both adult and paediatric cohorts. Sample size of cases in each study ranged from 17 to 3,220. Vitamin A, C, D and folate were the most frequently reported vitamins. Calcium, iron and zinc were the most commonly reported minerals. Most studies showed that people with epilepsy had poorer dietary intake and nutritional status compared with control groups or reference standards.

CONCLUSION

There were limited studies on dietary intake and nutritional status in people with epilepsy. Most available studies suggested poorer status compared to non-epilepsy controls. The development of a validated dietary assessment tool specifically for epilepsy cohorts would enable comparison of findings across studies, and aid with appropriately tailoring nutrition advice to individuals with epilepsy.

Modified low ratio ketogenic therapy in the treatment of adults with super-refractory status epilepticus

BACKGROUND

Induction of ketosis by manipulation of nutrition intake has been proposed as an adjunctive treatment for super-refractory status epilepticus (SRSE). However, the classical 4:1 ketogenic ratio may not meet the nutrition needs, specifically protein for critically ill adults. The aim of this study was to analyze the outcomes of adults with SRSE who received a lower ketogenic ratio of 2:1 grams of fat to non-fat grams, including 20%-30% of energy from medium chain triglycerides.

METHODS

We reviewed patients aged ≥18 years with SRSE treated with ketogenic therapy between July 2015 and December 2020 at two quaternary teaching hospitals in Melbourne, Australia. Data collected from medical records included patient demographics, nutrition prescription, clinical outcomes, and ketogenic therapy-related complications. The primary outcome of the study was to assess tolerability of ketogenic therapy.

RESULTS

Twelve patients (female = 7) were treated with ketogenic therapy for SRSE. Patients received between 4 and 8 antiseizure medications and 1-5 anesthetic agents prior to commencement of ketogenic therapy. Blood beta-hydroxybutyrate concentrations were variable (median = 0.5 mmol/L, range: 0.0-6.1 mmol/L). SRSE resolved in 10 cases (83%) after a median of 9 days (range: 2-21 days) following commencement of ketogenic therapy. Ketogenic therapy-associated complications were reported in five patients, leading to cessation in two patients.

CONCLUSION

Despite the challenge in maintaining ketosis during critical illness, low ratio 2:1 ketogenic therapy incorporating medium chain triglycerides is tolerable for adults with SRSE. Further studies are required to determine the optimal timing, nutrition prescription and duration of ketogenic therapy for SRSE treatment.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Practical Considerations for Ketogenic Diet in Adults With Super-Refractory Status Epilepticus

Purpose of Review

Ketogenic diet therapy can be used as an adjuvant treatment of super-refractory status epilepticus (SRSE). However, the drug and metabolic interactions with concomitant treatments present a challenge for clinicians. In this review, we focus on the practical considerations of implementing ketogenic dietary therapy in the acute setting, including the dietary composition, potential drug-diet interactions, and monitoring during ketogenic treatment.

Recent Findings

This report describes the ketogenic diet therapy protocol implemented for the treatment of SRSE and a review of the current evidence to support clinical practice.

Summary

The control of SRSE is critical in reducing morbidity and mortality. There is emerging evidence that ketogenic diet may be a safe and effective treatment option for these patients.

Practical considerations of dietary therapies for epilepsy in adults

Despite the increasing number of anti-seizure medications becoming available, the proportion of patients with drug-resistant epilepsy remains unchanged. Dietary therapy for epilepsy is well-established practice in paediatric care, but relatively underutilised in adults. Recently, international recommendations have been published to guide the treatment of adults receiving dietary therapy for epilepsy.

This review focuses on the specific aspects of care unique to the management of adults receiving dietary therapy for epilepsy, including patient selection, diet composition, initiation, monitoring and cessation of dietary treatment. We emphasise the need for a multidisciplinary team approach with appropriately trained neurologists and dietitians to provide holistic care while the patients are receiving dietary therapy. Future research should focus on the optimal diet composition and meeting the psychosocial needs of adults with epilepsy to maximise efficacy and adherence to dietary treatment.

A benchmarking study of home enteral nutrition services

BACKGROUND & AIMS

Patients receiving home enteral nutrition (HEN) via an enteral feeding tube often have complex healthcare requirements. There is limited information regarding how HEN care is provided within Australia and New Zealand. This study aimed to investigate the characteristics of HEN services and the provision of nutrition care to individuals receiving HEN within Australia and New Zealand.

METHODS

A cross-sectional study, surveying lead HEN dietitians for HEN services was conducted from the period 09 July 2019 to 20 September 2019 inclusive. An online survey was used to obtain data relating to the demographics, funding and clinical resources of respondents' HEN services. Services were benchmarked against a HEN service implementation checklist adapted from the Agency for Clinical Innovation (ACI).

RESULTS

Responses were received from 107 HEN services, with an estimated combined population of 7122 HEN patients. Services were predominantly government-funded (n = 102, 95.3%) and operated from acute hospitals (n = 57, 53.3%). The reported combined cost of all HEN equipment to the patient ranged from $0-$77 per week or $0-$341 per month. Fifty-two services were reported to have a dedicated HEN dietitian/coordinator, which was positively associated with the undertaking of quality improvement activities (p = 0.019). Mean compliance to the ACI HEN implementation checklist was 70.4% (±15.7%) with a range of 13.0-98.2%. Mean compliance was significantly higher in services with a HEN dietitian/coordinator than services without one (75.5% (±12.0%) vs 64.3% (±16.6%); p < 0.001).

CONCLUSIONS

This study provides detailed information regarding the characteristics of HEN services and nutrition care provided to enterally-fed patients across Australia and New Zealand. The majority of HEN services are not adhering to the ACI HEN service guidelines and there is considerable variation in cost burden for consumers indicating inequitable delivery of care to patients.

Open-label long-term treatment of add-on triheptanoin in adults with drug-resistant epilepsy

Objective

To investigate feasibility, safety, and tolerability of long‐term (48 weeks) add‐on treatment with triheptanoin (UX007), the triglyceride of heptanoate, in adults with drug‐resistant epilepsy.

Methods

This extension study was offered to adult participants with drug‐resistant epilepsy who completed a 12‐week randomized controlled trial of add‐on medium‐chain triglycerides (MCT) vs triheptanoin. Participants were asked to titrate triheptanoin to their maximum tolerated dose over 3 weeks, followed by 48‐week maintenance before tapering or treatment extension. The primary aims were to assess retention and safety of the triheptanoin treatment, and secondary aims to assess the tolerated doses and changes in seizure frequency.

Results

Eleven adults were enrolled and ten people were analyzed (because one patient was diagnosed as having nonepileptic seizures while on the study). Two adults finished the study and extended their treatment. Eight participants withdrew from the study, due to lack of efficacy (n = 3), unknown reasons (n = 2), belief of weight gain (n = 1), wanting to try a different treatment (n = 1), and a colonoscopy (n = 1). Diarrhea in two people and bloating in one person were deemed possibly related to treatment, but other adverse events were not. The duration of maintenance treatment dose was 27‐513 days (median 247 days, range 27‐513 days), and 0.49 ‐1.1 mL/kg triheptanoin was taken per day (0.77 ± 0.19 mL/kg, mean ± standard deviation, 40‐100 mL/d). Two participants experienced >90% and three people >50% reduction in seizure frequency, and all had focal seizures. The median seizure reduction was 48% (average 38%).

Significance

Our results indicate antiseizure effects of triheptanoin on focal seizures in 5 out of 10 adults. However, only two people finished and extended the 48‐week add‐on treatment phase, despite lack of safety or tolerability issues.

More studies focused on improved treatment formulations, the potential of lower dosages, and efficacy are needed. Trial registration number: ACTRN12615000406505.

Randomized trial of add-on triheptanoin vs medium chain triglycerides in adults with refractory epilepsy

OBJECTIVE

To investigate the feasibility, safety, and tolerability of add-on treatment of the triglycerides of heptanoate (triheptanoin) vs the triglycerides of octanoate and decanoate (medium chain triglycerides [MCTs]) in adults with treatment-refractory epilepsy.

METHODS

After an 8-week prospective baseline period, people with drug-resistant epilepsy were randomized in a double-blind fashion to receive triheptanoin or MCTs. Treatment was titrated over 3 weeks to a maximum of 100 mL/d to be distributed over 3 meals and mixed into food, followed by 12-week maintenance before tapering. The primary aims were to assess the following: (a) safety by comparing the number of intervention-related adverse events with triheptanoin vs MCT treatment and (b) adherence, measured as a percentage of the prescribed treatment doses taken.

RESULTS

Thirty-four people were randomized (17 to MCT and 17 to triheptanoin). There were no differences regarding (a) the number of participants completing the study (11 vs 9 participants), (b) the time until withdrawal, (c) the total number of adverse events or those potentially related to treatment, (d) median doses of oils taken (59 vs 55 mL/d, P = 0.59), or (e) change in seizure frequency (54% vs 102%, P = 0.13). Please note that people with focal unaware seizures were underrepresented in the triheptanoin treatment arm (P = 0.04). The most common adverse events were gastrointestinal disturbances (47% and 62.5% of participants). Five people taking on average 0.73 mL/kg body weight MCTs (0.64 mL/kg median) and one person taking 0.59 mL/kg triheptanoin showed >50% reduction in seizure frequency, specifically focal unaware seizures.

SIGNIFICANCE

Add-on treatment with MCTs or triheptanoin was feasible, safe, and tolerated for 12 weeks in two-thirds of people with treatment-resistant epilepsy. Our results indicate a protective effect of MCTs on focal unaware seizures. This warrants further study.

Study of the Physicochemical Properties of Fish Oil Solid Lipid Nanoparticle in the Presence of Palmitic Acid and Quercetin

ω-3 polyunsaturated fatty acids, naturally found in fish oil, are highly desirable for their associated health benefits. However, they are highly prone to oxidation and degradation. We examined the feasibility of simultaneously adding a solid lipid (palmitic acid) and an antioxidant (quercetin) into a whey-protein-isolate-stabilized solid lipid nanoparticle emulsion for encapsulating fish oil. The goal was to find a rational and new formulation containing both solid lipid and antioxidant that can encapsulate fish oil and give it the best physicochemical stability. Our results show that adding palmitic acid improved the physical stability of the emulsions by decreasing the size of the oil-in-water droplets. On the basis of the thiobarbituric acid reactive substances assay, we found out that at low concentrations of palmitic acid the addition of quercetin played a dominant role in increasing the oxidation stability of fish oil. On the contrary, at high concentrations of palmitic acid, it was palmitic acid that dominated the oxidation inhibition by the solidification of the encapsulates' core.

A novel dual-color bifocal imaging system for single-molecule studies

In this paper, we report the design and implementation of a dual-color bifocal imaging (DBI) system that is capable of acquiring two spectrally distinct, spatially registered images of objects located in either same or two distinct focal planes. We achieve this by separating an image into two channels with distinct chromatic properties and independently focusing both images onto a single CCD camera. The two channels in our device are registered with subpixel accuracy, and long-term stability of the registered images with nanometer-precision was accomplished by reducing the drift of the images to ∼5 nm. We demonstrate the capabilities of our DBI system by imaging biomolecules labeled with spectrally distinct dyes and micro- and nano-sized spheres located in different focal planes.

α-Tocopherol and Atherosclerosis

Cardiovascular disease is the leading cause of morbidity and mortality in the Western world. There is compelling evidence incriminating oxidative stress in the pathogenesis of the atherosclerotic lesion. Several lines of evidence suggest that antioxidants, especially α-tocopherol, have potential beneficial effects with regard to cardiovascular disease. In vitro, α-tocopherol has been shown to inhibit platelet adhesion and aggregation and smooth muscle cell proliferation, exert anti-inflammatory effects on monocytes, and improve endothelial function. Also, supplementation with α-tocopherol has been shown to decrease lipid peroxidation, platelet aggregation, and pro-inflammatory activity of monocytes. However, clinical trials with α-tocopherol supplementation to date have been equivocal. Thus, although mounting in vitro evidence and animal models provide a sound scientific basis for α-tocopherol supplementation, further clinical trials are required before a definitive recommendation can be made with respect to the primary and secondary prevention of heart disease.

Effects of α-tubulin K40 acetylation and detyrosination on kinesin-1 motility in a purified system

Long-range transport in cells is achieved primarily through motor-based transport along a network of microtubule tracks. Targeted transport by kinesin motors can be correlated with posttranslational modifications (PTMs) of the tubulin subunits in specific microtubules. To directly examine the influence of specific PTMs on kinesin-1 motility, we generated tubulin subunits that were either enriched in or lacking acetylation of α-tubulin lysine 40 (K40) or detyrosination of the α-tubulin C-terminal tail. We show that K40 acetylation does not result in significant changes in kinesin-1's landing rate or motility parameters (velocity and run length) across experimental conditions. In contrast, detyrosination causes a moderate increase in kinesin-1's landing rate. The fact that the effects of detyrosination are dampened by prior K40 acetylation indicates that the combination of PTMs may be an important aspect of the functional output of microtubule heterogeneity. Importantly, our results indicate that the moderate influences that single PTMs have on kinesin-1 in vitro do not explain the strong correlation between specific PTMs and kinesin-1 transport in cells. Thus, additional mechanisms for regulating kinesin-1 transport in cells must be explored in future work.

Paclitaxel-conjugated PAMAM dendrimers adversely affect microtubule structure through two independent modes of action

Paclitaxel (Taxol) is an anticancer drug that induces mitotic arrest via microtubule hyperstabilization but causes side effects due to its hydrophobicity and cellular promiscuity. The targeted cytotoxicity of hydrophilic paclitaxel-conjugated polyamidoamine (PAMAM) dendrimers has been demonstrated in cultured cancer cells. Mechanisms of action responsible for this cytotoxicity are unknown, that is, whether the cytotoxicity is due to paclitaxel stabilization of microtubules, as is whether paclitaxel is released intracellularly from the dendrimer. To determine whether the conjugated paclitaxel can bind microtubules, we used a combination of ensemble and single microtubule imaging techniques in vitro. We demonstrate that these conjugates adversely affect microtubules by (1) promoting the polymerization and stabilization of microtubules in a paclitaxel-dependent manner, and (2) bundling preformed microtubules in a paclitaxel-independent manner, potentially due to protonation of tertiary amines in the dendrimer interior. Our results provide mechanistic insights into the cytotoxicity of paclitaxel-conjugated PAMAM dendrimers and uncover unexpected risks of using such conjugates therapeutically.

Kinesin assembly and movement in cells

Long-distance transport in eukaryotic cells is driven by molecular motors that move along microtubule tracks. Molecular motors of the kinesin superfamily contain a kinesin motor domain attached to family-specific sequences for cargo binding, regulation, and oligomerization. The biochemical and biophysical properties of the kinesin motor domain have been widely studied, yet little is known about how kinesin motors work in the complex cellular environment. We discuss recent studies on the three major families involved in intracellular transport (kinesin-1, kinesin-2, and kinesin-3) that have begun to bridge the gap in knowledge between the in vitro and in vivo behaviors of kinesin motors. These studies have increased our understanding of how kinesin subunits assemble to produce a functional motor, how kinesin motors are affected by biochemical cues and obstacles present on cellular microtubules, and how multiple motors on a cargo surface can work collectively for increased force production and travel distance.

Patent ductus arteriosus device embolization

Nonsurgical closure of patent ductus arteriosus (PDA) using a duct occluder placed percutaneously is currently the first line of therapy and the success rate is quite high. Several devices are currently available. An eight year child underwent device closure of the ductus. However after deployment of the device it, became dislodged into the left pulmonary artery. Several attempts at catheter retrieval failed. The child underwent successful surgical removal of the device without cardiopulmonary bypass.

Recording single motor proteins in the cytoplasm of mammalian cells

Biomolecular motors are central to the function and regulation of all cellular transport systems. The molecular mechanisms by which motors generate force and motion along cytoskeletal filaments have been mostly studied in vitro using a variety of approaches, including several single-molecule techniques. While such studies have revealed significant insights into the chemomechanical transduction mechanisms of motors, important questions remain unanswered as to how motors work in cells. To understand how motor activity is regulated and how motors orchestrate the transport of specific cargoes to the proper subcellular domain requires analysis of motor function in vivo. Many transport processes in cells are believed to be powered by single or very few motor molecules, which makes it essential to track, in real time and with nanometer resolution, individual motors and their associated cargoes and tracks. Here we summarize, contrast, and compare recent methodological advances, many relying on advanced fluorescent labeling, genetic tagging, and imaging techniques, that lay the foundation for groundbreaking approaches and discoveries. In addition, to illustrate the impact and capabilities for these methods, we highlight novel biological findings where appropriate.

Effect of system variables involved in packed column supercritical fluid chromatography of stavudine taken as model analyte using response surface methodology along with study of thermodynamic parameters

A multifactor optimization technique is successfully applied to study the effect of simultaneously varying the system variables on feasibility of stavudine analysis by packed column supercritical fluid chromatography (PC-SFC). The effect of simultaneously varying the pressure, temperature and modifier concentration was studied to optimize the method in order to obtain excellent chromatographic figures of merit. The method is based on isocratic elution using methanol-modified supercritical carbon dioxide as the mobile phase at the flow rate of 3.0 ml/min through a JASCO Finepak SIL-5, ODS [C(18) (5 microm, 25 cm x 4.6 mm, i.d.)] column support using photodiode array detection. The optimal conditions were determined with the aid of the response surface methodology using 3(3) factorial designs. From the response surface graphs optimum regions were selected to be +1, -1, and +1 for temperature (60 degrees C), pressure (20 MPa) and percent modifier concentration (17.81%, v/v), respectively. Linearity dynamic range was found to be in the range of 2.0-150.0 microg/ml with significantly high value of correlation coefficient. The method was validated for precision, robustness and recovery to assess the viability of the established method. The chromatographic limit of detection and quantitation were 0.80 and 1.50 microg/ml respectively. The method has been successfully used to analyze commercial dosage form to assess the chromatographic performance of SFC system which was found to be 99.91%+/-1.62. The present work briefs the thermodynamic applications of PC-SFC with an emphasis on the results of stavudine. The foremost of such applications is the determination of solute diffusion coefficient in supercritical mobile phase by Taylor-Aris peak broadening technique.

Vitamin E and carotene status in pre-eclamptic pregnant women from India

BACKGROUND

The imbalance between oxidative stress and the protective antioxidant system of the body enhanced the free radical mediated membrane lipid peroxidation and possibly the vascular endothelial damage due to peroxidation plays a major role in the aetiology of pre-eclampsia. With present day awareness on micronutrient antioxidants, we did investigate vitamin E and carotene status in Indian pre-eclamptic pregnant and full term normotensive pregnant women. Fresh vegetables and oils are considered to be good sources of vitamin E and carotene. The subjects were used to have good intake of fresh vegetable and oil as per Indian standard prescribed by Indian council of Medical research (ICMR) for this sub-continent.

METHODS

The blood samples were processed for RBC vitamin E, serum carotene and serum cholesterol analysis. Routine laboratory tests like hemogram, serum urea, urate, malonyldialdehyde, urine sugar and albumin were performed.

RESULTS

All pregnant subjects, both cases and control were maternal and gestational age matched. Routine check up showed no significant differences in means of white blood cell count, Hb/hematocrit and platelets. Serum urate and malonyldialdehyde were significantly raised in pre-eclamptic cases. The severely affected pre-eclamptic cases (diastolic BP >100 mmHg with proteinuria 2+ and more) showed markedly low levels of vitamin E and carotene whereas their levels were comparable between mild cases (diastolic BP <100 mmHg with+/-trace albuminuria) and normotensive pregnant control.

CONCLUSIONS

The study concluded that the levels of vitamin E and carotene were markedly lowered in severe pre-eclamptic pregnant women from India. The mild pre-eclamptic cases did not show noticeable changes from that of control pregnant women. Further studies are needed to verify their therapeutic and prophylatic roles against pre-eclamptic complication suring pregnancy.

The effect of alpha-tocopherol on monocyte proatherogenic activity

Atherosclerosis is the leading cause of morbidity and mortality in Westernized populations. The monocyte is a crucial cell in the genesis of the atherosclerotic lesion and is present during all stages of atherosclerosis. alpha-Tocopherol (AT) is the most active component of the vitamin E family and is the principal and most potent lipid-soluble antioxidant in plasma and LDL. With regard to monocyte function, AT supplementation (1200 IU/d) has been shown to decrease release of reactive oxygen species, lipid oxidation, release of cytokines such as interleukin-1ss (IL-1ss) and tumor necrosis factor-alpha (TNF-alpha) and decrease adhesion of monocytes to human endothelium. The mechanism of inhibition of superoxide and lipid oxidation by monocytes appears to be via inhibition of protein kinase C (PKC), the decrease in IL-1ss and TNF-alpha release by inhibition of 5-lipoxygenase and the inhibition of monocyte-endothelial cell adhesion via decrease in adhesion molecules on monocytes, CD11b and VLA-4 and by decreasing DNA-binding activity of nuclear transcription factor kappaB. Thus, in addition to the decrease in oxidative stress resulting from AT supplementation, as evidenced by decreased F(2)-isoprostanes and LDL oxidizability, AT is anti-inflammatory and exerts beneficial antiatherogenic effects on cells crucial in atherogenesis such as monocytes.

Role of protein kinase C in basal and hydrogen peroxide-stimulated NF-kappa B activation in the murine macrophage J774A.1 cell line

In macrophages, hydrogen peroxide appears to be a physiological activator of the transcription factor, nuclear factor kappa B (NF-kappa B); however, the molecular basis of H2O2-stimulated NF-kappa B activation is not well defined. The observations that NF-kappa B can be activated in cells by phorbol 12-myristate 13-acetate and in vitro by addition of protein kinase C (PKC) are suggestive of a role of PKC in NF-kappa B activation, which was investigated in the J774A.1 murine macrophage cell line. Basal NF-kappa B DNA-binding activity and nuclear localization were decreased by PKC inhibitors. Although PKC activity was modified by H2O2 with a similar time course as H2O2 activation of NF-kappa B, the H2O2-stimulated increase in NF-kappa B DNA binding and translocation to the nucleus was unaffected by PKC inhibitors. Furthermore, PKC down-regulation (through preincubation with phorbol esters) also affected only baseline NF-kappa B DNA binding but not H2O2-stimulated NF-kappa B activation. Buffering of changes in intracellular free calcium concentration also had no effect upon H2O2-stimulated NF-kappa B activation. Thus, classical PKC activity may modulate basal NF-kappa B activity but does not participate in H2O2-stimulated NF-kappa B activation.

Transmembrane redox signaling activates NF-kappaB in macrophages

In macrophages, NF-kappaB can be activated by H2O2 generated by the respiratory burst or added exogenously. The mechanism of H2O2 signaling may involve changes in the cellular redox state or a redox reaction at the plasma membrane; however, the site of H2O2 action cannot be readily ascertained because of its membrane permeability. Ferricyanide, a nonpermeable redox active anion, activated NF-kappaB in the macrophage cell line, J774A.1. In contrast with exogenous H2O2, activation by ferricyanide did not correlate with net oxidation of NAD(P)H or glutathione, suggesting that a transplasma membrane redox reaction itself was the first signaling process in NF-kappaB activation.

Clinical significance of glycosylated haemoglobin (HbA1C) over fasting blood sugar for monitoring metabolic control in diabetic patients with or without complications

Glycosylated haemoglobin was studied in 30 cases of mild to severe diabetes in the age group 12-60 years. Ten patients were keto-acidotic. Glycosylated haemoglobin and fasting blood sugar levels were studied in patients with various complications of diabetes like neuropathy, nephropathy, retinopathy, keto-acidosis, cardiac and respiratory complications. There was a significant correlation between fasting blood sugar and glycosylated haemoglobin in normal subjects as well as in diabetic patients. There was a significant correlation between levels of glycosylated haemoglobin and blood sugar over preceding 4-6 weeks. Most frequent complication being retinopathy and keto-acidosis was associated with maximum glycosylated haemoglobin with poor metabolic control.

Probucol treatment reverses antioxidant and functional deficit in diabetic cardiomyopathy

Earlier we reported that probucol treatment subsequent to the induction of diabetes can prevent diabetes-associated changes in myocardial antioxidants as well as function at 8 weeks. In this study, we examined the efficacy of probucol in the reversal of diabetes induced myocardial changes. Rats were made diabetic with a single injection of streptozotocin (65 mg/kg, i.v.). After 4 weeks of induction of diabetes, a group of animals was treated on alternate days with probucol (10 mg/kg i.p.), a known lipid lowering agent with antioxidant properties. At 8 weeks, there was a significant drop in the left ventricle (LVSP) and aortic systolic pressures (ASP) in the diabetic group. Hearts from these animals showed an increase in the thiobarbituric acid reacting substances (TBARS), indicating increased lipid peroxidation. This was accompanied by a decrease in the myocardial antioxidant enzymes activities, superoxide dismutase (SOD) and glutathione peroxidase (GSHPx). Myocardial catalase activity in the diabetic group was higher. In the diabetic + probucol group both LVSP and ASP showed significant recovery. This was also accompanied by an improvement in SOD and GSHPx activities and there was further increase in the catalase activity. Levels of the TBARS was decreased in this group. These data provide evidence that diabetic cardiomyopathy is associated with an antioxidant deficit which can be reversed with probucol treatment. Improved cardiac function with probucol may be due to the recovery of antioxidants in the heart.

Activation of NF kappa B by the respiratory burst of macrophages

H2O2 and other reduced oxygen species have been proposed as activators of the transcription factor, NF Kappa B. Stimulated macrophages produce superoxide and H2O2 (the respiratory burst). We tested the hypothesis that production of these species could serve as part of the NF Kappa B activation pathway in rat alveolar macrophages and the J774A.1 mouse monocyte/macrophage cell line. Phorbol myristate acetate (PMA) and ADP, which stimulate the respiratory burst, caused NF Kappa B activation in both cells. Catalase abolished NF kappa B activation, while superoxide dismutase produced little inhibition. Thus, H2O2 was the principal agent of respiratory burst-associated NF kappa B activation. Abolition of NF kappa B activation by catalase also suggested that intermediate signaling pathways, such as protein kinase C activation or intracellular free calcium elevation must not be involved. Exogenous H2O2 added as a bolus > or = 50 microM (> or = 50 nmol/10(6) macrophages) also activated NF kappa B in macrophages. Nevertheless, the maximum endogenous production of H2O2 by stimulated alveolar macrophages during a 30-min incubation was < or = 1.3 nmol H2O2/10(6) cells for PMA stimulation and < or = 0.2 nmol H2O2/10(6) cells for ADP stimulation. Thus, relatively little endogenous H2O2 generation was required to produce NF kappa B activation compared to the required amount of exogenous H2O2. As H2O2 rapidly diffuses and is consumed, these results suggest that the site of action for endogenously generated H2O2 is probably close to its origin, the plasma membrane.

Probucol improves antioxidant activity and modulates development of diabetic cardiomyopathy

To examine the role of free radicals in diabetic cardiomyopathy, myocardial antioxidants as well as lipid peroxide content were examined in rats made diabetic with a single injection of streptozotocin (65 mg/kg i.v). At 4 wk, the left ventricular peak systolic (LVSP) as well as aortic pressures were depressed in the diabetic group. Hearts from diabetic animals showed about a 100% increase in thiobarbituric acid reactive substances (TBARS), indicating increased lipid peroxidation. This was accompanied by about a 50% decrease in superoxide dismutase (SOD) and 60% decrease in glutathione peroxidase (GSHPx) enzyme activities. Catalase activity in these hearts showed a small but significant increase. Treatment with probucol (10 mg/kg i.p., on alternate days), a known lipid-lowering drug with strong antioxidant properties, was initiated 1 d after the induction of diabetes and was continued for 4 wk. In probucol-treated diabetic animals, LVSP was not different from controls. Probucol treatment caused a small but significant improvement in serum insulin and decrease in glucose levels as well as increased myocardial SOD, GSHPx, and catalase activities with a concomitant decrease in TBARS in the diabetic animals. These data provide evidence that diabetic cardiomyopathy is associated with an antioxidant deficit, and a better cardiac function due to treatment with probucol may be related to the improved insulin levels as well as maintenance of the antioxidant status of the heart.

Hydrogen peroxide changes in ischemic and reperfused heart. Cytochemistry and biochemical and X-ray microanalysis

Active oxygen species including hydrogen peroxide (H2O2) play a major role in ischemia-reperfusion injury. In the present study, changes in myocardial H2O2 content as well as its subcellular distribution were examined in rat hearts subjected to ischemia-reperfusion. Isolated perfused rat hearts were made globally ischemic for 20 or 30 minutes and were reperfused for different durations. H2O2 content in these hearts was studied biochemically and changes were correlated with the recovery of function. These hearts were also analyzed for subcellular distribution of H2O2. Optimal conditions of tissue processing as well as incubation medium were established for reacting cerium chloride with H2O2 to form cerium perhydroxide, an insoluble electron-dense product. The chemical composition of these deposits was confirmed by x-ray micro-analysis. Global ischemia caused complete contractile failure in minutes and after 30 minutes of ischemia, these was a > 250% increase in the myocardial H2O2 content. Depressed contractile function recovery in the early phase of reperfusion was accompanied by approximately a 600% increase in the myocardial H2O2 content. Brief pre-fixation with low concentrations of glutaraldehyde, inhibition of alkaline phosphatase, glutathione peroxidase, and catalase, post-fixation but no post-osmication, and no counterstaining yielded the best cytochemical definition of H2O2. In normal hearts, extremely small amounts of cerium hydroperoxide precipitates were located on the endothelial cells. X-ray microanalysis confirmed the presence of cerium in the reaction product. Ischemia resulted in a stronger reaction, particularly on the sarcolemma as well as abluminal side of the endothelial cells; and upon reperfusion, cerium precipitate reaction at these sites was more intense. In the reperfused hearts, the reaction product also appeared within mitochondria between the cristae as well as on the myofibrils, but Z-lines were devoid of any precipitate. The data support a significant increase in myocardial H2O2 during both the phase of ischemia and the first few minutes of reperfusion. A stronger reaction on the sarcolemma and abluminal side of endothelial cells may also indicate enhanced H2O2 accumulation as well as vulnerability of these sites to oxidative stress injury.

Probucol promotes endogenous antioxidants and provides protection against adriamycin-induced cardiomyopathy in rats

BACKGROUND

The potential usefulness of adriamycin (ADR) is restricted because of its cardiotoxic side effects. Since free radicals and lipid peroxidation are suggested to be involved in ADR cardiomyopathy, we examined the beneficial effects of probucol, a lipid-lowering drug with strong antioxidant properties.

METHODS AND RESULTS

ADR was administered to rats in six equal intraperitoneal injections over a period of 2 weeks (cumulative dose of 15 mg/kg). After a 3-week posttreatment period, cardiomyopathy and congestive heart failure were characterized by ascites, congested liver, depressed cardiac function, elevated left ventricular end-diastolic pressure, and myocardial cell damage. Myocardial glutathione peroxidase (GSHPx) activity was decreased, and lipid peroxidation was increased. Probucol (cumulative dose, 60 mg/kg IP) was administered in six equal injections over a 2-week period on days alternating with ADR treatment. Probucol significantly attenuated the myocardial effects of ADR, improved left ventricular function, and lowered mortality as well as the amount of ascites. Treatment with probucol was also accompanied by an increase in myocardial GSHPx and superoxide dismutase activities, with a concomitant decrease in lipid peroxidation.

CONCLUSIONS

These data provide evidence that ADR cardiomyopathy is associated with an antioxidant deficit. Improved cardiac function resulting from treatment with probucol may be related to the maintenance of the antioxidant status of the heart. The study suggests potential usefulness of antioxidant (probucol) therapy in ADR cardiomyopathy.

Free radicals and the heart

Because of the molecular configuration, most free radicals are highly reactive and can cause cell injury. Protective mechanisms have evolved to provide defense against free-radical injury. Any time these defense systems are overwhelmed, such as during disease states, cell dysfunction may occur. In this review we discuss cellular sources as well as the significance of free radicals, oxidative stress, and antioxidants. A probable role of oxidative stress in various cardiac pathologies has been also analyzed. Although some methods for the detection of free radicals as well as oxidative stress have been cited, better methods to study the quantity as well as subcellular distribution of free radicals are needed in order to understand fully the role of free radicals in both health and disease.

Effect of nifedipine administration on the functional capacity of neutrophils

Administration of nifedipine to mice over a period of six months caused a significant (p < 0.05) decrease in neutrophilic functions viz superoxide generation, coupled to NADPH oxidase activity as well as NADPH production by HMP shunt. Properties like chemotaxis and phagocytosis showed a similar decrease. From this study, it is seen that nifedipine causes neutrophil functional abrogation which is therefore an apparent concern for the prolonged usage of the drug. However, relevance of the mouse model to clinical situation needs further investigation.

Oxygen free radicals and protective effect of captopril on myocardial infarct size

Captopril (0.25 mg/kg and 0.5 mg/kg, p.o.) decreased the myocardial infarct size and prevented the progressive decrease in voltage of the R wave in rats. It had no marked effect on systolic blood pressure at these dose levels but higher doses (1 mg/kg, p.o.) reduced systolic blood pressure. It also produced a concentration-dependent (50-700 ng/10(6) cells) decrease of chemiluminescence response from rat neutrophils and markedly reduced serum malonyldialdehyde levels, elevated as a consequence of left coronary artery ligation. It is suggested that the protective effect of captopril may be mediated through a decreased formation or scavenging of reactive oxygen species.

Significance of adaptation mechanisms in adriamycin induced congestive heart failure

Natural history of myocardial dysfunction due to chronic contractile deficit consists of physiological and pathophysiological adaptations culminating in congestive heart failure. Among the mechanisms considered is the combination of compensatory as well as the harmful overcompensatory role of the adrenergic system during the genesis of a congestive heart failure "spiral" due to the chronic treatment with adriamycin. Refractoriness of this spiral to various inotropic agents may involve reduced sympathetic support of the myocardium, structural loss of contractile elements and abnormalities of the Ca2+ metabolism.