Ultrasmall MnSe Nanoparticles as T1-MRI Contrast Agents for In Vivo Tumor Imaging

Magnetic resonance imaging (MRI) has excellent potential in the clinical monitoring of tumors because it can provide high-resolution soft tissue imaging. However, commercial contrast agents (CAs) used in MRI still have some problems such as potential toxicity to the human body, low relaxivity, and a short MRI acquisition window. In this study, ultrasmall MnSe nanoparticles are synthesized by living Staphylococcus aureus cells. The as-prepared MnSe nanoparticles are monodispersed with a uniform particle size (3.50 ± 0.52 nm). Due to the ultrasmall particle size and good water solubility, the MnSe nanoparticles exhibit in vitro high longitudinal relaxivity properties (14.12 ± 1.85 mM-1·s-1). The CCK-8 colorimetric assay, histological analysis, and body weight results show that the MnSe nanoparticles do not have appreciable toxicity on cells and organisms. Besides, the MnSe nanoparticles as T1-MRI CAs offer a long MRI acquisition window to tumor imaging (∼7 h). This work provides a promising T1-MRI CA for clinical tumor imaging and a good reference for the application of functional MnSe nanoparticles in the biomedicine field.

Low-Dose Radiation Exposure with 56MnO2 Powder Changes Gene Expressions in the Testes and the Prostate in Rats

To investigate the biological effects of internal exposure of radioactive ⁵⁶MnO₂ powder, the major radioisotope dust in the soil after atomic bomb explosions, on male reproductive function, the gene expression of the testes and the prostate was examined. Ten-week-old male Wistar rats were exposed to three doses of radioactive ⁵⁶MnO₂ powder (41-100 mGy in whole body doses), stable MnO₂ powder, or external ⁶⁰Co γ-rays (2 Gy). Animals were necropsied on Days 3 and 61 postexposure. The mRNA expressions of testicular marker protein genes and prostatic secretory protein genes were quantified by Q-RT-PCR. On Day 3 postexposure, the testicular gene expressions of steroidogenesis-related enzymes, Cyp17a1 and Hsd3b1, decreased in ⁵⁶MnO₂-exposed groups. Germ cell-specific Spag4 and Zpbp mRNA levels were also reduced. On postexposure Day 61, the Cyp11a1 gene expression became significantly reduced in the testes in the group exposed to the highest dose of ⁵⁶MnO₂, while another steroidogenesis-related StAR gene mRNA level reduced in the ⁶⁰Co γ-rays group. There were no differences in Spag4 and Zpbp mRNA levels among groups on Day 61. No histopathological changes were observed in the testes in any group following exposure. Expression in the prostatic protein genes, including CRP1, KS3, and PSP94, significantly decreased in ⁵⁶MnO₂-exposed groups as well as in the ⁶⁰Co γ-rays group on Day 61 postexposure. These data suggest that the internal exposure to ⁵⁶MnO₂ powder, at doses of less than 100 mGy, affected the gene expressions in the testis and the prostate, while 2 Gy of external γ-irradiation was less effective.

Internal exposure to neutron-activated 56Mn dioxide powder in Wistar rats-Part 2: pathological effects

To fully understand the radiation effects of the atomic bombing of Hiroshima and Nagasaki among the survivors, radiation from neutron-induced radioisotopes in soil and other materials should be considered in addition to the initial radiation directly received from the bombs. This might be important for evaluating the radiation risks to the people who moved to these cities soon after the detonations and probably inhaled activated radioactive "dust." Manganese-56 is known to be one of the dominant radioisotopes produced in soil by neutrons. Due to its short physical half-life, 56Mn emits residual radiation during the first hours after explosion. Hence, the biological effects of internal exposure of Wistar rats to 56Mn were investigated in the present study. MnO2 powder was activated by a neutron beam to produce radioactive 56Mn. Rats were divided into four groups: those exposed to 56Mn, to non-radioactive Mn, to 60Co γ rays (2 Gy, whole body), and those not exposed to any additional radiation (control). On days 3, 14, and 60 after exposure, the animals were killed and major organs were dissected and subjected to histopathological analysis. As described in more detail by an accompanying publication, the highest internal radiation dose was observed in the digestive system of the rats, followed by the lungs. It was found that the number of mitotic cells increased in the small intestine on day 3 after 56Mn and 60Co exposure, and this change persisted only in 56Mn-exposed animals. Lung tissue was severely damaged only by exposure to 56Mn, despite a rather low radiation dose (less than 0.1 Gy). These data suggest that internal exposure to 56Mn has a significant biological impact on the lungs and small intestine.

Attenuation of Combined Nickel(II) Oxide and Manganese(II, III) Oxide Nanoparticles' Adverse Effects with a Complex of Bioprotectors

Stable suspensions of NiO and Mn₃O₄ nanoparticles (NPs) with a mean (±s.d.) diameter of 16.7±8.2 and 18.4±5.4 nm, respectively, purposefully prepared by laser ablation of 99.99% pure nickel or manganese in de-ionized water, were repeatedly injected intraperitoneally (IP) to rats at a dose of 2.5 mg/kg 3 times a week up to 18 injections, either alone or in combination. A group of rats was injected with this combination with the background oral administration of a "bio-protective complex" (BPC) comprising pectin, vitamins A, C, E, glutamate, glycine, N-acetylcysteine, selenium, iodide and omega-3 PUFA, this composition having been chosen based on mechanistic considerations and previous experience. After the termination of injections, many functional and biochemical indices and histopathological features (with morphometric assessment) of the liver, spleen, kidneys and brain were evaluated for signs of toxicity. The Ni and Mn content of these organs was measured with the help of the atomic emission and electron paramagnetic resonance spectroscopies. We obtained blood leukocytes for performing the RAPD (Random Amplified Polymorphic DNA) test. Although both metallic NPs proved adversely bio-active in many respects considered in this study, Mn₃O₄-NPs were somewhat more noxious than NiO-NPs as concerns most of the non-specific toxicity manifestations and they induced more marked damage to neurons in the striatum and the hippocampus, which may be considered an experimental correlate of the manganese-induced Parkinsonism. The comparative solubility of the Mn₃O₄-NPs and NiO-NPs in a biological medium is discussed as one of the factors underlying the difference in their toxicokinetics and toxicities. The BPC has attenuated both the organ-systemic toxicity and the genotoxicity of Mn₃O₄-NPs in combination with NiO-NPs.

Understanding the metabolic fate and assessing the biosafety of MnO nanoparticles by metabonomic analysis

Recently, some types of MnO nanoparticle (Mn-NP) with favorable imaging capacity have been developed to improve the biocompatible profile of the existing Mn-based MRI contrast agent Mn-DPDP; however, the overall bio-effects and potential toxicity remain largely unknown. In this study, (1)H NMR-based metabolic profiling, integrated with traditional biochemical analysis and histopathological examinations, was used to investigate the absorption, distribution, metabolism, excretion and toxicity of Mn-NPs as candidates for MRI contrast agent. The metabolic responses in biofluids (plasma and urine) and tissues (liver, spleen, kidney, lung and brain) from rats could be divided into four classes following Mn-NP administration: Mn biodistribution-dependent, time-dependent, dose-dependent and complicated metabolic variations. The variations of these metabolites involved in lipid, energy, amino acid and other nutrient metabolism, which disclosed the metabolic fate and biological effects of Mn-NPs in rats. The changes of metabolic profile implied that the disturbance and impairment of biological functions induced by Mn-NP exposure were correlated with the particle size and the surface chemistry of nanoparticles. Integration of metabonomic technology with traditional methods provides a promising tool to understand the toxicological behavior of biomedical nanomaterials and will result in informed decision-making during drug development.

Preliminary assessment of cardiac short term safety and efficacy of manganese chloride for cardiovascular magnetic resonance in humans

BACKGROUND

Manganese based agents are intracellular and accumulate inside myocytes allowing for different imaging strategies compared to gadolinium contrasts. While previous agents release manganese very slowly in the circulation, MnCl2 allows for rapid Mn2+ uptake in myocytes, creating a memory effect that can be potentially explored. Data on animal models are very encouraging but the safety and efficacy of this approach in humans has not yet been investigated. Therefore, our objectives were to study the safety and efficacy of a rapid infusion of manganese chloride (MnCl2) for cardiovascular magnetic resonance (CMR) in humans.

METHODS

Fifteen healthy volunteers underwent a CMR scan on a 1.5 T scanner. Before the infusion, cardiac function was calculated and images of a short axis mid-ventricular slice were obtained using a 2D and 3D gradient-echo inversion recovery (GRE-IR) sequence, a phase-sensitive IR sequence and a single breath-hold segmented IR prepared steady-state precession acquisition for T1 calculations. MnCl2 was infused over three minutes at a total dose of 5 μMol/kg. Immediately after the infusion, and at 15 and 30 minutes later, new images were obtained and cardiac function re-evaluated.

RESULTS

There was a significant decrease in T1 values compared to baseline, sustained up to 30 minutes after the MnCl2 infusion (pre,839 ± 281 ms; 0 min, 684 ± 99; 15 min, 714 ± 168; 30 min, 706 ± 172, P = 0.003). The 2D and 3D GRE-IR sequence showed the greatest increase in signal-to-noise ratio compared to the other sequences (baseline 6.6 ± 4.2 and 9.7 ± 5.3; 0 min, 11.3 ± 4.1 and 15.0 ± 8.7; 15 min, 10.8 ± 4.0 and 16.9 ± 10.2; 30 min, 10.6 ± 5.2 and 16.5 ± 8.3, P < 0.001 for both). There was a slight increase in systolic pressure and heart rate after three and four minutes of the infusion with normalization of these parameters thereafter. Patients showed good tolerance to MnCl2 with no major adverse events, despite all reporting transient facial flush.

CONCLUSIONS

In the short term, MnCl2 appears safe for human use. It effectively decreases myocardium T1, maintaining this effect for a relatively long period of time and allowing for the development of new imaging strategies in CMR, especially in ischemia research.

The mutagenicity and carcinogenicity of inorganic manganese compounds: a synthesis of the evidence

Manganese (Mn), a naturally occurring element present in many foodstuffs, is an essential trace element with many biological functions. In industry, inorganic Mn compounds have a range of different applications, although the majority of Mn is used to make alloys and steel. For the general population, the major source of exposure to Mn is dietary, although drinking water may constitute an additional source in some regions. However, in occupationally exposed humans, inhalation of Mn is likely to be an important additional route. In general, Mn and its inorganic compounds are considered to possess low mutagenic or carcinogenic potential compared with some heavy metals. In this review, an up-to-date analysis of the available published studies on the carcinogenic and genotoxic potential of inorganic Mn is provided (organic Mn compounds are not considered). The current literature indicates that Mn may be weakly mutagenic in vitro and possibly clastogenic in vivo, with unknown genotoxic effects in humans; the possible mechanisms underlying these effects are discussed. The experimental evidence on carcinogenicity (quantitative increase in incidence of thyroid tumors in mice but not rats) does not provide any clear evidence, while the available occupational and environmental epidemiological evidence is equivocal as to whether exposure to inorganic Mn is associated with a significant cancer risk. Hence, it is concluded that there is insufficient evidence to indicate that inorganic Mn exposure produces cancer in animals or humans.

In vitro cytotoxicity screening of water-dispersible metal oxide nanoparticles in human cell lines

In this study, we present in vitro cytotoxicity of iron oxide (Fe(3)O(4)) and manganese oxide (MnO) using live/dead cell assay, lactate dehydrogenase assay, and reactive oxygen species detection with variation of the concentration of nanoparticles (5-500 microg/ml), incubation time (18-96 h), and different human cell lines (lung adenocarcinoma, breast cancer cells, and glioblastoma cells). The surface of nanoparticles is modified with polyethyleneglycol-derivatized phospholipid to enhance the biocompatibility, water-solubility, and stability under an aqueous media. While the cytotoxic effect was negligible for 18 h incubation even at highest concentration of 500 microg/ml, MnO nanoparticle represented higher level of toxicity than those of Fe(3)O(4) and the commercial medical contrast reagent, Feridex after 2 and 4 day incubation time. However, the cytotoxicity of Fe(3)O(4) is equivalent or better than Feridex based on the live/dead cell viability assay. The engineered MnO and Fe(3)O(4) exhibited excellent stability compared with Feridex for a prolonged incubation time.

[Peculiarities of nervous system functional state in electric welders exposed to manganese compounds]

Peculiarities of nervous system functional state in electric welders exposed to manganese compounds. To evaluate nervous system functional state in electric welders exposed to manganese compounds, the authors conducted transverse study with matched pairs. The electric welders' tests for response rate, diadochokinesis and grasping power were not reliable. No changes were found in tremor characteristics and posture steadiness. Bradykinesia appeared to prevail in welders.

Neuromotor function in a cohort of Danish steel workers

OBJECTIVE

With a longitudinal design to evaluate possible neuromotor impairment in a cohort of steel workers exposed to metal dust.

MATERIAL

Ninety-two employees from a steel works were examined in 1989 and 1995. Sixty were re-examined in 2003. A non-matched control group was examined in 1996 (n=19) and in 2003 (n=14). Median blood manganese in 1989, 1995 and 2003 was 149, 171 and 155 nmol/l. Median blood lead in 1989 and 2003 was 0.76 and 0.22 micromol/l. Median air concentration of manganese at the steel works was estimated to be 0.11 mg/m3 in 1970s and was 0.03 mg/m3 in 1990s. Median air concentration of lead was estimated to be 0.13 mg/m3 in 1970s and was 0.01 mg/m3 in 1990s.

METHOD

The Catsys 2000 system developed by Danish Product Development is computer-based device for measuring hand tremor, hand coordination and reaction time.

RESULTS

Over all there were no statistically significant differences in neuromotor function between the participating steel workers, non-participating steel workers and controls in 1995/1996. Only reaction time for the right hand was slower for the participating steel workers. Compared with the control group the steel workers showed a decline in the ability to perform fast precise hand pronation/supination and finger tapping from 1995 to 2005. Correlation analysis showed no associations between test results for fast hand coordination and blood manganese and lead. Only seniority was associated with deterioration of beat regulation of fast pronation/supination of the hands.

DISCUSSION

On a group basis the changes were subclinical, but they should none the less be taken seriously.

CONCLUSION

Changes of neuromotor function measured as the ability to perform fast precise pronation/supination of the hands and fast precise finger tapping was shown in this cohort of steel workers. No causal relationships could be shown.

Cognitive function in a cohort of Danish steel workers

OBJECTIVE

The aim of this study was to evaluate the level of possible cognitive impairment in a cohort of steel workers occupationally exposed to manganese and lead.

MATERIAL

Ninety-two employees from an electro-steel works were examined in 1989 and 1995. Fifty-three were re-examined in 2003. Median age of the participants was 53 years, median duration of employment was 24 years, median blood manganese in 1989 and 1995 was 148 and 171 nmol/l, respectively, and median blood lead in 1989 was 0.79 micromol/l. Non-participants were comparable with participants, although they had a higher level of blood manganese in 1989 (186 nmol/l) and 1995 (186 nmol/l). Manganese level in the air was estimated below 1.9 mg/m3 in the 1970s. In the 1990s, manganese level in the air was below 0.28 mg/m3 in the majority of measurements.

METHOD

Cognitive function was examined with the Cognitive Function Scanner, a computer-based neuropsychological test battery. From a published set of norms a subgroup (n=106) matched for gender, age and social status was extracted and used for comparison.

RESULTS

Learning and memory, visuomotor and visuospatial function, concentration, attention, perception and vigilance were examined. Despite many statistically significant differences between the groups, it was not possible to interpret the results for the steel workers as being better or worse. In a visuomotor subtest, the pen-to-point test, the steel workers were much less accurate than the comparison group. This could be the result of an impaired ability to make fast accurate movements. There were no associations between pen-to-point test results and duration of employment or blood levels of manganese and lead.

CONCLUSION

Intellectual impairment could not be shown with the Cognitive Function Scanner in this cohort of low to moderate manganese and lead exposed steel workers. A slight subclinical impairment of the visuomotor function was possibly found.

Sequelae of fume exposure in confined space welding: a neurological and neuropsychological case series

Welding fume contains manganese (Mn) which is known to be bio-available to and neurotoxic for the central nervous system. Although an essential metal, Mn overexposure may cause manganism, a parkinsonian syndrome. The present welder study sought to improve the clinical portrait of manganism and to determine dose-effect relationships. The welders were employed in the construction of the new Bay Bridge (San Francisco) and welded in confined spaces for up to 2 years with minimal protection and poor ventilation. Neurological, neuropsychological, neurophysiological, and pulmonary examinations were given to 49 welders. Clinical cases were selected on the basis of apriori defined criteria pertaining to welding history and neurological/neuropsychological features. Among the 43 eligible welders, 11 cases of manganism were identified presenting with the following symptoms: sleep disturbance, mood changes, bradykinesia, headaches, sexual dysfunction, olfaction loss, muscular rigidity, tremors, hallucinations, slurred speech, postural instability, monotonous voice, and facial masking. Significant associations between outcome variables and cumulative exposure index (CEI) or blood Mn (MnB) were obtained with CEI for variables implicating attention and concentration, working and immediate memory, cognitive flexibility, and verbal learning; and with MnB for executive function, cognitive flexibility, visuo-spatial construction ability, and visual contrast sensitivity. This study strongly suggests that neuropsychological features contribute in a dose-effect related way to the portrait of manganism usually characterized by tremor, loss in balance, diminished cognitive performance, and signs and symptoms of parkinsonism.

Effect of manganese exposure on the neuroendocrine system in welders

To evaluate the effect of occupational exposure to manganese (Mn) on serum prolactin (PRL) and the interrelationship among other hypophyseal-pituitary hormones, a cross-sectional study was conducted on 251 welders and 100 age-matched, office workers. We analyzed serum PRL, dopamine (DA), thyroid stimulating hormone releasing hormone (TRH), follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone (TST) and measured current airborne Mn concentration in the welders. Cumulative exposure index (CEI) of airborne Mn was calculated. CEI and the present Mn level of the welders were 1.4+/-1.1mg/m3 year (range: 0.0-4.9) and 0.4+/-3.84 mg/m3 (range: 0.0-3.8), respectively. TRH, FSH and LH were higher in welders (5.08 pg/ml, 7.40 and 4.91 mIU/ml, respectively) than in office workers (3.91 pg/ml, 6.15 and 4.00 mIU/ml, respectively) (p<0.05). DA was decreased and TRH was increased significantly with increasing CEI. DA increased up to CEI 2.0mg/m3 year or mean Mn level up to 0.2mg/m3, then decreased. PRL showed increasing tendency above the CEI and mean Mn level at which DA started to decrease. PRL was positively associated with DA in the office workers. However, such a normal feedback control of DA on PRL was not observed in the welders. Structural equation model (SEM) analysis showed that CEI was positively related to TRH and negatively related to DA. TRH increased PRL. PRL increased LH and perhaps FSH, and on the other hand, decreased TST. These results showed that Mn suppresses the inhibitory feedback control of DA on the hypophyseal-pituitary axis. In conclusion, we postulate that suppressed dopaminergic inhibitory function on the hypophyseal-pituitary axis might be the mechanism for the increased PRL exhibited in the welders.

Evaluation of MR signal index for the assessment of occupational manganese exposure of welders by measurement of local proton T1 relaxation time

Magnetic resonance (MR) imaging has become a useful tool for the estimation of occupational exposure to manganese (Mn). However, validity of signal indices on T1-weighted imaging, a proxy measurement of T1 relaxation time shortening due to Mn deposition, needs to be evaluated in an occupationally exposed population. We performed MR imaging on 20 male welders and 10 age- and gender-matched, non-office workers in a shipyard. We measured the relative signal intensity ratio of the globus pallidus (GP) to the frontal white matter on T1-weighted MR images (pallidal index, PI). We also assessed the visual scale for the relative signal intensity of the GP, which was graded as 0-2 by a radiologist. We evaluated both signal index and visual scale in relation to the T1 relaxation time measured at the GP. Both PI and T1 relaxation time were significantly increased in the welders compared to the non-welders. T1 relaxation time began to decrease from visual scale 2, while PI began to increase from visual scale 1. Environmental Mn exposure indices correlated well with both T1 relaxation time and PI. However, blood Mn level correlated only with T1 relaxation time, and not with PI. T1 relaxation time correlated with PI only at the higher level of PI. These results indicate the possible inaccuracy of visual scoring and the discrepancy between T1 relaxation time and PI, especially at the lower level of signal intensity. Although both T1 and PI are good biomarkers for the environmental Mn exposure, non-linearity of the relationship between T1 and PI must be considered in the assessment of Mn exposure using MRI.

Effect of occupational manganese exposure on the central nervous system of welders: 1H magnetic resonance spectroscopy and MRI findings

This study investigated the relationship between long-term occupational manganese (Mn) exposure on the regional Mn concentration in the brain, neuronal loss, and neurobehavioral effects on welders. 1H MRS of the basal ganglia (BG) was performed on 20 male welders and 10 age- and gender-matched, non-office, control workers in a shipyard to assess the metabolic change, and the N-acetylaspartate (NAA)/creatine (Cr), choline (Cho)/Cr and NAA/Cho ratios, by the level of Mn exposure. We also assessed the signal intensity of T1-weighted image of magnetic resonance imaging (MRI) on globus pallidus (GP) compared to that of the frontal white matter (pallidal index, PI). The welders had significantly higher signal intensity than the controls. PI showed a significant dose-response relationship with cumulative exposure index (CEI) (r=0.54, p=0.002). CEI and PI showed different relationships with NAA/Cr according to smoking status, and the correlation was evident only in non-smokers (r=-0.73 and -0.57, respectively). There were no significant differences between the welders and the controls in NAA/Cr, Cho/Cr, and NAA/Cho ratios obtained from BG. CEI was positively correlated with simple reaction time. PI was positively correlated with mean sway (MSWAY), sway area (SWAYA), and sway intensity (SWAYI), and negatively correlated with maximum frequency (MAXF). After categorizing the subjects into two groups according to NAA/Cr ratio level, the low NAA/Cr ratio group showed significantly lower score on digit span backward and significantly higher score on MSWAY, SWAYA and SWAYI in regression analysis than the high NAA/Cr ratio group. We speculated that the NAA/Cr ratio of MRS in BG seems to reflect the cumulative effect of Mn exposure on the human brain. Due to uneven distribution of smoking among the welders and the controls, in addition to the small number of subjects in our study, our findings are needed further studies with a larger number of subjects.

High signal intensity on magnetic resonance imaging as a predictor of neurobehavioral performance of workers exposed to manganese

INTRODUCTION

Using previously obtained cross-sectional data from a nationwide survey on workers exposed to manganese (Mn), we assessed the relation of high signal intensity with neurobehavioral effects, and reevaluated the preexisting cross-sectional data to get additional findings on the relation of high signals with other Mn-exposure indices.

SUBJECTS AND METHODS

Subjects were the same as those in the previous study. The exposure status was reassessed based on similar exposure groups. The signal intensity of the globus pallidus (GP) relative to frontal white matter was subjectively evaluated as either with or without increased signals, and the increased signals were further graded into three categories. For quantitative evaluation of signal intensities of the GP we also calculated the pallidal index (PI). Neurobehavioral function was assessed using the World Health Organization Neurobehavioral Core Test Battery. In addition, computerized finger tapping speed was included to assess motor speed.

RESULTS

The mean blood Mn for those with grade III was significantly greater than those without increased signals and those with grade I. Airborne Mn and PI also showed similar findings. PI paralleled subjective MRI gradings. The proportion of workers with increased signals increased with all the Mn-exposure variables, airborne and blood Mn, the duration of work, and cumulative exposure. The PI was significantly associated with a correct score of pursuit aiming II tests and finger tapping of the dominant hand after control of age and educational level among neurobehavioral performances.

DISCUSSION

The present findings showed that signal index on T1-weighted MRI showed a dose-response relationship with all the Mn-exposure variables. The two neurobehavioral tests reflecting fine motor function were significantly decreased above 107.1 of PI, the cutoff point between those with and without increased signals. Hence, signal intensity on MRI is an effective predictor of the neurobehavioral performance of Mn exposed workers.

[Thyroid functional activity in an experiment upon exposure to manganeferous dust]

The purpose of the study was to examine the effect of polymetallic manganeferous dust on thyroid function in an experiment. Biochemical and cytological studies were used. Seventy-day exposure caused decreased thyroid hormonal levels and thyroid cellular composition changes, which suggest that the dust in question has a cytotoxic effect. A prolonged (3-month) exposure provided evidence that suggests the tension of adaptive mechanisms in the thyroid system under the influence of a toxic factor. Nitric oxide was found to take an active part in the formation of adaptive mechanisms in thyroid tissue.

[The treatment of patients with toxic encephalopathy caused by using surrogate psychoactive manganese-containing compounds]

Toxic encephalopathy caused by using surrogate psychoactive manganese-containing compounds was characterized clinically by a combination of parkinsonian, dystonic and pseudobulbar syndromes, eye-movement disturbances, autonomic insufficiency, affective disorders and moderate intellectual and memory impairment. Pharmacotherapeutic efficacy of mexidol has been studied. The results of the study showed that mexidol therapeutic course has a moderate effect on the expression of movement disorders and intellectual and memory impairment. Mexidol treatment significantly reduced severity of affective disorders and improved quality of life and daily activity of patients.

In vitro effect of manganese chloride exposure on reactive oxygen species generation and respiratory chain complexes activities of mitochondria isolated from rat brain

Manganese (Mn) is known to induce mitochondrial dysfunction in excessive dose; however the mechanisms underlying its action are not elucidated clearly. To determine if Mn2+ can act directly on mitochondria or indirectly by producing reactive oxygen species (ROS), isolated mitochondria were exposed to different concentration of Mn2+ (5, 50, 500, 1000 microM). ROS generation, respiratory control ratio (RCR), mitochondrial membrane potential (MMP) and respiratory chain complexes activities were investigated. Dose-dependent inhibition of respiratory chain complexes and induction of ROS were observed; these changes were paralleled by decreasing of respiratory control ratio (RCR) both with succinate or glutamate + malate. Further investigation indicated that the membrane potential determined by Rhodamine123 release decreased after MnCl2 exposure at 1000 microM. In addition, effects of the antioxidants NAC (500 microM), GSH (500 microM) and Vitamin C (500 microM) were studied at 500 microM Mn2+. The results indicate that the effect of Mn2+ exposure on respiratory chain is not site-specific, and antioxidants can protect the mitochondria function by reducing the formation of free radicals.

Manganese oxidation state mediates toxicity in PC12 cells

The role of the manganese (Mn) oxidation state on cellular Mn uptake and toxicity is not well understood. Therefore, undifferentiated PC12 cells were exposed to 0-200 microM Mn(II)-chloride or Mn(III)-pyrophosphate for 24 h, after which cellular manganese levels were measured along with measures of cell viability, function, and cytotoxicity (trypan blue exclusion, medium lactate dehydrogenase (LDH), 8-isoprostanes, cellular ATP, dopamine, serotonin, H-ferritin, transferrin receptor (TfR), Mn-superoxide dismutase (MnSOD), and copper-zinc superoxide dismutase (CuZnSOD) protein levels). Exposures to Mn(III) >10 microM produced 2- to 5-fold higher cellular manganese levels than equimolar exposures to Mn(II). Cell viability and ATP levels both decreased at the highest Mn(II) and Mn(III) exposures (150-200 microM), while Mn(III) exposures produced increases in LDH activity at lower exposures (> or =50 microM) than did Mn(II) (200 microM only). Mn(II) reduced cellular dopamine levels more than Mn(III), especially at the highest exposures (50% reduced at 200 microM Mn(II)). In contrast, Mn(III) produced a >70% reduction in cellular serotonin at all exposures compared to Mn(II). Different cellular responses to Mn(II) exposures compared to Mn(III) were also observed for H-ferritin, TfR, and MnSOD protein levels. Notably, these differential effects of Mn(II) versus Mn(III) exposures on cellular toxicity could not simply be accounted for by the different cellular levels of manganese. These results suggest that the oxidation state of manganese exposures plays an important role in mediating manganese cytotoxicity.

Hypersensitivity to metals in orthodontics

To study the incidence of hypersensitivity to orthodontic metals, patch tests were carried out before and 2 months after the placement of orthodontic appliances in 38 patients (17 male, 21 female). The tested substances were cobalt chloride, copper sulfate, potassium dichromate, iron sulfate, manganese chloride, molybdenum salt, nickel sulfate, and titanium oxide. Eight strips containing the test substances were positioned on the patients' backs. They were removed after 48 hours and assessed by a dermatologist at 48 and 72 hours after antigen application. The obtained data were analyzed by the chi-square test and McNemar's chi-square test. Statistically significant positive reactions were observed for nickel sulfate (21.1%), potassium dichromate (21.1%), and manganese chloride (7.9%); reactions to nickel sulfate had the greatest intensity. No differences were observed between the reactions before and after placement of the orthodontic appliances; this indicates that they did not sensitize the patients or affect their tolerance to these metals during the study period. No statistical difference was observed regarding sex for any evaluated substance, although a greater tendency to positivity to nickel sulfate was observed among female patients and to potassium dichromate in male patients.

Blood manganese and alcohol consumption interact on mood states among manganese alloy production workers

Long-term exposure to manganese (Mn) can induce neurotoxic effects including neuromotor, neurocognitive and neuropsychiatric effects, but there is a great interpersonal variability in the occurrence of these effects. It has recently been suggested that blood Mn (MnB) may interact with alcohol use disorders, accentuating neuropsychiatric symptoms. The objective of the present study was to explore a possible interaction between alcohol consumption and MnB on mood states, using an existing data set on Mn exposed workers. Respirable Mn exposure in the plant averaged 0.23mg/m(3) and was correlated with MnB. All participants for whom all data on MnB concentration and mood (assessed with the Profile of Mood States (POMS)) were available and who reported currently drinking alcohol were included in the analyses (n=74). Workers were grouped according to their MnB concentration (<10 and > or =10 microg/l) and alcohol consumption (<400 and > or =400g per week). Two-way ANOVAs were performed on each POMS scale and Mann-Whitney tests were used to assess group differences. Workers in the higher alcohol consumption group had higher scores on three POMS scales: tension, anger and fatigue. There was no difference for POMS scale scores between MnB subgroups. Dividing the group with respect to alcohol consumption and MnB showed that the group with high alcohol consumption and high MnB displayed the highest scores. In the lower MnB category, those in the higher alcohol consumption group did not have higher scores than the others. The interaction term for alcohol consumption and MnB concentration was statistically significant (P<0.05) for the depression, anger, fatigue and confusion POMS scales. There was a tendency for tension (P<0.06), and it was not significant for vigor. This study shows the first evidence of an interaction between MnB and alcohol consumption on mood states among Mn exposed workers and supports the results from a previous population-based study.

[Definition of neurotoxic risk based on the benchmark dose in vitro: illustration with experimental models based on the use of known neurotoxic substances]

The BMD approach has been used to compare the cell viability (MTT assay) of different rat (C6 and PC12, glial and neuronal, respectively) and human cell lines (D384 and SK-N-MC, glial and neuronal, respectively) after 24-h exposure to the following neurotoxic substances: Manganese Chloride (MnCl2), Methyl-mercury (Me-Hg) and the enantiomers of Styrene Oxide (SO). For all rat and human cell lines, the potency of the examined compounds was: MnCl2 < S-SO < R-SO < Me-Hg. A preliminary comparison with in vivo toxicity data for these substances gave rise to consistent results. Whereas a reasonable agreement between in vitro and in vivo data has been found for Mn and styrene oxide, a wide scatter of LOAEL has been reported for Me-Hg and these appear to be either much higher or lower than the BMD for the MTT assay we observed in vitro.

Magnetic resonance imaging of neuronal connections in the macaque monkey

Recently, an MRI-detectable, neuronal tract-tracing method in living animals was introduced that exploits the anterograde transport of manganese (Mn2+). We present the results of experiments simultaneously tracing manganese chloride and wheat germ agglutinin conjugated to horseradish peroxidase (WGA-HRP) to evaluate the specificity of the former by tracing the neuronal connections of the basal ganglia of the monkey. Mn2+ and WGA-HRP yielded remarkably similar and highly specific projection patterns. By showing the sequential transport of Mn2+ from striatum to pallidum-substantia nigra and then to thalamus, we demonstrated MRI visualization of transport across at least one synapse in the CNS of the primate. Transsynaptic tract tracing in living primates will allow chronic studies of development and plasticity and provide valuable anatomical information for fMRI and electrophysiological experiments in primates.

Carcinogenicity, mutagenicity and teratogenicity of manganese compounds

Manganese, an essential trace element, is one of the most used metals in the industry. Recently, several new manganese compounds have been introduced as fungicide, as antiknock agent in petrol and as contrasting agent in nuclear magnetic resonance tomography. Manganese displays a somewhat unique behaviour with regard to its toxicity. It is relatively non-toxic to the adult organism except to the brain where it causes Parkinson-like symptoms when inhaled even at moderate amounts over longer periods of time. Relatively high doses of manganese affect DNA replication and repair in bacteria and causes mutations in microorganism and mammalian cells although the Ames test does not appear to be particularly responsive to manganese. In mammalian cells, manganese causes DNA damage and chromosome aberrations. Information on organic manganese derivatives is still insufficient. Large amounts of manganese affect fertility in mammals and are toxic to the embryo and foetus. The fungicide MANEB and the contrasting agent MnDPDP also can be embryotoxic, but the latter only at doses much higher than those clinically employed. Information on the anti-knock agent MMT is inadequate. On the other hand, manganese deficiency can also affect fertility and be teratogenic. Information on cancer due to manganese is scanty but the results available do not indicate that inorganic manganese is carcinogenic. More information is desirable with regard to the organic manganese derivatives. It may surprise that an agent that causes mutations is not also carcinogenic. The experience with manganese shows that conclusions with regard to carcinogenicity of an agent based on the observation of mutations are subject to uncertainties. Altogether, it appears that, because of the very high doses at which positive effects have been found, manganese would not represent a significant carcinogenic risk to the population and workers. Care must, however, be exercised with respect to central-nervous symptoms after chronic exposure and with respect to effects on the embryo. Pregnant women should not be exposed to manganese at the work place.

Brain lipid peroxidation and changes of trace metals in rats following chronic manganese chloride exposure

The aim of this study was to investigate the effects of chronic, daily, 30-d administration of manganese chloride (MnCl2) to male Sprague-Dawley rats on lipid peroxidation and changes of trace elements (manganese, iron, copper, zinc) in various brain regions. Rats were intraperitoneally injected with MnCl2 (20 mg/kg) once daily for 30 consecutive days. The Mn accumulated in frontal cortex, corpus callosum, hippocampus, striatum, hypothalamus, medulla, cerebellum, and spinal cord. Malondialdehyde, an end product of lipid peroxidation, was markedly decreased in frontal cortex and cerebellum. An increased level of Cu was observed in frontal cortex, medulla, and a cerebellum. A decreased Fe level was found only in cerebellum, and a decreased Zn level was observed in hippocampus and striatum. In a second group of animals, Mn (20 mg/kg/d) and glutathione (GSH, 15 mg/kg/d) were administered ip for 30 d. In CSH-Mn-treated rats, compared to Mn-treated rats, MDA concentrations were significantly reduced in frontal cortex, medulla and cerebellum. The changes of trace elements in rat brain were similar to the Mn-treated group. We suggest that Mn is an atypical antioxidant, as well as not involved in oxidative damage in rat brain. Fe and Cu may play roles in the protective effect of Mn against lipid peroxidation in rat brain.

Results of magnetic resonance imaging in long-term manganese dioxide-exposed workers

Within a cross-sectional study, the neurotoxic effects of occupational exposure to manganese were examined. From a group of 90 (58 male and 32 female) workers, 11 men with long-term and high exposure to manganese dioxide (MnO2) dust were defined as exposed workers. Eleven age-matched workers of similar socioeconomic status were used as a reference group. Ambient air and biological monitoring (blood, urine, hair), clinical (Webster Rating Scale, WRS), neurophysiological (visual evoked potentials (VEP), nerve conduction velocity (NCV), electroencephalography (EEG)), and motor performance (Wiener Testsystem) examinations were performed. The pallidal index (PI), the ratio of globus pallidus to subcortical frontal white-matter signal intensity in T1-weighted magnetic resonance imaging (MRI) planes multiplied by 100, was used. For the individual body burden, manganese in blood was the most reliable biomarker. A "job-exposure matrix" for the cumulative Mn-exposure index (CEI) was calculated for each worker. The results of WRS, VEP, NCV, EEG, and motor performance tests showed no significant group differences. However, the pallidal index was increased in Mn-exposed persons. Furthermore, a statistically significant positive correlation was found between CEI and pallidal index. The results of other studies are discussed. The meaning of MRI findings for health status as well as gender-specific differences should be examined in further follow-up studies.

Environmental exposure to manganese and combined exposure to gaseous upper respiratory irritants: mechanism of action and adverse health effects

This review relates to possible explanations of the often-observed findings that exposure to certain air pollutants or their mixture results in an increased rate of acute respiratory diseases. Epidemiological investigations have shown that exposure to manganese (MnO2) concentrations only 10 to 50 times higher than the normal urban concentrations of 0.01 to 0.03 microgram/m3 air might have an adverse health effect on respiratory organs. The assumption that one possible mechanism of action could be that manganese at such exposure levels disturbs certain protective functions in the lung--thus making the organism more susceptible to infections--is supported by toxicological studies. In vitro studies have demonstrated the cytotoxic action of manganese, including the inhibition of activities of alveolar macrophages. Animal experiments showed a decrease in resistance toward respiratory infections that were caused by simultaneous exposure to MnO2 and pathogenic bacteria. In cases of combined exposure to gaseous upper respiratory tract irritants and suspended particles, the involvement of adsorption of gaseous compounds on solid particles as carriers has been suggested. The assumption is that through such a mechanism, water-soluble gaseous irritants can be transported deep into air passages, which such irritants normally do not reach. As the adsorption is reversible, the gaseous compounds can later be released from the particles, inducing a local irritating effect in the small airways and alveoli.

[Magnetic resonance tomography of the brain in workers with chronic occupational manganese dioxide exposure]

AIM

Changes within the brain detected by MRI after chronic manganese poisoning raised the question whether morphological changes of the basal ganglia, particularly of the globus pallidus, could be detected after chronic occupational exposure to manganese dioxide.

METHOD

In a cross-sectional study, healthy workers (48 male and 27 female) at a dry cell battery factory were examined. Actual internal exposure was quantified by the analysis of manganese in the blood using atomic absorption spectrometry. Chronic exposure was defined as a cumulative index (CBI) including duration of exposure, individual workplace factors, and previously measured concentrations of MnO2 in dust samples. A Philips Gyroscan T5-II (0.5 T) was used for the MRI of the brain. The following indicators were taken to ascertain possible manganese-induced changes; Pallidum-Index (PI), width of 3rd ventricle and cella media index in addition to clinical examinations.

RESULTS

No cases of parkinsonism were detected in clinical examinations or by other means. The mean manganese concentration in blood was 12 micrograms/l (range: 3.9-23.3 micrograms/l). In comparison to the upper reference value of 10 micrograms/l, 42 workers (56%) had a higher body burden. A significant positive correlation between manganese levels in blood and the PI (indicated by T1-shortening) was observed as well as between the CBI and workplace-specific exposure. Brain atrophy was not detected in any of the observed cases.

CONCLUSIONS

Long-term exposure to manganese dioxide dust correlates with the Pallidum-Index in MRI scans. Although the MRI findings have no current clinical relevance for individuals, further studies are necessary to evaluate specificity and potential prognostic value.

Neurotoxicity of manganese chloride in neonatal and adult CD rats following subchronic (21-day) high-dose oral exposure

The purpose of this study was to evaluate the relative sensitivity of neonatal and adult CD rats to manganese-induced neurotoxicity. Identical oral manganese chloride (MnCl(2)) doses (0, 25, or 50 mg kg(-1) body wt. day(-1)) were given to neonatal rats throughout lactation (i.e. from postnatal day (PND) 1 through 21) and to adult male rats for 21 consecutive days. The MnCl(2) doses administered to neonates were ca. 100-fold higher than those resulting from the consumption of an equivalent volume of rat's milk. Rats were assessed using similar behavioral and neurochemical evaluations. Several statistically significant changes occurred in Mn-exposed rats relative to control animals. Neonates given the high dose of MnCl(2) had reduced body weight gain. An increased pulse-elicited acoustic startle response amplitude was observed in neonates from both MnCl(2) treatment groups on PND 21. Increased striatal, hippocampal, hindbrain and cortical Mn concentrations were observed in all Mn-exposed neonates on PND 21. Increased hypothalamic and cerebellar Mn concentrations were also observed on PND 21 in neonates from the high-dose group only. Increased striatal, cerebellar and brain residue Mn concentrations were observed in adult rats from the high-dose group. Increased striatal dopamine and 3,4-dihydroxyphenylacetic acid levels were observed only in PND 21 neonates from the high-dose group. No treatment-related changes were observed in clinical signs, motor activity (assessed in neonates on PND 13, 17, 21 +/- 1 and in adults), passive avoidance (assessed in neonates on PND 20 +/- 1 and in adults) or neuropathology (assessed in PND 21 neonates only). The results of our experiment suggest that neonates may be at greater risk for Mn-induced neurotoxicity when compared to adults receiving similar high oral levels of Mn.

Manganese--a public health concern: its relevance for occupational health and safety policy and regulation in South Africa

Concerns about the effects of low-level manganese exposures on human health arise at a time when South Africa finds itself in competition with newcomers to the market economy, China and the CIS. This case study illustrates how decisions about occupational health and safety and the environment are influenced by incompleteness of scientific knowledge, competing interests, differences over what is fair or just, and the compartmentalization of public policy. In addition, an assessment is made of the ability of the occupational health and safety system in South Africa in its current form to address the challenges posed by manganese-related issues. The importance of tracking developments abroad, strengthening participatory processes, developing national policy, linking economic policy and OHS policy, and establishing appropriate trade agreements is stressed.

A multisite phase III study of the safety and efficacy of a new manganese chloride-based gastrointestinal contrast agent for MRI of the abdomen and pelvis

The purpose of this study was to evaluate the safety and efficacy of a manganese chloride-based oral magnetic resonance (MR) contrast agent during a Phase III multisite clinical trial. Two hundred seventeen patients were enrolled who were already scheduled for MRI of the abdomen and/or pelvis. In this group of patients, it was postulated that the use of an oral agent would better allow discrimination of pathology from bowel. Patients with known gastrointestinal pathology including peptic ulcer disease, inflammatory bowel disease, obstruction, or perforation were excluded to minimize confounding variables that could affect the safety assessment. Of these 217 patients, 18 received up to 900 mL of placebo, and 199 patients were given up to 900 mL of a manganese chloride-based oral contrast agent, LumenHance (Bracco Diagnostics, Inc.). Safety was determined by comparing pre- and post-dose physical examinations, vital signs, and laboratory examinations and by documenting adverse events. Efficacy was assessed by unblinded site investigators and two blinded reviewers who compared pre- and post-dose T1- and T2-weighted MRI scans of the abdomen and/or pelvis. In 111 (57%) of the 195 cases evaluated for efficacy by site investigators (unblinded readers), MRI after LumenHance provided additional diagnostic information. Increased information was found by two blinded readers in 52% and 51% of patients, respectively. In 44/195 cases (23%) unblinded readers felt the additional information would have changed patient diagnosis and in 50 patients (26%), it would have changed management and/or therapy. Potential changes in patient diagnosis or management/therapy were seen by the two blinded readers in 8-20% of patients. No clinically significant post-dose laboratory changes were seen. Forty-eight patients (24%) receiving LumenHance and four patients (22%) receiving placebo experienced one or more adverse events. Gastrointestinal tract side effects were most common, seen in 29 (15%) of LumenHance patients and in 3 (17%) of the placebo patients. LumenHance is a safe and efficacious oral gastrointestinal contrast agent for MRI of the abdomen and pelvis.

[The function of the cholinergic and sympathoadrenal systems in miners with long-term exposure to manganese oxides]

Long-term exposure to manganese oxides (MO) exceeding MPL leads at first to adaptation strain such as an increase in the activity of acetyl chlonesterase and correspondingly a decline in acetylcholine; greater excretion of catecholamin precursors with subsequent depletion of adaptive mechanisms. Under exposure to manganese concentration of 5.9 to 16.3 mg/m3, the adaptation exhaustion reactions in the sympathoadrenal system (SAS) and the cholinergic system (ChS) develop 7 to 9 years earlier than with 0.4-2.8 mg/m3 of MO. Moreover, ChS responds sooner than SAS to manganese exposure--about ten years earlier under high concentrations of manganese, 5-6 years earlier when being exposed to smaller concentrations. The above changes are believed to be the underlying reason why the nervous system pathologies should develop, with their incidence being at its greatest after thirteen and more- and twenty-one and more-year exposure to MO in concentrations exceeding MLP 19.5 to 54-fold and 1.3 to 9.3-fold respectively.

Nickel chloride/chlorides of divalent metal interactions in nickel-sensitive subjects

To verify if the counter-ion Cl- permits the same interactions between nickel and divalent metals with physicochemical similarities as the counter-ion SO4- does, 50 sensitive subjects to nickel sulfate 5% pet. who previously gave positive patch test reactions either to 8 mu 1 of aq. nickel sulfate 0.1 M or to 8 mu 1 of aq. nickel chloride 0.1 M, or to both, were patch retested simultaneously to 8 mu 1 of, respectively, aq. nickel sulfate 0.1 M and aq. nickel chloride 0.1 M, and to 8 mu 1 of aq. mixed solutions containing, respectively, nickel chloride 0.1 M+magnesium chloride 0.3 M, nickel chloride 0.1 M+zinc chloride 0.3 M, nickel chloride 0.1 M+zinc chloride 0.5 M, nickel chloride 0.1 M+manganese chloride 0.3 M, and nickel chloride 0.1 M+manganese chloride O.5 M. Whilst 4 subjects gave a positive patch test response to only nickel sulphate, 8 gave a positive response to nickel chloride alone and the remaining 38 gave a concomitant positive response to both. In all subjects who gave positive responses to nickel chloride, the chlorides of divalent metals were not able to inhibit or reduce the positive reaction. 25 healthy subjects patch tested to both single salts and mixed solutions, and all gave negative responses. 9 of the 50 subjects, 4 who previously gave positive reactions to only nickel chloride 0.1 M, and 5 with concomitant reactions of equal intensity to both nickel chloride and nickel sulfate 0.1 M, were patch retested simultaneously to 8 mu 1 of, respectively, aq. nickel sulfate 0.1 M, aq. nickel chloride 0.1 M and aq. mixed solutions containing nickel sulfate (0.1 M) mixed with sulfates (0.3 M) and nickel chloride (0.1 M) mixed with chlorides of Mg, Zn, Mn (0.3 M). Whilst the mixed sulfate solutions were able to reduce nickel sulfate, 0.1 M patch test positive reactions, those containing chlorides, at all concentrations tested, did not inhibit the nickel chloride reactions in any of the subjects. The results of the tests to chlorides, compared to those reached on testing to sulfates of the same metals, lead us to hypothesize that the anion probably affects the uptake and local tissue distribution of the metal, modulating in this way, together with the individual cutaneous ligands, its effects.

Safety and optimum concentration of a manganese chloride-based oral MR contrast agent

To determine the safety of a manganese chloride-based oral magnetic resonance (MR) contrast agent and the ideal concentration of the agent for marking in three different anatomic sites (stomach, middle of the small bowel, and ileocecal region), six healthy volunteers were evaluated before and after administration of 900 mL of three different concentrations of the contrast agent. Images were evaluated subjectively and objectively. No adverse events were noted. There was a minimal rise in manganese blood levels at 6 hours after administration, with a return to baseline at 24 hours. The imaging data demonstrated good-to-excellent bowel marking on T1-weighted images at all three concentrations. However, on T2-weighted images, the 40 mg Mn+2/L concentration provided improved hypointense bowel marking relative to the 20 mg/L concentration. Little difference was seen between the 40 and 60 mg/L concentrations. Fast T1- and T2-weighted sequences provided superior image quality to that of conventional spin-echo sequences.

[The inhalation of low concentrations of manganese powders produces changes in respiratory mucociliary clearance]

The aim of this study is to verify whether inhaling metallic dusts, containing a lower concentration of Mn (as Mn3O4) than current TLV can cause alterations in exposed workers tracheobronchial mucociliary clearance. We studied 20 grinders using an 11.5-13% Mn steel, and a control group of 21 standard steel grinders, employed in the same foundry. Environmental Mn dust was measured by personal samplers. All workers were administered a questionnaire about chronic bronchitis; the following examinations were also carried out: medical examination, spirometry, chest standard X-ray and urinary Mn dosage. Mucociliary clearance was measured by human respiratory mucus transportability on frog palate and expressed as normalized frog palate transport rate (NFPTR). Mucus was obtained through a sputum so protected as to avoid salivary contamination. Environmental measurements showed a Mn concentration from 0.1 to 1 mg/m3 with respect to a TLV of 5 mg/m3. Exposed workers and control group were homogeneous as far as age, working period, tobacco smoking habit and spirometric parameters are concerned. Chest X-ray examination showed no evidence of pneumoconiosis. Mn exposed workers showed a NFPTR reduction, if compared to normal level (0.70). NFPTR average value in exposed group has come out to be much lower than in control group. NFPTR alteration in Mn exposed group appears to be strictly linked to a longer than 15 years working seniority. Urinary Mn values resulted extremely low in each worker and their average was not significantly different between the groups.(ABSTRACT TRUNCATED AT 250 WORDS)