Exploring individual fixel-based white matter abnormalities in epilepsy.

Diffusion MRI has provided insight into the widespread structural connectivity changes that characterize epilepsies. Although syndrome-specific white matter abnormalities have been demonstrated, studies to date have predominantly relied on statistical comparisons between patient and control groups. For diffusion MRI techniques to be of clinical value, they should be able to detect white matter microstructural changes in individual patients. In this study, we apply an individualized approach to a technique known as fixel-based analysis, to examine fibre-tract-specific abnormalities in individuals with epilepsy. We explore the potential clinical value of this individualized fixel-based approach in epilepsy patients with differing syndromic diagnoses. Diffusion MRI data from 90 neurologically healthy control participants and 10 patients with epilepsy (temporal lobe epilepsy, progressive myoclonus epilepsy, and Dravet Syndrome, malformations of cortical development) were included in this study. Measures of fibre density and cross-section were extracted for all participants across brain white matter fixels, and mean values were computed within select tracts-of-interest. Scanner harmonized and normalized data were then used to compute Z-scores for individual patients with epilepsy. White matter abnormalities were observed in distinct patterns in individual patients with epilepsy, both at the tract and fixel level. For patients with specific epilepsy syndromes, the detected white matter abnormalities were in line with expected syndrome-specific clinical phenotypes. In patients with lesional epilepsies (e.g. hippocampal sclerosis, periventricular nodular heterotopia, and bottom-of-sulcus dysplasia), white matter abnormalities were spatially concordant with lesion location. This proof-of-principle study demonstrates the clinical potential of translating advanced diffusion MRI methodology to individual-patient-level use in epilepsy. This technique could be useful both in aiding diagnosis of specific epilepsy syndromes, and in localizing structural abnormalities, and is readily amenable to other neurological disorders. We have included code and data for this study so that individualized white matter changes can be explored robustly in larger cohorts in future work.

Phytochemical Analysis of the Fruit Pulp Extracts from Annona crassiflora Mart. and Evaluation of Their Antioxidant and Antiproliferative Activities.

Annona crassiflora Mart., the marolo fruit of the Cerrado biome, is one of the most frequently consumed species from the Brazilian Midwest. This study aimed to evaluate the chemical composition and the antioxidant and cytotoxic properties of the fruit pulp of A. crassiflora collected at Chapada das Mesas, Maranhão, Brazil. The volatile concentrate was identified as mainly ethyl octanoate, ethyl hexanoate, and methyl octanoate. From the ethanol (LFP-E) and ethyl acetate (LFP-A) extracts were identified phenolic acids (p-coumaric, gallic, quinic, and ferulic), flavones and derivatives (apigenin, epicatechin, 2'-5-dimethoxyflavone, 3',7-dimethoxy-3-hydroxyflavone, kaempferol-3-O-glucoside and 3-O-rutinoside, quercetin-3-O-glucoside, procyanidin B2, and rutin), aporphine alkaloids (xylopine, stephagine, and romucosine), and acetogenin (annonacin). For the LFP-E and LFP-A extracts, the total phenolic compound values were 15.89 and 33.16 mg GAE/g, the flavonoid compound content values were 2.53 and 70.55 mg QE/g, the DPPH radical scavenging activity showed EC50 values of 182.54 and 57.80 µg/mL, and the ABTS radical activity showed TEAC values of 94.66 and 192.61 µM TE/g. The LFP-E extract showed significant cytotoxicity and cell selectivity for the U251-glioma strain, presenting a GI50 value of 21.34 µg/mL, which is close to doxorubicin (11.68 µg/mL), the standard chemotherapeutic drug. The marolo fruit seems to be a promising source for developing innovative and healthy products for the food industry.

Daratumumab utilization and cost analysis among patients with multiple myeloma in a US community oncology setting.

Background: The introduction of daratumumab into the treatment of multiple myeloma has improved outcomes in patients; however, community oncologists often dose more frequently than the US FDA-approved label. Materials and methods: Integra analyzed its database to elucidate daratumumab treatment patterns and the impact of increased utilization on the cost of care for multiple myeloma. Results: Following week 24, 671 (65%) of 1037 patients remained on daratumumab-containing regimens, with 330 patients continuing more frequent treatments than the expected once-every-4-weeks dosing described in the standard dosing schedule. Patients received an average of 14% more daratumumab doses than the FDA-approved label indicates, increasing the 1-year daratumumab costs by an estimated US$31,353. Conclusion: Daratumumab is utilized more frequently than the FDA-recommended dosing, leading to higher multiple myeloma treatment costs.

Lay abstract Since its first approval in 2015, daratumumab has become the backbone of many multiple myeloma treatment regimens. While its approval has improved outcomes in many patients who undergo treatment, it is expensive and has largely contributed to the increasing costs of care in multiple myeloma. In its most common treatment schedule, patients should transition from weekly and biweekly dosing to treatment once every 4 weeks. However, many providers maintain their patients on a more frequent dosing schedule, which increases Medicare 1-year costs by an estimated US$31,353 and may have unforeseen impacts on adverse events and patient outcomes.

Real-world estimate of the value of one metabolic equivalent in a population of patients planning major surgery.

BACKGROUND: One metabolic equivalent (MET) is equal to resting oxygen consumption. The average value for one MET in humans is widely quoted as 3.5 mL/kg/min. However, this value was derived from a single male participant at the end of the 19th century and has become canonical. Several small studies have identified varied estimates of one MET from widely varying populations. The ability of a patient to complete 4 MET (or 14 mL/kg/min) is considered an indicator of their fitness to proceed to surgery. AIMS: To define a typical value of one MET from a real-world patient population, as well as determine factors that influenced the value. METHODS: A database of cardiopulmonary exercise testing (CPET) was interrogated to find a total of 1847 adult patients who had undergone CPET testing in the previous 10 years. From this database, estimates of oxygen consumption (VO2 ) at rest and at the anaerobic threshold and several other variables were obtained. The influence of age, body mass index (BMI), sex and the use of beta-blockers was tested. RESULTS: The median resting VO2 at rest was 3.6 mL/kg/min (interquartile range (IQR): 3.0-4.2). Neither sex, age >65 years or the use of beta-blockers produced a significant difference in resting VO2 , while those with a BMI >25 kg/m2 had a significantly lower VO2 at rest (3.4 mL/kg/min vs 4.0 mL/kg/min; P < 0.001). CONCLUSIONS: The estimate of 3.6 mL/kg/min for resting VO2 presented here is consistent with the previous literature, despite this being the first large study of its kind. This estimate can be safely used for pre-operative risk stratification.

The Effects of Dietary Supplements that Overactivate the Nrf2/ARE System.

BACKGROUND: Inflammation is one of the most misunderstood aspects of human health. People have been encouraged to eat foods that have a high antioxidant capacity, and in vitro tests for total antioxidant capacity emerged. They were based on measuring the destruction of oxidized test compounds in direct reactions with the antioxidants in foods. Many dietary supplements arrived in the market. They contained purified antioxidants, such as resveratrol and EGCG that were and still are widely assumed by many to be quite healthy at any dose. METHODS: The literature on inflammation and the Nrf2/ARE antioxidant system was searched systematically. Articles from prestigious, peer-reviewed journals were obtained and read. The information obtained from them was used to write this review article. RESULTS: Over 150 articles and books were read. The information obtained from them showed that very few dietary antioxidants exert their effects by reacting directly with Reactive Oxygen and Nitrogen Species (RONS). Instead, most of the effective antioxidants activate the endogenous Nrf2/ARE antioxidant system. This helps prevent smoldering inflammation and the diseases that it can cause. However, when overactivated or activated constitutively, the Nrf2/ARE antioxidant system can cause some of these diseases, including many types of multidrug resistant cancer, autoimmune, neurodegenerative and cardiovascular diseases. CONCLUSION: Even though green tea, as well as many fruits, vegetables and spices are quite healthy, dietary supplements that deliver much higher doses of antioxidants may not be. People who are diagnosed with cancer and plan to start chemotherapy and/or radiotherapy should probably avoid such supplements. This is because multidrug resistant tumors can hijack and overactivate the Nrf2/ARE antioxidant system.

Predicting the Dimensions of an Intracardiac Partial-Assist Pump for Percutaneous Delivery by Analytical and Numerical Methods.

A minimally invasive ventricular assist device is under development for percutaneous insertion into the left atrium via transseptal access from the right atrium (RA). This study aimed to mathematically describe the vascular anatomy along possible insertion pathways to determine the device's maximum outer dimensions. We developed 2-dimensional mathematical models describing the vascular anatomy to the RA from three access points: subclavian vein (SCV), internal jugular vein (IJV), and femoral vein (FV). All pathways terminated by turning from the superior or inferior vena cava (SVC/IVC) into the RA. The model equations were based on restriction points in the pathways and were solved using anatomic size values 1 SD below published mean values so that the device will accommodate most patients. Vessels were considered rigid so that vessel deformation (and therefore risk) is minimized during device insertion. Maximum device length was calculated for a range of device diameters. The length at the most constraining angle in each turn was the maximum allowable device length. The least restrictive pathway was from the right FV, the turn from the IVC through the atrial septum being the most restrictive point. For a 10-mm diameter device, the length restriction for this pathway was 45 mm, whereas those for the right IJV and SCV were 42 and 21 mm, respectively. Medical device developers can apply these models to determine size specifications of new devices, whereas interventional physicians can apply them to determine if an existing device is appropriate for an individual patient.

Evaluation of the effects of passion fruit peel flour (Passiflora edulis fo. flavicarpa) on metabolic changes in HIV patients with lipodystrophy syndrome secondary to antiretroviral therapy

ABSTRACT This study evaluated the effects of using passion fruit peel flour together with diet therapy and counseling in 36 patients with HIV lipodystrophy who were in an ambulatory clinic in a university hospital. The patients were divided into two groups. One received 30 g of passion fruit peel flour daily for 90 days and diet therapy counseling. The other group received only diet therapy counseling. The metabolic changes were analyzed before and after the intervention, with a significance level predetermined at p ≤ 0.05. The use of passion fruit peel flour was effective in reducing total cholesterol and triacylglycerides after 30 days. The concentrations of LDL-C decreased, while HDL-C increased in the blood of lipodystrophy patients after 90 days passion fruit peel flour treatment. No significant differences in food consumption were seen between groups. The use of 30 g of passion fruit peel flour for 90 days together with diet therapy counseling was effective in improving plasma concentrations of total cholesterol, LDL-C, HDL-C and triacylglycerides.

Phytochemicals and botanical extracts regulate NF-κB and Nrf2/ARE reporter activities in DI TNC1 astrocytes.

The increase in oxidative stress and inflammatory responses associated with neurodegenerative diseases has drawn considerable attention towards understanding the transcriptional signaling pathways involving NF-κB (nuclear factor kappa-light-chain-enhancer of activated B cells) and Nrf2 (Nuclear Factor Erythroid 2-like 2). Our recent studies with immortalized murine microglial cells (BV-2) demonstrated effects of botanical polyphenols to inhibit lipopolysaccharide (LPS)-induced nitric oxide (NO) and enhance Nrf2-mediated antioxidant responses (Sun et al., 2015). In this study, an immortalized rat astrocyte (DI TNC1) cell line expressing a luciferase reporter driven by the NF-κB or the Nrf2/Antioxidant Response Element (ARE) promoter was used to assess regulation of these two pathways by phytochemicals such as quercetin, rutin, cyanidin, cyanidin-3-O-glucoside, as well as botanical extracts from Withania somnifera (Ashwagandha), Sutherlandia frutescens (Sutherlandia) and Euterpe oleracea (Açaí). Quercetin effectively inhibited LPS-induced NF-κB reporter activity and stimulated Nrf2/ARE reporter activity in DI TNC1 astrocytes. Cyanidin and the glycosides showed similar effects but only at much higher concentrations. All three botanical extracts effectively inhibited LPS-induced NF-κB reporter activity. These extracts were capable of enhancing ARE activity by themselves and further enhanced ARE activity in the presence of LPS. Quercetin and botanical extracts induced Nrf2 and HO-1 protein expression. Interestingly, Ashwagandha extract was more active in inducing Nrf2 and HO-1 expression in DI TNC1 astrocytes as compared to Sutherlandia and Açaí extracts. In summary, this study demonstrated NF-kB and Nrf2/ARE promoter activities in DI TNC1 astrocytes, and further showed differences in ability for specific botanical polyphenols and extracts to down-regulate LPS-induced NF-kB and up-regulate the NRF2/ARE activities in these cells.

UPLC–QTOF–MS and NMR analyses of graviola (Annona muricata) leaves

ABSTRACT Graviola leaves (Annona muricata L., Annonaceae) are used by some people to try to treat or even cure cancer, even though over-consumption of the fruit, which contains the neurotoxins annonacin and squamocin has caused an atypical form of Parkinson's disease. In previous analyses, the fruits were extracted with methanol under ambient conditions before analyses. In the present study, UPLC–QTOF–MS and NMR were used to analyze freeze-dried graviola leaves that were extracted using dry methanol and ethanol at 100 ºC and 10 MPa (100 atm) pressure in a sealed container. Methanol solubilized 33% of the metabolites in the lyophilized leaves. Ethanol solubilized 41% of metabolites in the lyophilized leaves. The concentrations of total phenolic compounds were 100.3 ± 2.8 and 93.2 ± 2.0 mg gallic acid equivalents per g of sample, for the methanolic and ethanolic extracts, respectively. Moreover, the toxicophore (unsaturated γ-lactone) that is present in neurotoxic acetogenins was found in the lipophilic portion of this extract. The concentrations of the neurotoxins annonacin and squamocin were found by UPLC–QTOF–MS to be 305.6 ± 28.3 and 17.4 ± 0.89 µg/g-dw, respectively, in the dried leaves. Pressurized methanol solubilized more annonacin and squamocin than ethanol. On the other hand, a hot, aqueous infusion solubilized only 0.213% of the annonacin and too little of the squamocin to be detected. So, graviola leaves contain significant amounts of the neurotoxins annonacin and squamocin, as well as some potentially healthy phenolic compounds. Finally, the potential neurotoxicity of whole leaves in dietary supplements could be much higher than that of a tea (hot aqueous infusion) that is made from them.

APF530 (granisetron injection extended-release) in a three-drug regimen for delayed CINV in highly emetogenic chemotherapy.

AIM: APF530, extended-release granisetron, provides sustained release for ≥5 days for acute- and delayed-phase chemotherapy-induced nausea and vomiting (CINV). We compared efficacy and safety of APF530 versus ondansetron for delayed CINV after highly emetogenic chemotherapy (HEC), following a guideline-recommended three-drug regimen. METHODS: HEC patients received APF530 500 mg subcutaneously or ondansetron 0.15 mg/kg intravenously, with dexamethasone and fosaprepitant. Primary end point was delayed-phase complete response (no emesis or rescue medication). RESULTS: A higher percentage of APF530 versus ondansetron patients had delayed-phase complete response (p = 0.014). APF530 was generally well tolerated; treatment-emergent adverse event incidence was similar across arms, mostly mild-to-moderate injection-site reactions. CONCLUSION: APF530 versus the standard three-drug regimen provided superior control of delayed-phase CINV following HEC. ClinicalTrials.gov : NCT02106494.

Spilanthol: occurrence, extraction, chemistry and biological activities

Abstract Spilanthol (C14H23NO, 221.339 g/mol) is a bioactive compound that is found in many different plants that are used as traditional remedies throughout the world. It is present in Heliopsis longipes and several species in the genus Acmella, including A. oleracea L., also known as paracress and jambu. Its leaves and flowers have sensory properties (pungency, tingling, numbing, mouth-watering) that make it a popular spice and ingredient in several Brazilian dishes. Spilanthol can exert a variety of biological and pharmacological effects including analgesic, neuroprotective, antioxidant, antimutagenic, anti-cancer, anti-inflammatory, antimicrobial, antilarvicidal and insecticidal activities. So, the aim of this review is to present a literature review on the spilanthol that describes its occurrence, chemistry, extraction and biological activities.

All-Cause Mortality and Progression Risks to Hepatic Decompensation and Hepatocellular Carcinoma in Patients Infected With Hepatitis C Virus.

BACKGROUND: A key question in care of patients with chronic hepatitis C virus (HCV) infection is beginning treatment immediately vs delaying treatment. Risks of mortality and disease progression in "real world" settings are important to assess the implications of delaying HCV treatment. METHODS: This was a cohort study of HCV patients identified from 4 integrated health systems in the United States who had liver biopsies during 2001-2012. The probabilities of death and progression to hepatocellular carcinoma, hepatic decompensation (hepatic encephalopathy, esophageal varices, ascites, or portal hypertension) or liver transplant were estimated over 1, 2, or 5 years by fibrosis stage (Metavir F0-F4) determined by biopsy at beginning of observation. RESULTS: Among 2799 HCV-monoinfected patients who had a qualifying liver biopsy, the mean age at the time of biopsy was 50.7 years. The majority were male (58.9%) and non-Hispanic white (66.9%). Over a mean observation of 5.0 years, 261 (9.3%) patients died and 34 (1.2%) received liver transplants. At 5 years after biopsy, the estimated risk of progression to hepatic decompensation or hepatocellular carcinoma was 37.2% in stage F4, 19.6% in F3, 4.7% in F2, and 2.3% in F0-F1 patients. Baseline biopsy stage F3 or F4 and platelet count below normal were the strongest predictors of progression to hepatic decompensation or hepatocellular carcinoma. CONCLUSIONS: The risks of death and progression to liver failure varied greatly by fibrosis stage. Clinicians and policy makers could use these progression risk data in prioritization and in determining the timing of treatment for patients in early stages of liver disease.

The Role of the Nrf2/ARE Antioxidant System in Preventing Cardiovascular Diseases.

It is widely believed that consuming foods and beverages that have high concentrations of antioxidants can prevent cardiovascular diseases and many types of cancer. As a result, many articles have been published that give the total antioxidant capacities of foods in vitro. However, many antioxidants behave quite differently in vivo. Some of them, such as resveratrol (in red wine) and epigallocatechin gallate or EGCG (in green tea) can activate the nuclear erythroid-2 like factor-2 (Nrf2) transcription factor. It is a master regulator of endogenous cellular defense mechanisms. Nrf2 controls the expression of many antioxidant and detoxification genes, by binding to antioxidant response elements (AREs) that are commonly found in the promoter region of antioxidant (and other) genes, and that control expression of those genes. The mechanisms by which Nrf2 relieves oxidative stress and limits cardiac injury as well as the progression to heart failure are described. Also, the ability of statins to induce Nrf2 in the heart, brain, lung, and liver is mentioned. However, there is a negative side of Nrf2. When over-activated, it can cause (not prevent) cardiovascular diseases and multi-drug resistance cancer.

Network medicine and high throughput screening.

A new paradigm is emerging in modern drug discovery. It is a fusion of traditional and modern medicine, phenotypic and targeted drug discovery, or systems and reductionist thinking. This is exemplified by using a combination of network medicine and high throughput screening. It blends the use of physiologically relevant biological systems with the high throughput and statistical robustness of modern assay technologies. The basic principles of network theory and tools of network medicine are described. Scale-free networks and their organizing principles are discussed. They are emergent properties of living, autopoietic systems. This includes networks of people who do high throughput screening (HTS), and microscopic networks of ions, metabolites, DNA, RNA, proteins, lipids, carbohydrates, viruses, bacteria, fungi, human cells and tissues. Databases have been constructed based on the metabolome, genome, transcriptome, proteome, lipidome, glycocode, virome, bacteriome and many others. Modern HTS can be used to examine the interactions of many parts of the complex human network. High content screening (HCS) can look at perturbations that occur when test compounds are added to single cells. Allo-network drugs can have effects far beyond a single protein and can be transmitted to other cells. Interactions and hidden connections can be revealed, with the goal of developing new drugs that have few, if any harmful side effects and are effective against multi-drug resistant cancer cells or bacteria.

Finding of pesticides in fashionable fruit juices by LC-MS/MS and GC-MS/MS.

Products labelled as containing extracts from two mushrooms (cordyceps plus reishi) and the juices from açaí, goji, mangosteen, noni, pomegranate, and sea buckthorn have been analysed for 174 different pesticides, using the validated QuEChERS method for sample preparation and electrospray LC-MS/MS in the positive ion mode for analysis. Pesticides were found in 10 of the 21 samples analysed. Most pesticides found were below the tolerance levels (1-6 µg/g, depending on the pesticide), but some were not. This included boscalid, dimethomorph, iprovalicarb, pyridaben, pyrimethanil, and imazalil, for which there is no tolerance reported or zero tolerance in any fruit. However, genuine açaí that was harvested in the state of Pará and lyophilised in Rio de Janeiro had no detectable pesticides, when analysed by both LC-MS/MS and GC-MS/MS, which can detect 213 more pesticides and industrial chemicals. Likewise no pesticides were found in one sample each of cordyceps plus reishi, sea buckthorn and noni.

Collaborative validation of the QuEChERS procedure for the determination of pesticides in food by LC-MS/MS.

Seven FDA pesticide laboratories collaborated to develop and validate an LC-MS/MS method to determine 173 pesticides in <20 min. The average determination coefficient (r²) was >0.99 for all but two compounds tested. The limits of detection were <20 ng/mL for all compounds and <10 ng/mL for 363 of the 368 transitions reported. The method was used to determine pesticides in two AOAC sponsored proficiency samples. The LC-MS/MS determination was used for the analysis of oranges, carrots and spinach using the QuEChERS (Quick, Easy, Cheap, Effective, Rugged, Safe) method. Each matrix was fortified at 20, 100, 400, and 1000 ng/g. No false positive responses were detected in controls of the three matrices. 165 pesticides had recoveries between 70 and 130%, and 161 had minimum detection levels less than 10 ng/g. Recoveries of 169 compounds for the 1000 ng/g spikes were within 50-150%. A matrix effect study indicated all three matrices caused a small net suppressing effect, the most pronounced attributable to the citrus matrix. The procedure proved to be accurate, precise, linear, sensitive and rugged, and adds 100 pesticides to the scope of the FDA pesticide program.

Determination of polycyclic aromatic hydrocarbons (PAHs) in shrimp.

A simple and rapid method for determining polycyclic aromatic hydrocarbons (PAHs) in shrimp is described. For sample preparation, the quick and simple QuEChERS procedure was used. Reverse-phase chromatography using an octadecyl silica (C18) column and water/acetonitrile gradient elution was used to separate analyte mixtures. After separation, PAHs were detected using liquid chromatography-tandem mass spectrometry (LC-MS/MS) equipped with the atmospheric pressure photoionization (PhotoSpray APPI) source operating in the positive-ion mode. In this methodology, all 16 common PAHs were used and toluene served as a charged dopant to efficiently ionize analyte molecules through secondary reactions. Spikes were performed at 0.2 and 1 µg/g with and without primary and secondary amine (PSA) sorbent cleanup. Recoveries of PAHs were good, with ion ratios that agreed well between the spikes and standards. Without cleanup at 0.2 µg/mL, seven compounds had relatively low recovery (49-69%) and one compound, naphthalene, had a somewhat high recovery of 129%. At 1 µg/mL without cleanup, only three compounds had slightly lower recovery (66-67%). When PSA cleanup was performed, all PAH recoveries were within 75-125% at both spike levels.

Wellness: Pharmacy education's role and responsibility.

The root cause of most chronic diseases in America is self-inflicted through an unhealthy lifestyle including poor diet, insufficient exercise, inability to maintain a healthy weight, tobacco use, and excessive alcohol consumption. Americans' ability to adhere to healthy lifestyles appears to be declining.1,2 The pharmacy profession, while positioned to provide an answer to this problem, has done little. In addition, academic pharmacy's primary focus is on drugs and diseases with limited instruction in the area of wellness. It is time for pharmacy education to step up and take a leadership role in enhancing the wellness of Americans.

The clinical and economic burden of anemia.

Anemia is a prevalent condition that goes underrecognized and undertreated, yet still carries substantial costs for payers and is a burden on the health and quality of life of those diagnosed. Clinicians should recognize anemia of chronic diseases, such as cancer, chronic kidney disease, and human immunodeficiency virus infection, as a surrogate for more severe illness. Because of its prevalence and the health consequences associated with anemia, better detection and response is needed in vulnerable patient populations. Clinicians need to be more cognizant of the symptoms of anemia and more vigilant in its treatment to ensure better outcomes both clinically and financially.