Improvement of Decellularization Efficiency of Porcine Aorta Using Dimethyl Sulfoxide as a Penetration Enhancer.

Decellularization of tissues and organs enables researchers to obtain extracellular matrix (ECM) with the natural conformation and chemical composition of specific tissues. However, drawbacks exist such as the structural alteration of ECM or loss of some important components in ECM due to overexposure to chemicals during the decellularization process. In this study, porcine aorta was decellularized by sodium dodecyl sulfate (SDS). Dimethyl sulfoxide (DMSO) was used as a penetration enhancer in the decellularization process to enhance the penetration of SDS, consequently reducing the exposure time of SDS to treated tissues. It is revealed that by addition of DMSO to the decellularization process 64.4% more DNA was removed when compared with just SDS exposure within a 3 h reaction. Cross-validation by DAPI staining showed that, in the presence of DMSO, the penetration of SDS was improved and almost all cells were removed from the aorta within the 3 h exposure time. Collagen staining revealed that just SDS treatment showed less polarized collagen fibers, while the DMSO addition groups revealed denser and organized collagen fibers. Moreover 77% glycosaminoglycan content was preserved by addition of DMSO in resultant tissues. Scanning electron microscopy analysis of decellularized aortic matrix showed that ECM components remained in the adventitia layer with the addition of DMSO treatment, while the layer was removed with just SDS treatment. Biocompatibility assays proved that after washing the decellularized samples with media supplemented with 3% antibiotic and antimycotic solution for 2 days there was no cytotoxic effect related to the SDS + DMSO decellularization protocol. This study demonstrates that the new decellularization protocol not only improves the removal efficiency of cellular components but also protects the crucial ECM components.

Fabrication of Plasmonic Nanorod-Embedded Dipeptide Microspheres via the Freeze-Quenching Method for Near-Infrared Laser-Triggered Drug-Delivery Applications.

Control of drug release by an external stimulus may provide remote controllability, low toxicity, and reduced side effects. In this context, varying physical external stimuli, including magnetic and electric fields, ultrasound, light, and pharmacological stimuli, have been employed to control the release rate of drug molecules in a diseased region. However, the design and development of alternative on-demand drug-delivery systems that permit control of the dosage of drug released via an external stimulus are still required. Here, we developed near-infrared laser-activatable microspheres based on Fmoc-diphenylalanine (Phe-Phe) dipeptides and plasmonic gold nanorods (AuNRs) via a simple freeze-quenching approach. These plasmonic nanoparticle-embedded microspheres were then employed as a smart drug-delivery platform for native, continuous, and pulsatile doxorubicin (DOX) release. Remarkable sustained, burst, and on-demand DOX release from the fabricated microspheres were achieved by manipulating the laser exposure time. Our results demonstrate that AuNR-embedded dipeptide microspheres have great potential for controlled drug-delivery systems.

A facile in vitro model to study rapid mineralization in bone tissues.

BACKGROUND: Mineralization in bone tissue involves stepwise cell-cell and cell-ECM interaction. Regulation of osteoblast culture microenvironments can tailor osteoblast proliferation and mineralization rate, and the quality and/or quantity of the final calcified tissue. An in vitro model to investigate the influencing factors is highly required. METHODS: We developed a facile in vitro model in which an osteoblast cell line and aggregate culture (through the modification of culture well surfaces) were used to mimic intramembranous bone mineralization. The effect of culture environments including culture duration (up to 72 hours for rapid mineralization study) and aggregates size (monolayer culture as control) on mineralization rate and mineral quantity/quality were examined by osteogenic gene expression (PCR) and mineral markers (histological staining, SEM-EDX and micro-CT). RESULTS: Two size aggregates (on average, large aggregates were 745 µm and small 79 µm) were obtained by the facile technique with high yield. Cells in aggregate culture generated visible and quantifiable mineralized matrix within 24 hours, whereas cells in monolayer failed to do so by 72 hours. The gene expression of important ECM molecules for bone formation including collagen type I, alkaline phosphatase, osteopontin and osteocalcin, varied temporally, differed between monolayer and aggregate cultures, and depended on aggregate size. Monolayer specimens stayed in a proliferation phase for the first 24 hours, and remained in matrix synthesis up to 72 hours; whereas the small aggregates were in the maturation phase for the first 24 and 48 hour cultures and then jumped to a mineralization phase at 72 hours. Large aggregates were in a mineralization phase at all these three time points and produced 36% larger bone nodules with a higher calcium content than those in the small aggregates after just 72 hours in culture. CONCLUSIONS: This study confirms that aggregate culture is sufficient to induce rapid mineralization and that aggregate size determines the mineralization rate. Mineral content depended on aggregate size and culture duration. Thus, our culture system may provide a good model to study regulation factors at different development phases of the osteoblastic lineage.

Antiproliferative and Apoptotic Effects of Tempol, Methotrexate, and Their Combinations on the MCF7 Breast Cancer Cell Line.

Breast cancer holds the top position among the cancers occurring in women. Despite the utilization of surgical removal, chemotherapy, and radiation therapy, there is currently no conclusive treatment available to prevent breast cancer. New treatment approaches are being studied since traditional chemotherapeutics also damage healthy cells. Tempol (TPL) is a potent antioxidant agent that has been shown to exhibit anticancer activity. The objective of this research was to examine the impacts on cell proliferation and apoptosis by using methotrexate (MTX) and TPL individually and in combination on MCF7 breast cancer cells. MCF7 cells were exposed to TPL, MTX, and MTX + TPL for 48 h. The effects of the administered drugs on cell viability were determined using a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Enzyme-linked immunosorbent assay analysis was conducted to assess the levels of the antiapoptotic protein Bcl-2, the pro-apoptotic protein Bax, and the activity of caspase-3 in MCF7 cells. Increasing concentrations of TPL and MTX significantly decreased the proliferation in MCF7 cells in both solo and combined use. Solo and combined use of TPL and MTX significantly increased caspase-3 activity and Bax levels and significantly decreased Bcl-2 levels in the cells. This study revealed that the solo use of TPL and MTX inhibited proliferation and increased apoptotic activity in the cells. In addition, TPL increased the antiproliferative and apoptosis efficiency of MTX on cancer cells as a result of the combined use of these drugs.

Nutrition for the older adult - Current concepts. Report from an ESPEN symposium.

BACKGROUND & AIMS: In view of the global demographic shift, a scientific symposium was organised by the European Society for Clinical Nutrition and Metabolism (ESPEN) to address nutrition-related challenges of the older population and provide an overview of the current state of knowledge. METHODS: Eighteen nutrition-related issues of the ageing global society were presented by international experts during the symposium and summarised in this report. RESULTS: Anorexia of ageing, dysphagia, malnutrition, frailty, sarcopenia, sarcopenic obesity, and the metabolic syndrome were highlighted as major nutrition-related geriatric syndromes. Great progress has been made in recent years through standardised definitions of some but not all syndromes. Regarding malnutrition, the GLIM approach has shown to be suitable also in older adults, justifying its continuous implementation. For anorexia of ageing, a consensus definition is still required. Intervention approaches should be integrated and person-centered with the aim of optimizing intrinsic capacity and maintaining functional capacity. Landmark studies like EFFORT and FINGER have impressively documented the potential of individualised and multifactorial interventions for functional and health benefits. Combining nutritional intervention with physical training seems particularly important whereas restrictive diets and drug treatment should generally be used with caution because of undesirable risks. Obesity management in older adults should take into account the risk of promoting sarcopenia. CONCLUSIONS: In the future, even more individualised approaches like precision nutrition may enable better nutritional care. Meanwhile all stakeholders should focus on a better implementation of currently available strategies and work closely together to improve nutritional care for older adults.

Adipocytokines and aging: adiponectin and leptin.

Adipose tissue is an active metabolic organ secreting adipocytokines which are involved in the energy homeostasis and regulation of glucose and lipid metabolism. Aging is associated with fat redistribution, which is characterized by loss of peripheral subcutaneous fat and accumulation of visceral fat. Visceral adipose tissue is more involved in the developement of metabolic diseases than subcutaneous adipose tissue. Aging also alters the function, proliferation, size, and number of adipose cells which leads to alterations in the secretion, synthesis and function of the adipocytokines. Adiponectin is an insulin sensitizing, anti-inflammatory, and antiathoregenic adipokine. Centarians have higher adiponectin levels associated with longevity. However, in older individuals ­ age 65 or more ­ adiponectin is associated with higher mortality. Dysregulation of adiponectin in older individuals may be due to loss of function of circulating adiponectin or a response to increased inflammatory process. Longitidunal increase in adiponectin levels 5with aging rather than genetically high adiponectin levels may translate to increased mortality in older patients. The adipocytokine leptin is traditionally viewed as a product of adipocytes that can exert endocrine effects. There have been conflicting reports of not only the effects of aging on leptin, but also the effects of leptin on age-related diseases including sarcopenia, Alzheimer's disease and cardiovascular diseases. Aging is also associated with resistance to leptin and/or to a decrease of receptors for this hormone. In this review, we briefly discuss the role of two major adipocytokines adiponectin and leptin in the aging process and age-related diseases.

An alternative way for the evaluation of zinc status in the elderly; nail zinc levels and relationship with Alzheimer's disease.

BACKGROUND: Zinc is one of the most important elements for human body. Zinc deficiency can occur in any age, if it is seen in elderly its clinical results can be more harmful due to already diminished functions. Some studies showed zinc deficiency has an important role in the pathogenesis of Alzheimer disease. In this study we measured the nail zinc levels and aimed to show its clinical implications in geriatric patients, especially Alzheimer disease. PATIENTS AND METHODS: 43 patients with Alzheimer disease and 89 patients with normal cognitive function were evaluated. The diagnosis of Alzheimer disease was made according to DSM-IV and NINCDS-ADRDA criteria after cognitive assessment and neuroimaging performed using magnetic resonance. Hand fingernail samples are obtained from the patients. RESULTS: Mean zinc level from fingernail samples was 117.99 ± 73.44 ppm in Alzheimer Disease patients, 123.86 ± 77.98 ppm in control group (p: 0.680). CONCLUSIONS: This is the first study measuring nail zinc levels in elderly patients with and without Alzheimer disease. Our data reveal no significant difference in nail zinc levels between two groups. However, fingernail zinc may be a useful biomarker in elderly population.  

Synthesis of Conductive Carbon Aerogels Decorated with ß-Tricalcium Phosphate Nanocrystallites.

There has been substantial interest in research aimed at conductive carbon-based supports since the discovery that the electrical stimulus can have dramatic effect on cell behavior. Among these carbon-aerogels decorated with biocompatible polymers were suggested as future materials for tissue engineering. However, high reaction temperatures required for the synthesis of the aerogels tend to impair the stability of the polymeric networks. Herein, we report a synthetic route towards carbon-aerogel scaffolds decorated with biocompatible ceramic nanoparticles of tricalcium phosphate. The composites can be prepared at temperature as high as 1100 °C without significant effect on the morphology of the composite which is comparable with the original aerogel framework. Although the conductivity of the composites tends to decrease with the increasing ceramic content the measured conductivity values are similar to those previously reported on polymer-functionalized carbon-aerogels. The cell culture study revealed that the developed constructs support cell proliferation and provide good cell attachment suggesting them as potentially good candidates for tissue-engineering applications.

Critical-size alveolar defect treatment via TGF-ß3 and BMP-2 releasing hybrid constructs.

In the present study a combination of Transforming Growth Factor Beta 3 (TGF-ß3) and Bone Morphogenetic Protein-2 (BMP-2) loaded gelatin films sandwiched between poly (L-lactide) (PLLA)/poly (ε-caprolactone) (PCL) matrices were produced to enhance bone formation in alveolar bone defects. Osteogenic properties of tissue constructs were tested in alveolar bone defect model in rats. Bone healing was assessed by osteogenic gene expression levels of bone sialoprotein (BSP), alkaline phosphatase (ALP), osteonectin (ON, SPARC), osteocalcin (OC), runt-related transcription factor 2 (RUNX2), bone specific alkaline phosphatase (BALP) activity, histomorphometry and microtomography. Increase in osteogenic gene expression levels and BALP activity results showed that new bone formation was significantly accelerated in TGF-ß3 + BMP-2 loaded scaffold group compared to growth factor free and only BMP-2 loaded groups. The micro-computed tomography (µ-CT) data from the 4th months revealed that (TGF-ß3+ BMP-2) loaded scaffolds displayed increased bone formation and was able to fulfill 84% of the defect area (p < 0.05). Accelerated bone formation in the S-GF-B-T group compared to that of the S-GF group at the end of the 4th month was further verified via histomorphometric analysis (p = 0.008). Gene expression, BALP activity, microtomography and histomorphometry analysis indicated that (TGF-ß3 + BMP-2) loaded PLLA/PCL scaffolds increased the new bone formation. BMP-2 loaded scaffolds were less effective than combination of TGF-ß3 and BMP-2 loaded scaffolds. These findings demonstrated that focusing on the PLLA/PCL hybrid scaffolds combined with (TGF-ß3 + BMP-2) may lay the groundwork for future therapy-oriented efforts to enhance bone formation in alveolar defects.

Advanced age is associated with endothelial dysfunction in healthy elderly subjects.

BACKGROUND: Aging is associated with an increased risk for atherosclerosis in which endothelial dysfunction is an early marker. OBJECTIVE: The purpose of this study was to determine if endothelial function is altered with increasing age in healthy subjects. METHOD: The study population consisted of 30 elderly and 36 younger subjects free from major cardiovascular risk factors. Transthoracic echocardiography was performed for each subject to rule out structural heart disease. Endothelial function was evaluated by flow-mediated dilation (FMD) of the brachial artery via ultrasound. RESULTS: Baseline characteristics of the elderly and the younger group were similar, except for age (mean age: 71.3 +/- 5.8 vs. 26.5 +/- 7.2). Transthoracic echocardiography was normal in all subjects. FMD of the elderly group was significantly lower than the younger group (7.9 +/- 3.1 in the elderly, 10.8 +/- 1.9 in the younger group, p < 0.001). A negative relationship was found between FMD and age (r = -0.528, p < 0.001). CONCLUSION: It can be concluded that endothelial function detected by FMD declines with increasing age in healthy human subjects. Advanced age is a predictor of impaired endothelial function.

Assessment of drug administration via feeding tube and the knowledge of health-care professionals in a university hospital.

BACKGROUND/OBJECTIVES: The use of drugs via feeding tube is problematic. Appropriate techniques must be used during the administration to prevent obstruction of a feeding tube, to avoid inadequate drug effects and to minimize the risk of toxicity of the given pharmaceuticals. SUBJECTS/METHODS: In this study, medications of all the patients in a University Hospital with 1100 beds were monitored to identify the appropriateness of administration. The study was performed on 5 days each in 5 consecutive weeks to observe the current practice. After evaluation of practice, a questionnaire was given to doctors, nurses and pharmacists to determine the health-care professionals' attitudes on drug administration through a feeding tube. RESULTS: A total of 225 drugs (out of 13 935) were administered via feeding tube during the study period and 40.5% (n=91) were not administered in appropriate dosage forms. Only 86% of the doctors and 98% of the nurses stated that they pay attention to the suitability of drugs when they prescribe or administer drugs via feeding tube. Only 58% of pharmacists, 17% of nurses and 24% of doctors were aware of the fact that enteric-coated tablets should not be crushed owing to the risk of tube occlusion and lack of efficacy when they are administered via feeding tube. CONCLUSIONS: This study demonstrated the discordance between the theoretical knowledge and the practical performance of the health-care professionals in drug administration. In patients with feeding tubes, assessment of drug dosage forms by a pharmacist would be beneficial for appropriate administration and to prevent drug interactions.

Cognitive aspects of frailty: mechanisms behind the link between frailty and cognitive impairment.

Whereas physical impairment is the main hallmark of frailty, evidence suggests that other dimensions, such as psychological, cognitive and social factors also contribute to this multidimensional condition. Cognition is now considered a relevant domain of frailty. Cognitive and physical frailty interact: cognitive problems and dementia are more prevalent in physically frail individuals, and those with cognitive impairment are more prone to become frail. Disentangling the relationship between cognition and frailty may lead to new intervention strategies for the prevention and treatment of both conditions. Both frailty and cognitive decline share common potential mechanisms. This review examines the relationship between frailty and cognitive decline and explores the role of vascular changes, hormones, vitamin D, inflammation, insulin resistance, and nutrition in the development of physical frailty and cognitive problems, as potential underlying mechanisms behind this link. Dual tasking studies may be a useful way to explore and understand the relation between cognitive and physical frailty. Further studies are needed to elucidate this complex relation to improve the outcomes of frailty.

[Angiosarcoma of the spleen with consumption coagulopathy]. / Angiosarkoma selezenki s koagulopatiei potrebleniia.

A female patient with intravitally diagnosed splenic angiosarcoma is described. Progress of the cancerous process was attended by the development of consumption coagulopathy with profound fibrinogenopenia and thrombocytopenia. In this case the DIC syndrome was characterized by the lack of systemic fibrinolysis activation. The rupture of the cavernous tumor of the spleen and profound disorders of hemostasis determined profuse intraperitoneal hemorrhage and the patient's death. Diagnostic criteria that contribute to early recognition of splenic angiosarcoma are suggested.

Sarcopenia assessment project in the nursing homes in Turkey.

BACKGROUND/OBJECTIVES: Sarcopenia and sarcopenic obesity (SO) are geriatric syndromes leading to physical disability, poor quality of life and death. The aim of this study was to investigate the prevalence of sarcopenia and SO in nursing homes in Turkey and to define local disparities for diagnosing sarcopenia and SO. SUBJECTS/METHODS: This cross-sectional multicenter study was performed in 711 patients in 14 nursing homes. Comprehensive geriatric assessment tests, handgrip strength and calf circumference (CC) measurements were carried out. Sarcopenia was both defined by handgrip strength and CC criteria. RESULTS: According to handgrip strength measurement, 483 (68%) of patients were sarcopenic (male: 72%, female: 63.8%), 228 were non-sarcopenic. The prevalence of SO was 22% (13.7% in men, 30.2% in women). Patients (82.5%) who were diagnosed as sarcopenic by the handgrip strength test were not sarcopenic according to CC sarcopenia criteria. Therefore, we tried to determine the optimal CC value for diagnosing sarcopenia in our population. CONCLUSIONS: Both sarcopenia and SO were prevalent among Turkish nursing home elderly residents. Most of the patients with sarcopenia were obese or overweight. We showed that diagnosing sarcopenia with CC measurement underestimated the sarcopenia prevalence assessed by handgrip strength. So we concluded that, although different assessment methods are recommended for the diagnosis of sarcopenia local disparities should be considered.

Malnutrition in Turkish nursing homes: a correlate of short term mortality.

OBJECTIVE: Elderly nursing home residents are under high risk of malnutrition. Early interventions to prevent malnutrition may play a critical role in malnutrition-mortality correlation. This study aimed to obtain insight into the prevalence of malnutrition in nursing homes in the capital city of Turkey and the role of malnutrition in predicting the risk for short-term mortality. DESIGN: This study was conducted in seven different residential care facilities in Ankara. MEASUREMENTS: Nutritional status was evaluated by Mini Nutritional Assessment-Short Form. RESULTS: The mean age of the 534 participants was 79.46±7.22 years. Nutritional assessment revealed that 15.9% of all older adults suffered from malnutrition and another 53.6% were at risk of malnutrition. The mortality rate for all subjects was 118 (22.1%) over 18 months, which was significantly higher in participants with malnutrition. CONCLUSIONS: We noted a high prevalence of malnutrition and a strong correlation of increased mortality with malnutrition in nursing home residents. Given the negative impact of malnutrition on mortality and morbidity, an emphasis should be placed on an effective nutritional policy in nursing homes.

Iron deficiency can cause cognitive impairment in geriatric patients.

OBJECTIVES: Deficiency of iron, which plays an important role in oxygen transport and storage, may lead to cerebral hypoxia and cognitive decline. This relationship which was studied in children and adults was not evaluated in the elderly. The objective of this study is to examine the effect of iron deficiency on cognitive function in the elderly. DESIGN, SETTING, PARTICIPANTS: This is a cross-sectional study conducted in a geriatric medicine outpatient clinic of a university hospital. Consecutive 2009 patients admitted to Geriatric Medicine outpatient clinic were examined and 622 patients who fulfilled the inclusion criteria were enrolled in the study. MEASUREMENTS: Comprehensive geriatric assessment, cognitive assessment and laboratory analysis including blood count, iron, total iron binding capacity, ferritin, and transferrin saturation were performed. RESULTS: Mean age of the study group was 72.5±6.5 and 439 (70.6%) were women. MMSE scores were moderately and significantly correlated with iron levels (r=0.33, p<0.001) and transferrin saturation (r=0.32, p<0.001). Transferrin saturation was significantly lower in the patients with dementia (p=0.040). It was found that patients with iron deficiency had lower MMSE scores (p<0.001) and this relationship was also present in patients without anemia (p=0.004). CONCLUSION: The results of this study revealed a negative influence of iron deficiency on cognitive function and this influence was independent from the presence of anemia. As iron deficiency can be easily diagnosed and treated, detecting its effect on cognitive function is of importance. Screening for iron deficiency and initiating appropriate treatment should be a routine part of comprehensive geriatric assessment.

Potential biomarkers for vascular damage in Alzheimer's disease: thrombomodulin and von Willebrand factor.

OBJECTIVES: Evidence regarding the vascular basis of Alzheimer's disease (AD) is growing. In vascular damage thrombomodulin tears of the cell wall and its level increases in the plasma. von Willebrand factor (vWF) is also thought to be a biomarker for vascular damage. The aim of this study was to examine the levels of vWF and thrombomodulin in AD as possible markers for vascular damage and to test their utility as an early biomarker in AD. DESIGN: Case-control study. SETTING: Geriatric medicine outpatient clinic of a university hospital. PARTICIPANTS: Twenty Alzheimer's disease patients free from vascular risk factors and 20 controls were enrolled in the study. MEASUREMENTS: Thrombomodulin and VWF levels of 20 AD patients and 20 controls were analyzed by commercial kits. RESULTS: Thrombomodulin levels were not different between Alzheimer's disease and control groups [median (range) = 4.25 (2.27-37.00) ng/ml in Alzheimer's disease and 3.55 (2.27-14.00) in control group, p=0.15]. Von Willebrand Factor antigen (%) levels were 188.5 (96-306) in Alzheimer's disease, and 181 (112- 284) in control group (p=0.74). CONCLUSION: Although vascular damage is thought to play role in the pathogenesis of AD, vWF and thrombomodulin failed to demonstrate the vascular damage in AD. Their utility to be used as early biomarkers of AD could not be shown.

Intra-erythrocyte magnesium levels and their clinical implications in geriatric outpatients.

OBJECTIVES: Magnesium deficiency has been implicated as a factor in numerous chronic diseases and previous studies suggest a greater prevalence of occult magnesium deficiency among older adults. Serum is the choice for the assessment of most analyses used in clinical medicine, although serum magnesium concentrations have been shown to be poor predictors of intracellular magnesium concentration. The aim of this study was to compare intracellular and extracellular magnesium concentrations in geriatric outpatients. Moreover, we examined whether a significant correlation between magnesium parameters and clinical outcome existed. DESIGN: Cross-sectional study. SETTING: Geriatric medicine outpatient clinic of a university hospital. PARTICIPANTS: A total of 246 patients with a mean age of 71.9 ± 5.7 years were involved. MEASUREMENTS: Intra-erythrocyte magnesium levels were analyzed with atomic absorption spectrophotometry. RESULTS: Serum magnesium levels were within normal range in all patients, whereas intra-erythrocyte magnesium measurements were low in 57% of the patients. Increase in serum levels were together with just only a slightly increase in intra-erythrocyte measurements and the relationship was very weak. Intra-erythrocyte Mg levels were not significantly correlated with many laboratory or clinical parameters. CONCLUSION: Our results confirm that intra-erythrocyte Mg does not correlate with serum levels and clinical parameters in geriatric outpatients, but further studies are needed to define the correlation.

Serum vitamin-E levels and its relation to clinical features in nonalcoholic fatty liver disease with elevated ALT levels.

BACKGROUND: Oxidative stress and free oxygen radicals play an important role in the progression from simple fatty liver to steatohepatitis. Deficiency of antioxidants like vitamin-E has been reported to trigger this progression. The main aims of our study were to measure plasma vitamin-E levels in nonalcoholic fatty liver disease (NAFLD), to explain its relationship with biochemical parameters and to examine the possible therapeutic and prophylactic role of vitamin-E. METHODS: 52 patients with NAFLD and elevated liver function tests were enrolled. After 6 months of follow-up with a standard low-fat, low-calorie diet, changes in liver enzymes were evaluated. RESULTS: Deficiency of vitamin-E was detected in 16 patients with NAFLD. Homogenous echo pattern of the liver and attenuation was found to be significantly higher in the low vitamin-E group (p = 0.03). The low vitamin-E group had significantly higher levels of triglyceride (p = 0.02). After 6 months, patients in the low vitamin-E group did not respond to the diet and no decrease in ALT levels was detected (p = 0.04). CONCLUSION: This is the first study measuring the serum vitamin-E levels in nonalcoholic fatty liver disease. A correlation was found between low vitamin-E levels, high triglyceride levels, as well as sonographic findings, both of which are negative prognostic factors causing progression of fatty liver to steatohepatitis. Patients with low vitamin-E levels did not respond to a classical diet for fatty liver disease. Based on the data, we suggest that diet alone is not adequate for patients with fatty liver, and vitamin-E supplementation should be added.