Repetitive transcranial magnetic stimulation in the treatment of resistant depression: changes of specific neurotransmitter precursor amino acids.

Repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant major depression offers an alternative therapy, since more than every third patient is not responding to adequate antidepressive treatment. In this interventional study safety, symptom development and changes of serum concentrations of neurotransmitter precursor amino acids, of immune activation and inflammation markers, of brain-derived neurotrophic factor (BDNF), nitrite as well as of salivary amylase were measured before and after a frontal polar cortex stimulation using rTMS as add-on treatment in 38 patients with treatment-resistant depression. Out of these, 17 patients received sham stimulation as a control. Treatment was well tolerated: with the exception of one patient of the verum group, who described discomfort during the second treatment, no serious adverse effects were observed. Improvement of depression with a significant decrease in the HAMD-7 scale (p = 0.001) was found in patients treated with rTMS, but not in sham-treated patients. Furthermore, serum phenylalanine and tyrosine dropped significantly (p = 0.03 and p = 0.027, respectively) in rTMS-treated patients. The kynurenine to tryptophan ratio (Kyn/Trp) tended to decrease under rTMS (p = 0.07). In addition, associations between concentrations of BDNF and neopterin as well as serum nitrite levels were found in patients after rTMS treatment, which indicates an influence of immune regulatory circuits on BDNF levels. In the sham-treated patients, no changes of biomarker concentrations were observed. Results show that rTMS is effective in the treatment of resistant depression. rTMS appears to influence the enzyme phenylalanine hydroxylase, which plays a central role in the biosynthesis of neurotransmitter precursors tyrosine and dihydroxyphenylalanine (DOPA).

Influence of acute normovolemic hemodilution on the pharmacokinetics of Cisatracurium Besylate.

BACKGROUND: Acute normovolemic hemodilution (ANH) is an efficacious blood conservation strategy for avoiding or reducing allogeneic blood transfusion. In a previous publication, on a different cohort of patients, we demonstrated that cisatracurium's potency and duration of action were not influenced by ANH, but we could not establish which role, if any, pharmacokinetics played. METHODS: Forty patients were randomly allocated to the ANH or control groups. Patients received cisatracurium single 100 µg kg-1 bolus dose, serial arterial blood samples were collected and assayed for pharmacokinetic analysis. RESULTS: Central and steady state apparent volumes of distribution (V1, Vdss) and slope factor (γ) were larger, effect-compartment concentration at 50% neuromuscular block was lower in the ANH (90.8±41.6 mL kg-1, 159.1±39.2 mL kg-1, 6.0±0.9 and 136.4±29.1 ng·mL-1) compared with the control group (65.5±26.1 mL kg-1, 134.8±31.8 mL kg-1, 5.5±0.8 and 158.5±26.0 ng·mL-1) respectively. Elimination half-life (t1/2 ß) and mean residence time (MRT) were longer in the ANH (37.2±20.9, 23.5±13.2 min) than the control group (26.8±9.8, 16.9±6.2 min), albeit not statistically significant (P=0.051, P=0.051). There were no significant differences in distribution half-life (t1/2 α), effect-compartment equilibration rate-constant (keo), central and total clearances (Clc, Cl) between the ANH (2.4±1.2 min, 0.070±0.013 min-1, 6.1±1.9 mL kg-1 min-1 and 7.7±2.3 mL kg-1 min-1) and control group (1.9±1.2 min, 0.063±0.008 min-1, 7.0±1.8 mL kg-1 min-1 and 8.5±2.1 mL kg-1 min-1) respectively. CONCLUSION: ANH altered some pharmacokinetic parameters such as significantly larger volumes of distribution. Other parameters such as elimination half-life were considerably longer albeit not statistically significant.

Influence of acute normovolaemic haemodilution on the dose-response relationship, time-course of action and pharmacokinetics of rocuronium bromide.

BACKGROUND: Acute normovolaemic haemodilution (ANH) is an effective strategy for avoiding or reducing allogeneic blood transfusion. We aimed to study its effect on the pharmacological profile of rocuronium. METHODS: In two study centres, 28 patients undergoing major surgery with ANH were matched with 28 control patients. In the dose-response groups, using the mechanomyograph, neuromuscular block of six consecutive incremental doses of rocuronium 50 microg kg(-1), followed by 300 microg kg(-1), was evaluated. In the pharmacokinetics groups, serial arterial blood samples were withdrawn for rocuronium assay after a single dose of rocuronium 600 microg kg(-1). RESULTS: ANH resulted in a shift to the left of rocuronium dose-response curve. Rocuronium effective dose(95) (ED(95)) was 26% lower (P<0.05) in the ANH group [283.4 (92.0) microg kg(-1)] compared with the control group [383.5 (127.3) microg kg(-1)]. Times from administration of last incremental dose until 25% of first response of train-of-four (TOF) recovery (Dur(25)) and 0.8 TOF ratio recovery (Dur(0.8)) were 28% longer in the ANH group [39.9 (8.4), 66.7 (14.2) min] compared with the control group [31.1 (6.6), 52.1 (15.8) min] (P<0.01, P<0.05), respectively. Volume of distribution was higher (P<0.01), central clearance was lower (P<0.05) and terminal elimination half-life was longer (P<0.0001) in the ANH group [234.97 (47.11) ml kg(-1), 4.70 (0.94) ml kg(-1) min(-1), 77.29 (12.25) min] compared with the control group [181.22 (35.73) ml kg(-1), 5.71 (1.29) ml kg(-1) min(-1), 56.86 (10.05) min, respectively]. CONCLUSION: ANH resulted in prolongation of rocuronium time-course of action, thus careful monitoring of neuromuscular block is recommended in patients who undergo ANH.

Pteridine derivatives as modulators of oxidative stress.

Pteridine derivatives which have a widespread occurrence in nature have been investigated upon their interactions with free radicals and free radical mediated reactions utilizing a number of different experimental systems. Searching for biological functions, which are still unknown for the majority of pteridine compounds, the effect of pteridines in systems like luminol-induced chemiluminescence, enzyme activity, DNA photodamage, EPR experiments or radical induced injury--just to name a few--have been investigated. The general view during the initial phase of investigations on this special field was, that reduced pterins, i. e., tetra- as well as dihydropterins, generally act as radical scavengers, while aromatic pterins, if not inactive, exert radical promoting activity. Meanwhile the data available provide a more complex view: pteridines of all oxidation states have been shown to act anti- or prooxidatively, depending on the special conditions of the experiment. The reason is that reduced pterins, besides of being scavengers of free radicals, also are strongly reducing agents and therefore, in the presence of transition metal ions promote Fenton chemistry. Aromatic pterins have been described as inhibitors or substrates of enzymes involved--in vitro and in vivo--in free radical generation. Together with the unknown local concentrations of, e.g., neopterin and dihydroneopterin occurring in vivo, these reasons make it impossible to unequivocally predict a physiological net effect of pterins of different oxidation states concerning free radical mediated reactions in real biological systems.

Radical-scavenging and iron-chelating properties of carvedilol, an antihypertensive drug with antioxidative activity.

Carvedilol, an antihypertensive agent, has been in clinical use for several years. In addition to its function as a beta-blocker, carvedilol has been shown to act as an antioxidant. However, there is some controversy as to how carvedilol achieves its antioxidative ability: by radical scavenging or ion chelation? We therefore used a method of radical generation independent of metal ions to investigate the antioxidative properties of carvedilol. We showed that carvedilol decreased low-density lipoprotein (LDL) oxidation induced by a peroxyl radical-generating system [2,2'-azobis(2-amidinopropane)hydrochloride]. Formation of thiobarbituric acid-reactive substances, lipid hydroperoxides, and newly generated epitopes on oxidised LDL was used to monitor LDL oxidation. We further showed that carvedilol was consumed during reaction with peroxyl radicals. However, carvedilol showed no reaction with nitrogen-centered radicals (1,1-diphenyl-2-picrylhydrazyl and 2,2'-azino-di-[3-ethylbenzthiazoline sulphonate]), which are often used in assays for determining antioxidative properties. On the other hand, we found that carvedilol acted as a chelator of ferric ions. Using mass spectrometry and NMR spectroscopy, we observed complex formation with free and acetylacetonate-complexed ferric ions. The binding constant with Fe(3+) was in the range of 10(5) L/mol. From our data, we concluded that carvedilol acts as both a metal chelator and a radical scavenger in vitro. However, it is selective in reacting with different radicals and is not an electron-donating radical scavenger as is alpha-tocopherol. Therefore, taking into account the low physiological concentration, the antioxidative properties reported earlier may not solely be explained by its radical-scavenging activity.

Induction of apoptosis by 7,8-dihydroneopterin: involvement of radical formation.

Interferon-gamma is a cytokine released in large amounts during cell-mediated immune response. It induces the expression of proinflammatory cytokines and enhances macrophage capacity to secrete reactive oxygen intermediates and the pteridines neopterin and 7,8-dihydroneopterin. To assay the role of these pteridines in the immune system several studies were performed. Thereby, 7,8-dihydroneopterin was found to induce apoptosis in T lymphocytes. In this study we report that caspases are involved in 7,8-dihydroneopterin-mediated apoptosis in Jurkat T cells. In connection with this result we found that 7,8-dihydroneopterin can increase Fas ligand expression detected in Western blot analysis and promoter reporter assays. Antioxidants potently reduced the effect of 7,8-dihydroneopterin on Fas ligand promoter activation suggesting an involvement of oxidative stress. In further investigations, ESR-measurements were performed to evaluate the role of 7,8-dihydroneopterin in the formation of radicals. We found that the pteridine in combination with the spin trap DMPO induces the production of DMPO-OH spin adducts. This reaction was sensitive to the presence of chelated metal ions and could completely be blocked by the addition of superoxide dismutase. These data suggest that 7,8-dihydroneopterin in aqueous solution leads to the formation of .OH radicals via generation of superoxide anion. We hypothesize that an overproduction of radicals caused by high levels of 7,8-dihydroneopterin is likely to be responsible for the pro-apoptotic effects observed in cell cultures and possibly contributes to the pathogenesis of diseases involving immune activation and elevated concentrations of neopterin-derivatives.

Orthogonal factor coefficient development of subcutaneous adipose tissue topography (SAT-Top) in girls and boys.

The new optical device Lipometer allows noninvasive, quick, and safe determination of the thickness of subcutaneous adipose tissue (SAT) layers (in mm) at any site of the human body. The specification of 15 evenly distributed body sites enables the precise measurement of subcutaneous body fat distribution, so-called subcutaneous adipose tissue topography (SAT-Top). SAT-Top was measured in 980 children aged 7-19 years. In this paper we describe the degree to which SAT-Top body sites are intercorrelated. We consider whether a meaningful reduction of data is possible using factor analysis, which factors can be extracted, and how SAT-Top data of children can be added to a factor value plot, depicting the essential results of age-dependent subcutaneous fat development. SAT layers situated on the same body area provide correlation coefficients up to +r = 0.91. Two factors are extracted: factor 1, containing all upper body sites (from neck to hip); and factor 2, consisting of all leg body sites. When all 980 children are divided into three age groups in a factor value plot, the first age group (7-11 years) shows almost equal SAT-Top development in boys and girls. Afterwards, for the consecutive age groups 2 (11-15 years) and 3 (15-19 years), the age-dependent subcutaneous fat development of boys and girls progresses into nearly orthogonal directions.

Artificial neural networks compared to factor analysis for low-dimensional classification of high-dimensional body fat topography data of healthy and diabetic subjects.

Subcutaneous adipose tissue thickness was measured in 590 healthy subjects at 15 specific body sites by means of the new optical device, lipometer, providing a high-dimensional and partly highly intercorrelated set of data, which had been analyzed by factor analysis previously. N-2-N back-propagation neural networks are able to perform low-dimensional display of high-dimensional data as a special application. We report about the performance of such a 15-2-15 network and compare its results with the output of factor analysis. As test data for verification, measurement values on women with proven diabetes mellitus type II (NIDDM) are used. Surprisingly our 15-2-15 neural network is able to reproduce the classification pattern resulting from factor analysis very precisely. After extracting the network weights the classification of new subjects is even more simple with the neural network as compared with factor analysis. In addition, the network weights are able to cluster highly correlated body sites nicely to different groups, corresponding to different regions of the human body. Thus, the analysis of these weights provides additional information about the structure of the data. Therefore, N-2-N networks seem to be a good alternative method for analyzing high-dimensional data with strong intercorrelation.

Differences of subcutaneous adipose tissue topography in type-2 diabetic (NIDDM) women and healthy controls.

Women suffering from type-2 diabetes mellitus (non-insulin-dependent diabetes mellitus [NIDDM]) have more total body fat and upper body obesity compared with healthy controls. However, the standard measurement methods have disadvantages such as radiological burden, lack of precision, or high time consumption. A new optical device, the Lipometer, enables the noninvasive, quick, and save determination of the thickness of subcutaneous adipose tissue layers at any given site of the human body. The specification of 15 evenly distributed body sites allows the precise measurement of subcutaneous body fat distribution, so-called subcutaneous adipose tissue topography (SAT-Top). SAT-Tops of 20 women with clinically proven NIDDM and 122 healthy controls matched by age group were measured. In this paper, we describe the precise SAT-Top differences of these two groups and present the multidimensional SAT-Top information condensed in a two-dimensional factor plot and in a response plot of an artificial neural network. NIDDM women provide significantly lower leg SAT-Top and significantly higher upper trunk SAT-Top development ("apple"-type) compared with their healthy controls.

Artificial neural networks as a method to improve the precision of subcutaneous adipose tissue thickness measurements by means of the optical device LIPOMETER.

The LIPOMETER is an optical device for measuring the thickness of a subcutaneous adipose tissue layer. It illuminates the interesting layer, measures the backscattered light signals and from these, it computes absolute values of subcutaneous adipose tissue layer thickness (in mm). Previously, these light pattern values were fitted by nonlinear regression analysis to absolute values provided by computed tomography. Nonlinear regression analysis might provide slight limitations for our problem: a selected curve type cannot be changed afterwards during the application of the measurement device. Artificial neural networks yield a more flexible approach to this fitting problem and might be able to refine the fitting results. In the present paper we compare nonlinear regression analysis with the behaviour of different architectures of multilayer feed forward neural networks trained by error back propagation. Specifically, we are interested whether neural networks are able to yield a better fit of the LIPOMETER light patterns to absolute subcutaneous adipose tissue layer thicknesses than the nonlinear regression techniques. Different architectures of these networks are able to surpass the best result of regression analysis in training and test, providing higher correlation coefficients, regression lines with absolute values obtained from computed tomography closer to the line of identity, decreased sums of absolute and squared deviations, and higher measurement agreement.

Dynamic renal function testing by compartmental analysis: assessment of renal functional reserve in essential hypertension.

BACKGROUND: In essential hypertension, acute haemodynamic changes due to dietary protein load cause patterns of acute changes in renal function that are fundamentally different from changes in normal controls. METHODS: Renal clearances of sinistrin, an inulin-like polyfructosan, and p-aminohippurate were determined before and after protein ingestion. These tests were performed in healthy controls and in patients with essential hypertension (mean arterial pressure of 112+/-2 mmHg, age, 52+/-2 years; mean+/-SEM) within a washout period, and after long-term treatment with carvedilol and fosinopril, respectively. RESULTS: In 15 healthy volunteers, protein ingestion increased glomerular filtration rate (GFR) from 110.3+/-3.6 to 120. 6+/-4.4 ml/min (P=0.0006; two-tailed pairwise t-test). In contrast, it led to an acute decrease in GFR in 16 hypertensive patients, from 111.8+/-2.9 to 103.6+/-3.3 ml/min (P=0.0010). The eight patients who were randomized to receive carvedilol improved in their renal response to protein (GFR increased from 101.4+/-6.4 to 107.1+/-5.4 ml/min; P=0.04), whereas the eight other patients randomized to receive fosinopril exhibited no change in GFR (final value 105+/-4.9 ml/min). In the patients, the acute shifts in renal plasma flows were not significant. Mean arterial blood pressure of the patients decreased from 112+/-2 to 100+/-3 mmHg (P=0.0015). CONCLUSIONS: In essential hypertension an acute protein load induces a decrease in GFR that may normalize under antihypertensive treatment. The acute changes in GFR can be reliably monitored by the here-described compartmental analysis method of renal functional reserve.

Quantifying the 'appleness' or 'pearness' of the human body by subcutaneous adipose tissue distribution.

To quantify subcutaneous adipose tissue topography (SAT-Top) describing individual SAT distribution for a subject or even a group we measured subcutaneous adipose tissue thickness at 15 specified body sites of 303 healthy women aged 20-69 yrs and 20 women with proven non-insulin-dependent diabetes mellitus (NIDDM) by the optical device 'LIPOMETER'. The type of upper-body- and lower-body-fat pattern, (apples or pears), was determined by factor analysis of the data. Upper body sites were highly loaded in factor 1, whereas factor 2 included highly loaded body sites from the lower extremities. For an individual, factor 1 scores > factor 2 scores, was described as an 'apple'-type, while factor 2 > factor 1 was described as a 'pear'-type. We found about 80% 'pears' and 20% 'apples' in 20-29 year olds and 20% 'pears' and 80% 'apples' in 60-69 year old women. Women with NIDDM tended to be 'super-apples'. SAT-Top provides a useful differentiation between apples and pears and we recommend this approach as a screening method.

Hyperhomocysteinemia in dementia.

Hyperhomocysteinemia is a strong risk factor for atherosclerotic vascular disease, and elevated serum homocysteine is correlated with vitamin B deficiency. In this pilot study, significantly elevated homocysteine levels were found in patients with Alzheimer's disease as well as in patients with vascular dementia, probably indicating similar pathophysiological pathways. We found significant correlations between low folic acid concentrations as well as high homocysteine concentrations and cognitive decline. Supplementation with folic acid may be an inexpensive way to reduce elevated homocysteine levels in demented patients.

Artificial neural networks in laboratory medicine and medical outcome prediction.

Since the early nineties the number of scientific papers reporting on artificial neural network (ANN) applications in medicine has been quickly increasing. In the present paper, we describe in some detail the architecture of network types used most frequently in ANN applications in the broad field of laboratory medicine and clinical chemistry, present a technique-structured review about the recent ANN applications in the field, and give information about the improvements of available ANN software packages. ANN applications are divided into two main classes: supervised and unsupervised methods. Most of the described supervised applications belong to the fields of medical diagnosis (n = 7) and outcome prediction (n = 9). Laboratory and clinical data are presented to multilayer feed-forward ANNs which are trained by the back propagation algorithm. Results are often better than those of traditional techniques such as linear discriminant analysis, classification and regression trees (CART), Cox regression analysis, logistic regression, clinical judgement or expert systems. Unsupervised ANN applications provide the ability of reducing the dimensionality of a dataset. Low-dimensional plots can be generated and visually understood and compared. Results are very similar to that of cluster analysis and factor analysis. The ability of Kohonen's self-organizing maps to generate 2D maps of molecule surface properties was successfully applied in drug design.

Formation of oxygen radicals in solutions of 7,8-dihydroneopterin.

Neopterin and 7,8-dihydroneopterin, two compounds which are secreted by activated macrophages, have been shown to interfere with radicals generated by cellular and certain chemical systems. Reduced pterins were reported to scavenge whereas aromatic pterins promoted or reduced radical mediated reactions or had no effect. However, recently it was found that high concentrations of 7, 8-dihydroneopterin enhanced luminol dependent chemiluminescence and T-cell apoptosis, suggesting an enhancement of free radical formation. In this study hydroxylation of salicylic acid was used for detection of hydroxyl radicals. It is shown that in solutions of 7,8-dihydroneopterin hydroxyl radicals were formed in the absence of any radical source. The presence of EDTA chelated iron enhanced hydroxyl radical formation. Whereas the addition of iron accelerated the hydroxylation reaction, 7,8-dihydroneopterin was responsible for the amount of hydroxylation products. In the presence of superoxide dismutase or catalase, as well as by helium purging, hydroxylation was inhibited. Our data suggest that in solutions of 7, 8-dihydroneopterin superoxide radicals are generated which are converted to hydroxyl radicals by Fenton or Haber-Weiss type reactions. While superoxide might be generated during autoxidation of ferrous iron, dihydroneopterin seems to be involved in regeneration of ferrous iron from the ferric form.

The determination of three subcutaneous adipose tissue compartments in non-insulin-dependent diabetes mellitus women with artificial neural networks and factor analysis.

The optical device LIPOMETER allows for non-invasive, quick, precise and safe determination of subcutaneous fat distribution, so-called subcutaneous adipose tissue topography (SAT-Top). In this paper, we show how the high-dimensional SAT-Top information of women with type-2 diabetes mellitus (non-insulin-dependent diabetes mellitus (NIDDM)) and a healthy control group can be analysed and represented in low-dimensional plots by applying factor analysis and special artificial neural networks. Three top-down sorted subcutaneous adipose tissue compartments are determined (upper trunk, lower trunk, legs). NIDDM women provide significantly higher upper trunk obesity and significantly lower leg obesity ('apple' type), as compared with their healthy control group. Further, we show that the results of the applied networks are very similar to the results of factor analysis.