The antifibrogenic effect of etanercept on development of liver cirrhosis induced by thioacetamide in rats.

Liver cirrhosis is an elevating cause of morbidity and mortality worldwide. TNF-α/TNF-R1 signal is implicated in progression of many liver diseases. This study provides histological and ultrastructural view that clarifies the effect of etanercept, a TNF-α inhibitor, on development of thioacetamide (TAA)-induced liver cirrhosis and the accompanied hemosiderosis in rats, highlighting the implication and distribution pattern of hepatic TNF-R1. Sixty male albino rats (Rattus norvegicus) were equally randomized into three groups. Group I served as the control. Liver cirrhosis was triggered in the other two groups by intraperitoneal injection of TAA twice a week for five months. Group II received TAA only, while group III subcutaneously injected with etanercept one hour before TAA, along five months. At the end of the experiment, blood was collected for biochemical analysis and livers were excised for histological, immunohistochemical, and electron microscopical preparations. Rats treated with TAA only developed hepatic cirrhosis accompanied by massive deposition of hemosiderin; strong and widespread expression of hepatic TNF-R1 in sinusoidal endothelial cells (SECs), Kupffer cells (KCs), and many hepatocytes; and frequent appearance of fibrogenic, plasma, and mast cells, at the ultrastructural level. By contrast, administration of etanercept diminished the expression of TNF-R1, attenuated the accumulation of collagen and hemosiderin, and preserved the hepatic histoarchitecture. In conclusion, TNF-α signal via TNF-R1 may be implicated in the mechanism of fibrogenesis and the associated hemosiderosis. Etanercept may provide a promising therapeutic approach not only for attenuating the progression of fibrogenesis, but also for hepatic iron overload-associated disorders.

Multiparametric Cardiac Magnetic Resonance Survey in Children With Thalassemia Major: A Multicenter Study.

BACKGROUND: Cardiovascular magnetic resonance (CMR) plays a key role in the management of thalassemia major patients, but few data are available in pediatric population. This study aims at a retrospective multiparametric CMR assessment of myocardial iron overload, function, and fibrosis in a cohort of pediatric thalassemia major patients. METHODS AND RESULTS: We studied 107 pediatric thalassemia major patients (61 boys, median age 14.4 years). Myocardial and liver iron overload were measured by T2* multiecho technique. Atrial dimensions and biventricular function were quantified by cine images. Late gadolinium enhancement images were acquired to detect myocardial fibrosis. All scans were performed without sedation. The 21.4% of the patients showed a significant myocardial iron overload correlated with lower compliance to chelation therapy (P<0.013). Serum ferritin ≥2000 ng/mL and liver iron concentration ≥14 mg/g/dw were detected as the best threshold for predicting cardiac iron overload (P=0.001 and P<0.0001, respectively). A homogeneous pattern of myocardial iron overload was associated with a negative cardiac remodeling and significant higher liver iron concentration (P<0.0001). Myocardial fibrosis by late gadolinium enhancement was detected in 15.8% of the patients (youngest children 13 years old). It was correlated with significant lower heart T2* values (P=0.022) and negative cardiac remodeling indexes. A pathological magnetic resonance imaging liver iron concentration was found in the 77.6% of the patients. CONCLUSIONS: Cardiac damage detectable by a multiparametric CMR approach can occur early in thalassemia major patients. So, the first T2* CMR assessment should be performed as early as feasible without sedation to tailor the chelation treatment. Conversely, late gadolinium enhancement CMR should be postponed in the teenager age.

Low prevalence of cardiac siderosis in heavily iron loaded Egyptian thalassemia major patients.

Myocardial siderosis in thalassemia major remains the leading cause of death in developing countries. Once heart failure develops, the outlook is usually poor with precipitous deterioration and death. Cardiovascular magnetic resonance (CMR) can measure cardiac iron deposition directly using the magnetic relaxation time T2*. This allows earlier diagnosis and treatment and helps to reduce mortality from this cardiac affection. This study aims to determine the prevalence of cardiac siderosis in Egyptian patients who are heavily iron loaded and its relation to liver iron concentration, serum ferritin, and left ventricular ejection fraction. Eighty-nine ß-thalassemia patients receiving chelation therapy (mean age of 20.8 ± 6.4 years) were recruited in this study. Tissue iron levels were determined by CMR with cardiac T2* and liver R2*. The mean ± standard deviation (range) of cardiac T2* was 28.5 ± 11.7 ms (4.3 to 53.8 ms), the left ventricular ejection fraction (LVEF) was 67.7 ± 4.7 % (55 to 78 %), and the liver iron concentration (LIC) was 26.1 ± 13.4 mg Fe/g dry weight (dw) (1.5 to 56 mg Fe/g dw). The mean serum ferritin was 4,510 ± 2,847 ng/ml (533 to 22,360 ng/ml), and in 83.2 %, the serum ferritin was >2,500 ng/ml. The prevalence of myocardial siderosis (T2* of <20 ms) was 24.7 % (mean age 20.9 ± 7.5 years), with mean T2* of 12.7 ± 4.4 ms, mean LVEF of 68.6 ±5.8 %, mean LIC of 30.9 ± 13 mg Fe/g dw, and median serum ferritin of 4,996 ng/ml. There was no correlation between T2* and age, LVEF, LIC, and serum ferritin (P = 0.65, P = 0.085, P = 0.99, and P = 0.63, respectively). Severe cardiac siderosis (T2* of <10 ms) was present in 7.9 %, with a mean age of 18.4 ± 4.4 years. Although these patients had a mean T2* of 7.8 ± 1.7 ms, the LVEF was 65.1 ± 6.2 %, and only one patient had heart failure (T2* of 4.3 ms and LVEF of 55 %). LIC and serum ferritin results were 29.8 ± 17.0 mg/g and 7,200 ± 6,950 ng/ml, respectively. In this group of severe cardiac siderosis, T2* was also not correlated to age (P = 0.5), LVEF (P = 0.14), LIC (P = 0.97), or serum ferritin (P = 0.82). There was a low prevalence of myocardial siderosis in the Egyptian thalassemia patients in spite of very high serum ferritin and high LIC. T2* is the best test that can identify at-risk patients who can be managed with optimization of their chelation therapy. The possibility of a genetic component for the resistance to cardiac iron loading in our population should be considered.

Predicted costs of iron-chelators in myelodysplastic syndromes: a 10-year analysis based on actual prevalence and red cell transfusion rates.

Consideration of iron-chelation (IC) in transfusion-dependent patients is recommended in most clinical-practice guidelines on myelodysplastic syndromes (MDS). The financial impact of IC on health-care systems is predicted through economic modeling, but an analysis based on actual prevalence is lacking. Here, we have investigated the potential drug-costs and need for IC in a cohort of 189 United Kingdom-based MDS patients diagnosed from 2000 to 2010. Patients with low or intermediate-1 IPSS scores were identified as eligible for IC if ≥24 red cell units (RCU) had been transfused over 12 consecutive months or the transfusion-intensity averaged ≥2 RCU per month. Drug-costs were calculated from the time patients qualified for IC until death or last follow-up. In 159 patients with low/intermediate-1 MDS, survival was superior with a low IPSS score (P = 0.014), age <70 years (P = 0.043), transfusion-independence at diagnosis (P = 0.0056) and transfusion-intensity of <2 RCU per month (P = 0.009). Reflecting the time elapsed since diagnosis, longer survival was observed with a cumulative red cell load of ≥75 U (P = 0.046). By logistic-regression analysis, transfusion-intensity independently predicted survival (P = 0.0035) in low and intermediate-1 risk MDS patients. Forty-one patients fulfilled criteria for consideration of IC. Of these, 6 patients died within 1 month; 35 patients survived for a median of 16 months (range 1-61). Had patients commenced IC, the anticipated drug-costs alone would have been ~$526,880-$2,064,800 over 10 years. The lack of association between cumulative transfusion-load and survival calls for a prospective evaluation of the cost-utility of IC in patients surviving long-term, to enable evidence-based recommendations in MDS management.

Grape seed extract alleviates high-fat diet-induced obesity and heart dysfunction by preventing cardiac siderosis.

Obesity is a tremendous public health problem, characterized by ectopic accumulation of fat into non-adipose tissues, leading to oxidative stress and chronic inflammation, in which the heart is the most severely affected organ. We used an experimental model of high-fat-diet (HFD)-induced obesity to analyze the link between oxidative stress and heart dysfunction. We also studied the cardioprotective effect of a grape seed and skin extract (GSE). Exposure of rats to HFD during 45 days induced heart hypertrophy, inflammation as assessed by plasma CRP elevation and contractile dysfunction as revealed after ischemia/reperfusion of Langendorff-perfused hearts. HFD also induced cardiac steatosis and lipotoxicity, which are linked to an oxidative stress status, worsened by increased siderosis and resulting in Ca(2+) overload. Importantly, GSE alleviated all the deleterious effects of HFD treatment. These studies suggest that GSE is a safe anti-obesity and cardioprotective agent that should also find potential applications in other inflammatory damaging conditions as stroke.

Combination therapy with interferon and ribavirin for chronic hepatitis C infection in beta-thalassaemia major.

Treatment of chronic hepatitis C virus (HCV) infection in transfusion-dependent beta-thalassaemia major patients is complicated by existing hepatic siderosis and the fear of ribavirin-associated haemolysis. We evaluated the efficacy and side-effects of combination interferon-alpha (INF) and ribavirin therapy for HCV-infected thalassaemia patients. A total of 17 patients were enrolled (10 nonresponders to INF monotherapy, 7 naive to treatment, mean age 23.1 years) and they received 12 months of combination therapy. The sustained virological response rate 6 months after treatment was 58.8%. Blood transfusion requirements during treatment temporarily increased by 36.6%. Combination therapy was tolerated by, and may be useful for, HCV-infected thalassaemia major patients.

[Modified hemispherectomy for intractable epilepsy in patients with infantile hemiplegia].

OBJECTIVE: To explore the effectiveness of modified hemispherectomy for intractable epilepsy in patients with infantile hemiplegia. METHODS: Eighteen cases of patients were treated with modified hemispherectomy and the effectiveness was studied and followed up. RESULTS: The seizures in all 18 cases of patients were controlled effectively and stopped completely in 16 cases of them, without nervous disfunction worsened. The patients' cerebral peduncles on healthy side were much thicker than those on sick side (t = 58.32, P < 0.001) and healthy peoples' (t = 14.63, P < 0.001) and the patients' cerebral peduncles on sick side were much thinner than those of healthy peoples' (t = 51.27, P < 0.001). CONCLUSION: The modified hemispherectomy can effectively control the seizures of patients with infantile hemiplegia without superficial cerebral hemosiderosis happened.

Transfusional hemosiderosis and combined chelation therapy in sickle thalassemia.

Although the indications for transfusions in sickle cell syndromes are well listed, and chronic transfusion has become practicable since the recent advances in chelation therapy have essentially eliminated the risk of secondary iron overload, multi-transfused, non-compliant to long-term chelation therapy patients confront the complication of iron overload and secondary hemosiderosis. In thalassemia major patients, combined therapy with desferrioxamine and deferiprone has maximized tissue iron removal and may reduce the overall occurrence of hemosiderotic heart failure. Despite this, safety and contradictions of chelating agents are still controversial. The aim of this report is to present the results of this combination in a long-term transfused sickle beta-thalassemic patient suffering from severe heart failure and liver dysfunction.

Increased iron absorption in lemurs: quantitative screening and assessment of dietary prevention.

Iron storage disease (ISD) in lemurs has been reported since as early as the 1960s, and in the 1980s was demonstrated to be a consistent finding in postmortem investigations of captive lemurs. Since then this disease has consistently been diagnosed at the point of necropsy. In the current study we describe a preclinical screening procedure, as well as the quantified preventive effects of dietary intervention upon iron absorption. Twenty-three individual lemurs of four species were initially tested with the transferrin saturation test (%TS); 21 of these animals were on conventional zoo diets, and two were fed a specific diabetic diet. Initially, 20 of 21 lemurs on conventional zoo diets were demonstrated to have %TS levels above the normal range for humans; 17 of these lemurs were in the category (for humans) of excessive iron absorption. A dietary change aimed at reducing dietary iron and vitamin C levels and increasing the levels of iron-chelating tannins and/or phytates was instigated. After the animals were retested, a matched-pair comparison of %TS values before and after the diet change revealed significantly (P=0.038, n=7) lower %TS values after the diet change. All species averages were in the human hyperabsorption range on conventional zoo diets (n=21). No species averages were in that range after the dietary change (n=18). The results indicate that further investigations into the use of %TS testing in lemur husbandry, and specific preventive dietary measures, should be conducted.

Effective use of tea to limit dietary iron available to starlings (Sturnus vulgaris).

Wild-caught starlings (Sturnus vulgaris) were fed an iron-enriched diet, with or without supplemental black tea leaves, to determine whether tea-derived tannins would prevent intestinal iron absorption. Hepatic biopsies were obtained to determine hepatic iron concentrations by atomic absorption spectroscopy. Hepatic iron concentrations increased significantly (P = 0.04) in 21 birds that consumed only the iron-enriched diet for 6 mo but not in the 20 birds that consumed the iron-enriched diet with tea leaf supplementation for the same time period.

[Surgical treatment for pediatric intractable epilepsy--focusing on modified functional hemispherectomy in infants].

Our experience with modified functional hemispherectomy in 14 infants are presented. The etiology of intractable epilepsy was cortical dysgenesis in all of the cases. We applied our new surgical method, transopercular hemispherotomy, in which the frontal operculum was resected en bloc including the upper half of the insula. The corpus callosum was totally sectioned through the lateral ventricle. The resection cavity was communicated to the inferior ventricle, and the medial temporal structures were resected. Finally, the horizontal fibers emerging from the frontal lobe were sectioned along the posterior edge of the ala minor ossis sphenoidalis. There was no mortality or morbidity during and immediately after operation. In 12 cases with more than 1 year follow-up, remarkable seizure reduction was obtained in 75% of the cases and worthwhile improvement in the remaining 25%. No major complications were encountered, except for hydrocephalus in 3 cases and incomplete section of the callosum in 3. In cases showing catch-up of psychomotor development after surgery, swelling of the unaffected hemisphere was observed.

Kidney iron status in passive Heymann nephritis and the effect of an iron-deficient diet.

In the study presented here, the iron status in the kidney in passive Heymann nephritis, a complement-dependent model of membranous nephropathy, was examined. To examine whether the effect of immune injury on iron status has a pathogenic role, the effect of an iron-deficient diet was also determined. Injection of the anti-Fx1A antibody (10 mg/100 g body wt) in Sprague-Dawley rats resulted in no change in the serum iron level, a marked increase in the urinary excretion rate of iron, a marked increase in non-heme iron content of kidney cortex, and a marked increase in the non-heme iron level in tubules. These increases in iron were prevented by feeding the rats an iron-deficient diet. In the rats fed a normal iron diet and injected with anti-Fx1A-lgG, there was no significant change in the non-heme iron level in glomeruli. However, an iron-deficient diet resulted in a significant decrease in the non-heme iron level in glomeruli, compared with its respective control. In addition, an iron-deficient diet significantly reduced urinary protein excretion rate (Day 5: iron-replete, 68 +/- 12 mg/24 h, N = 12; iron-deficient, 36 +/- 11, N = 10, P < 0.05) in the complement-dependent immune phase of the glomerular injury. Taken together, these data indicate a marked alteration in the iron status in the kidney and suggest an important role of iron in glomerular injury of passive Heymann nephritis.

Antioxidant activity of silybin in vivo during long-term iron overload in rats.

BACKGROUND & AIMS: Hepatic iron toxicity may be mediated by free radical species and lipid peroxidation of biological membranes. The antioxidant property of silybin, a main constituent of natural flavonoids, was investigated in vivo during experimental iron overload. METHODS: Rats were fed a 2.5% carbonyl-iron diet and 100 mg.kg body wt-1.day-1 silybin for 4 months and were assayed for accumulation of hepatic lipid peroxidation by-products by immunocytochemistry, mitochondrial energy-dependent functions, and mitochondrial malondialdehyde content. RESULTS: Iron overload caused a dramatic accumulation of malondialdehyde-protein adducts into iron-filled periportal hepatocytes that was decreased appreciably by silybin treatment. The same beneficial effect of silybin was found on the iron-induced accumulation of malondialdehyde in mitochondria. As to the liver functional efficiency, mitochondrial energy wasting and tissue adenosine triphosphate depletion induced by iron overload were successfully counteracted by silybin. CONCLUSIONS: Oral administration of silybin protects against iron-induced hepatic toxicity in vivo. This effect seems to be caused by the prominent antioxidant activity of this compound.

Hemisferectomia: modificaçäo técnica / Hemisferectomy: a techinical modification

Os autores relatam uma modificaçäo técnica nas hemisferectomias totais, com intuito de prevenir os sangramentos tardios e distorçöes cerebrais