Aculebiphenyl A-B, new biphenyl derivatives from Ruscus aculeatus.

The investigation of chemical constituents from the rhizomes of Ruscus aculeatus resulted in the isolation of two new biphenyl derivatives, aculebiphenyls A and B (1-2), together with two known analogs (3-4). Their chemical structures were elucidated based on extensive spectroscopic interpretation and HR-ESI-MS analysis. Compounds 3-4 were isolated from the Ruscus genus for the first time. The isolated compounds were tested for anti-inflammatory activities and antibacterial activities. Compound 1 exhibited significant inhibitory effects on LPS-induced NO production and COX-2 with IC50 values of 10.8 µM and 0.4 µM. Compound 1 also significantly down-regulated the levels of inflammatory cytokines IL-1ß, IL-6, and TNF-α. Compound 1 showed moderate antibacterial activities.

Drugs containing extracts from Ruscus in chronic venal disease therapy - what's new we know about their effects?

Pharmacotherapy of venous insufficiency is based on the use of drugs which, through their mechanism of action, contribute to the complex pathomechanism of this disease. One of the drugs used in the treatment of CVD are extracts of Ruscus. Numerous studies have demonstrated a multidirectional mechanism of action involving the effect of the drug on the adrenergic and cholinergic systems and the intracellular calcium metabolism. All these mechanisms are responsible for the multidirectional mechanism of action of the drug.

Lymphotonic activity of Ruscus extract, hesperidin methyl chalcone and vitamin C in human lymphatic smooth muscle cells.

OBJECTIVE: Besides actions including their venotonic, anti-inflammatory, and anti-oxidant effects, venoactive drugs are expected to act on edema via their action on lymphatics. The objective of this study was to evaluate the effect of the combination of Ruscus, hesperidin methyl chalcone and Vitamin C (Ruscus/HMC/Vit C) on intracellular calcium mobilization and contraction of human lymphatic smooth muscle cells (LSMCs) to better characterize the mechanism of its lymphotonic activity. METHODS: Calcium mobilization was evidenced by videomicroscopy analysis of the fluorescence emitted by a specific Ca2+ sensitive dye and measured after injection of Ruscus/HMC/Vit C at 0.1, 0.3, 1.0, and 3.0 mg/mL into LSMCs. RESULTS: Ruscus/HMC/Vit C induced a strong and reproducible concentration-dependent calcium mobilization in LSMCs. On the contrary, another venoactive drug used as comparator, micronized purified flavonoid fraction (MPFF), did not induce calcium mobilization whatever the tested concentration. CONCLUSION: Although alternative mechanisms of action may result in potential lymphotonic effects, the efficacy of lymphotonic products is nonetheless related to their stimulating effect on the contractile activity of the smooth muscle cells surrounding lymphatic vessels. In the light of the results obtained in this study, the direct effect of Ruscus/HMC/Vit C on LSMC contraction may partially explain its clinical efficacy on lymphotonic activity, as has been observed in terms of objective signs of edema as reported in the recent guidelines on chronic venous disease.

[Efficacy of combination of needle extract, hesperidin and vitamin C in treatment of chronic venous diseases]. / Éffektivnost' kombinatsii ékstrakta iglitsy, gesperidina i vitamina S v lechenii khronicheskikh zabolevanii ven.

BACKGROUND: In Russia, physicians are virtually unaware of drugs based on needle extract. However, abroad, saponins and, in particular, a combined preparation containing needle extract, hesperidin and vitamin C is one of drugs of choice, if not the leading medication in treatment of venous oedemas and other venous symptoms. AIM: The authors conducted a systematic review of the Russian-and English-language literature using the following search terms: saponins, hesperidin, needle, ruscus, ruscogenin (and their Russian equivalents), each of which was entered in a combination with the word 'venous' or its Russian equivalent, respectively. RESULTS: Ruscogenin and neoruscogenin from the root of needle possess anti-inflammatory properties and induce venous wall contraction, thus making it possible to use needle extract in treatment of chronic venous insufficiency. It was experimentally determined that needle extract stimulates vein contractility, decreasing permeability of the venous wall, influencing extracellular matrix proteins, inhibiting leukocyte migration through regulation of both proteins and matrix ribonucleic acid. Analysed herein are the results of original studies of a combination of needle extract, flavonoid hesperidin methyl chalcone and ascorbic acid, also examining in detail the mechanism of action conditioned by synergism of pharmacological effects of these components. This is followed by discussing the place of saponins in the classification of phlebotropic drugs and comparing efficacy of needle root extract with that of other phlebotonics. CONCLUSION: It was experimentally determined that a combination of needle extract, hesperidin and vitamin C possesses multiple additive phlebotropic effects. According to clinical trials, it leads to relief of most symptoms and a decrease in the ankle volume (high level of evidence 1A), being not inferior by clinical efficiency and duration of action to the best-known flavonoids, whereas by the venotonizing effect, decreased permeability of the vascular wall, and inhibition of leukocytic aggression even superior thereto. Further experimental and clinical studies of efficacy of this combination for various forms of chronic venous diseases and venous thromboses are warranted.

Phenolic Compounds and Bioactive Properties of Ruscus aculeatus L. (Asparagaceae): The Pharmacological Potential of an Underexploited Subshrub.

Ruscus aculeatus L. is a subshrub used in traditional medicine in different parts of the world, namely in Europe and the Iberian Peninsula. According to reported folk knowledge, the aerial parts are mainly used as diuretics and the underground organs are used for the treatment of disorders of the urinary system and as a laxative. In this work, the aerial part and the roots and rhizomes of R. aculeatus were chemically characterized with regard to the content of phenolic compounds and bioactive properties. Aqueous (infusions and decoctions) preparations and hydroethanolic extracts from the two mentioned parts of the plant were prepared. Nine phenolic compounds were detected in all the extracts. Apigenin-C-hexoside-C-pentoside isomer II was the major compound in aqueous extracts and, in the hydroethanolic extract was quercetin-O-deoxyhexoside-hexoside followed by apigenin-C-hexoside-C-pentoside isomer II. All extracts revealed antioxidant activity and potential to inhibit some of the assayed bacteria; aqueous extracts of the aerial part and infusions of roots and rhizomes did not show cytotoxic effects on a non-tumor primary cell culture. This preliminary study provides suggestions of the biological potential associated with the empirical uses and knowledge of this species, in particular its bioactivities.

Effects of Ruscus extract on muscarinic receptors: Is there a role for endothelium derived relaxing factors on macromolecular permeability protection and microvascular diameter changes?

BACKGROUND: Protective effects of Ruscus extract on macromolecular permeability depend on its capacity to stimulate muscarinic receptors on endothelial cells and induce the release of endothelium derived relaxing factors (EDRFs). OBJECTIVE: To investigate if these effects depend only on activation of muscarinic receptors or if EDRFs release are also necessary. We have also investigated the participation of Ruscus extract on muscarinic-induced release of EDRFs on microvascular diameters. METHODS: Hamsters were treated daily during two weeks with Ruscus extract (50, 150 and 450 mg/kg/day) and then macromolecular permeability induced by histamine and arteriolar and venular diameters after cyclooxygenase (COX) and nitric oxide synthase (NOS) inhibitors: indomethacin and Nω-Nitro-L-arginine (LNA), respectively applied topically at 10-8M, 10-6M and 10-4M were observed on the cheek pouch preparation. RESULTS: Ruscus extract decreased macromolecular permeability in a dose-dependent fashion and did not affect microvascular diameters. NOS and COX inhibitors enhanced its effect on microvascular permeability. NOS inhibition reduced arteriolar diameter and COX blocking decreased arteriolar and venular diameters at the lowest dose and increased them at higher doses of Ruscus extract. CONCLUSION: The protective effect of Ruscus extract on macromolecular permeability seems to be mediated only via muscarinic receptors. Muscarinic activation attenuated vasoconstrictive tone through cyclooxygenase-independent endothelium derived relaxing factors.

Ruscus hypophyllum L. extracts: chemical composition, antioxidant, anticoagulant, and antimicrobial activity against a wide range of sensitive and multi-resistant bacteria.

The aim of this study is to evaluate the polyphenolic and flavonoid contents in the leaves extracts of Ruscus hypophyllum. Antioxidant activity was estimated by α,α-diphenyl-ß-picrylhydrazyl (DPPH) and 2,2'-azino-bis-3-ethylbenzthiazoline-6-sulfonic acid (ABTS) assays. The anticoagulant activity of Ruscus extracts was evaluated in vitro, using the prothrombin time (PT) and a PTT-activated partial thromboplastin time tests. The antibacterial activity was tested against large number of important medically and resistant bacteria by the broth dilution method. In this study, ethyl acetate and chloroform extracts displayed the highest total phenols contents (74.76 mg EAG/g and 73.89 mg EAG/g, respectively) and flavonoid content 40 and 32.43 mg EC/g, respectively. The GC-MS analysis of ethyl acetate extract confirmed the presence of oxygenated sesquiterpenes and hydrocarbon diterpenes with percentages of 16.41% and 10.72%, respectively, but chloroform extract was rich with, oxygenated monoterpenes, and oxygenated diterpenes, with percentages of 6.19 and 3.27%, respectively. Among tested extracts, ethyl acetate exhibited the best antioxidant and anticoagulant activities. Furthermore, ethyl acetate and chloroform extracts showed important antibacterial activity against resistant bacteria methicillin-resistant Staphylococcus aureus (SARM), Acinetobacter imipenem-resistant (IMP/R), P. aeruginosa imipenem-resistant (IMP/R) and extended-spectrum beta-lactamase producing E. cloacae (BLSE) with minimal inhibitory concentration (MIC) values varying between 0.125 and 0.5 mg/mL.

CEAP clinical classes C0S-C4: differences, similarities and role of Ruscus + HMC + vitamin C in patients with chronic venous disease.

Since the publication of the CEAP classification, new research has enriched our knowledge; notably on the heritability of CVD and the genetic and environmental factors involved in this condition, as well as the symptoms apparent within the spectrum of the CEAP clinical classes and the benefits of medical treatment. Using the CEAP classification as a special theme, a symposium with the same title as the present paper was held at the annual meeting of the 2019 European Venous Forum. The lectures presented much valuable information, from which some key points can be extracted. The influence of environmental factors was demonstrated, and the fact that a large amount of information can be obtained from comprehensive history taking. There is robust evidence for heritability. Many candidate genes/loci have been identified, potentially offering new targets for treatment. More research is needed, notably using genome-wide association studies and also on microbiota, which may play a role in CVD through the inflammation pathway. Ruscus + HMC + vitamin C acts by increasing venous and lymphatic tone, protecting microcirculation, and reducing inflammation. It improves quality of life in C0S to C3 CVD patients, while a review of clinical studies and a meta-analysis have confirmed its clinical efficacy across a wide spectrum of CVD clinical classes: C0S, C1S, C2, C3 and C4. It has been awarded a Grade 1A recommendation by the international guidelines.

Bone protective effects of purified extract from Ruscus aculeatus on ovariectomy-induced osteoporosis in rats.

Ruscus aculeatus is a source of steroidal saponins that could mimic sex hormones and could help alleviate the risk of fracture in osteoporotic patients. The aim of the present study was to evaluate the in vitro effects of an extract from R. aculeatus (ERA) on the proliferation of human osteoblast-like SaOS-2 cell line and to investigate the effects of the ERA administered orally for 10 weeks at three doses (50, 100 and 200 mg/kg) on the bone structure of rats with estrogen deficiency induced by bilateral ovariectomy. Bone turnover markers, hormones, histopathological and radiological disturbances were evidenced in the ovariectomized rats. ERA recovered most of the affected parameters in a dose-dependent manner similar to diosgenin and alendronate used as positive comparators. The main active compounds of ERA (ruscogenin and neoruscogenin) were docked into the Vit. D receptor and oestrogen receptors alpha and beta, and stable complexes were found with binding scores equal to those of estradiol and diosgenin. The findings of this study provide for the first time an insight into the effects of ERA on bone structure and suggest that ERA could be developed as a potential candidate for the prevention of postmenopausal osteoporotic complications.

Antiproliferative and pro-apoptotic activities of wild asparagus (Asparagus acutifolius L.), black bryony (Tamus communis L.) and butcher's broom (Ruscus aculeatus L.) aqueous extracts against T24 and A549 cancer cell lines.

The aim of this study was to determine the phenolic profile, antiproliferative, and pro-apoptotic activities of Asparagus acutifolius, Tamus communis, and Ruscus aculeatus aqueous extracts against human bladder (T24) and lung cancer (A549) cell lines. Antiproliferative activity of the extracts at the concentration range from 0.5 to 4 mg/ml was measured by MTT test, after the incubation period of 4, 24, 48, or 72 hr. Pro-apoptotic activity of selected plant extracts against T24 and A549 cells was analyzed by flow cytometry at the concentrations of 0.5, 1, and 2 mg/ml. The highest antiproliferative activity against both cancer cell lines was detected by T. communis aqueous extract. The highest pro-apoptotic effect was achieved by A. acutifolius aqueous extract and its effect was similar against A549 and T24 cells. PRACTICAL APPLICATIONS: Wild edible plants, such as wild asparagus, black bryony, and butcher's broom represent important aspect of the Mediterranean diet. They are rich source of various natural bioactive compounds which express different biological activities (antioxidative, antiproliferative, antibacterial, anti-inflammatory…). The current trend for natural and healthy diet, such as the Mediterranean diet, is in relation to the rapidly growing problem of chronic diseases in a modern society. Wild edible plants have a high direct-use value using them in dishes containing mixed vegetables, in soup preparation, as natural additives in fermented natural products containing cheese or fish, in water infusions (natural drinks).

Biotechnological production of ruscogenins in plant cell and organ cultures of Ruscus aculeatus.

Ruscus aculeatus is a threatened medicinal plant whose main bioactive components, the ruscogenins, have long been used in the treatment of hemorrhoids and varicose veins, but recently demonstrated activity against some types of cancer. Plant cell biofactories could constitute an alternative to the whole plant as a source of ruscogenins. In this pipeline, despite the in vitro recalcitrance of R. aculeatus, after many attempts we developed friable calli and derived plant cell suspensions, and their ruscogenin production was compared with that of organized in vitro plantlet and root-rhizome cultures. Root-rhizomes showed a higher capacity for biomass and ruscogenin production than the cell suspensions and the yields were greatly improved by elicitation with coronatine. Although ruscogenins accumulate in plants mainly in the root-rhizome, it was demonstrated that the aerial part could play an important role in their biosynthesis, as production was higher in the whole plant than in the root-rhizome cultures.

Chronic venous disease: from symptoms to microcirculation.

The recently published European Venous Forum (EVF) Guidelines 2018 update on the management of chronic venous disorders of the lower limbs has focused on several new aspects: a new place for early symptoms, new data on microcirculation alterations, and a re-evaluation of veno-active drugs (VADs), based on new criteria. The symposium "Chronic Venous Disease (CVD): From Symptoms to Microcirculation", held at the annual meeting of the EVF on 28 June 2018 in Athens, Greece, highlighted this perspective by answering three questions: What do symptoms mean and how do they influence our choice of investigations? Is there a link between symptoms and microcirculation alterations? How to choose the right VAD for the right patient based on the updated EVF guidelines? The answers given led the speakers to three conclusions: early symptoms reveal the initial stage of CVD and patients with C0S disease should be properly diagnosed, investigated, and treated; damage to the microcirculation is likely to be the first evidence of the onset of venous disease; Ruscus+HMC+VitC has proven efficacy in randomized controlled trials, and has been given a strong recommendation (Grade 1A) by the 2018 EVF guidelines for treatment of pain, heaviness, feeling of swelling, paresthesia, and edema, and should be considered as one of the preferred treatments to relieve these symptoms in CVD patients.

Occupational hazards and health problems among butchers in Uyo, Nigeria

Introduction: Butchers are exposed to various types of hazards in the course of their work, which could lead to health problems of varying severity. The aim of this study was to identify the occupational hazards and health problems of butchers in Uyo and also assess the physical conditions of their slaughter facilities. Materials and Methods: A descriptive cross-sectional study was carried out among 157 butchers in Uyo using a semi-structured questionnaire for data collection. Facility assessment was made using a checklist. Analysis was carried out using Statistical Package for Social Sciences version 20. Level of significance was set at 0.05. Results: The mean age of respondents was 33 ± 9.94 years. Most respondents were males (83.4%). The most commonly reported workplace hazards were knife (93.6%), bones (57.3%), and slippery floor (24.8%). The most common health problems were knife cuts (87.3%), cuts from bones (50.3%), and neck pain (36.9%). Having injuries from live animals and back pain were significantly associated with working with cows (P < 0.05). The most common de-furring method was burning with firewood (61.1%). The slaughter facilities lacked many expected amenities of a standard abattoir. Conclusion: Identified hazards and health problems of butchers were numerous. The slaughter facilities lacked appropriate equipment that promotes workers' health and safety. It is recommended that slaughter facilities be upgraded to meet the standard abattoir practice. Regular training of butchers should be organized by their association to encourage safer practice, including the use of appropriate protective wears. Use of the chemical method of de-furring should also be encouraged to limit exposure to harmful gases

Single herbal medicine for diabetic retinopathy.

BACKGROUND: Diabetic retinopathy is one of the major causes of blindness and the number of cases has risen in recent years. Herbal medicine has been used to treat diabetes and its complications including diabetic retinopathy for thousands of years around the world. However, common practice is not always evidence-based. Evidence is needed to help people with diabetic retinopathy or doctors to make judicious judgements about using herbal medicine as treatment. OBJECTIVES: To evaluate the effectiveness and harm of single herbal medicine for diabetic retinopathy. SEARCH METHODS: We searched CENTRAL, which contains the Cochrane Eyes and Vision Trials Register, MEDLINE, Embase, OpenGrey, the ISRCTN registry, ClinicalTrials.gov and the ICTRP. The date of the search was 12 June 2018. We also searched the following Chinese databases in June 2013: Chinese BioMedical Literature Database (CBM), Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), Wanfang China Dissertation Database (CDDB), Wanfang China Conference Paper Database (CCPD) and the Index to Chinese Periodical Literature. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs that investigated the effects of any single herb (or extracts from a single herb) as a treatment for people with diabetic retinopathy. We considered the following comparators: placebo, no treatment, non-herbal (conventional) medicine or surgical treatment. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed the risk of bias in the studies. Our prespecified outcomes were: progression of diabetic retinopathy, visual acuity, microaneurysms and haemorrhages in the retina, blood glycated haemoglobin A1c (HbA1c) (%) and adverse effects. We performed meta-analyses using risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). We assessed the certainty of the evidence using GRADE. MAIN RESULTS: We included 10 studies involving 754 participants, of which nine were conducted in China and one in Poland. In all studies, participants in both groups received conventional treatment for diabetic retinopathy which included maintaining blood glucose and lipids using medicines and keeping a stable diabetic diet. In three studies, the comparator group also received an additional potentially active comparator in the form of a vasoprotective drug. The single herbs or extracts included Ruscus extract tablet, Sanqi Tongshu capsule, tetramethylpyrazine injection, Xueshuantong injection, Puerarin injection and Xuesaitong injection. The Sanqi Tongshu capsule, Xueshuantong injection and Xuesaitong injection were all made from the extract of Radix Notoginseng (San qi) and the main ingredient was sanchinoside. The risk of bias was high in all included studies mainly due to lack of masking (blinding). None of the studies reported the primary outcome of this review, progression of retinopathy.Combined analysis of herbal interventions suggested that people who took these herbs in combination with conventional treatment may have been more likely to gain 2 or more lines of visual acuity compared to people who did not take these herbs when compared to conventional intervention alone at the end of treatment (RR 1.26, 95% CI 1.08 to 1.48; 5 trials, 541 participants; low-certainty evidence). Subgroup analyses based on the different single herbs found no evidence for different effects of different herbs, but the power of this analysis was low. One study reported Sanqi Tongshu capsule might be associated with a greater reduction in microaneurysms and haemorrhages in the retina (very low-certainty evidence). The pooled analysis of two studies on tetramethylpyrazine or Xueshuantong injection showed such herbs may have had little effect on lowering HbA1c (MD 0.00, 95% CI -0.58 to 0.58; 215 participants; low-certainty evidence).There was very low-certainty evidence on adverse events. Two studies reported minor adverse events such as uncomfortable stomach, urticaria, dizziness and headache. There was no report of observation on adverse events in the other studies. AUTHORS' CONCLUSIONS: No conclusions could be drawn about the effect of any single herb or herbal extract on diabetic retinopathy from the current available evidence. It was difficult to exclude the placebo effect as a possible explanation for observed differences due to the lack of placebo control in the included studies. Further adequately designed trials are needed to establish the evidence.

New data on chronic venous disease: a new place for Cyclo 3® Fort.

With our increasing knowledge of the epidemiology, pathophysiology, investigation and clinical aspects of chronic venous disease (CVD) and new data on the various therapies available, an update of the recommendations on CVD and its management appears to be necessary. The symposium New Data on Chronic Venous Disease: A New Place for Cyclo 3® Fort, held during the annual meeting of the European Venous Forum on June 30th, 2017 in Porto, Portugal, reported the recent developments on the Ruscus, hesperidin methyl chalcone (HMC), and vitamin C combination (Cyclo 3® Fort), including the results of a series of in-vivo pharmacological experiments and a recent meta-analysis. Additionally, the symposium provided first-hand information on the process, rules, main findings, and expected contents of the prospective 2018 CVD guidelines. Analysis of the evidence showed that the effect of the Ruscus, HMC, and vitamin C combination on pain, heaviness, feeling of swelling, tingling, ankle circumference and global symptoms score reached Grade A. Therefore, the new guidelines should specify that the Ruscus, HMC, and vitamin C combination merits a Grade 1A recommendation.

Effects of venotonic drugs on the microcirculation: Comparison between Ruscus extract and micronized diosmine1.

BACKGROUND: Chronic venous disease of the lower limbs is a common public health problem worldwide with negative impact on quality of life and results with drugs used to treat it are sparse, probably due to lack of good experimental models. OBJECTIVE: In this investigation we have tested the effects of two commonly used venotonic substances, Ruscus extract and micronized diosmine, on the microcirculation in vivo. METHODS: These substances were given orally, by gavage, during two weeks, twice daily and observations were made using the hamster cheek pouch preparation. RESULTS: The drugs elicited a dose-dependent inhibition of (1) macromolecular permeability increase induced by histamine or ischemia followed by reperfusion, being the Ruscus extract more active on both and (2) leukocyte-endothelium interaction, again being the Ruscus extract more effective in the inhibition of the number of adherent and rolling leukocytes. About the duration of the effect after the end of the treatment, both drugs had similar effects but Ruscus extract showed greater permanence of its effect on all observed parameters. CONCLUSIONS: Our results suggest that both drugs have antioxidant and anti-inflammatory properties being Ruscus extract more active. It should be added that only Ruscus extract showed a significant venular constriction.

Intraoperative awareness as an example of the influence of cardiac output on anesthetic dosing: case report / Despertar intraoperatorio como ejemplo de la influencia del gasto cardíaco en la dosificación anestésica. Reporte de caso

Abstract A case of intraoperative awareness during ablation of pulmonary veins-one of the most widely used techniques in interventional cardiology-is discussed. An infusion of isoproterenol was administered following the ablation of ectopic foci. A few seconds after the infusion the patient experienced increased heart rate and intraoperative awareness manifested as an abrupt patient movement and bispectral index elevation. This has been described in similar procedures, following the administration of isoproterenol. In our opinion, the isoproterenol infusion caused the increased heart rate and subsequent abrupt rise in cardiac output. As an inversely proportional relationship between the propofol concentrations and cardiac output has been described, we believe that this rise in cardiac output could have favored the decline in the concentrations of propofol, leading to an intraoperative awareness episode.

Resumen Presentamos un caso de despertar intraoperatorio durante la ablación de venas pulmonares, una de las técnicas más empleadas por los cardiólogos intervencionistas. Tras la ablación de focos ectópicos se procede a la infusión de isoproterenol. Segundos después de la infusión se produce un aumento de la frecuencia cardíaca seguido de un despertar intraoperatorio traducido como un movimiento brusco del paciente y un aumento en el índice bi-espectral (BIS). Esto ha sido descrito en procedimientos similares tras la administración de isoproterenol. En nuestra opinión, la infusión de isoproterenol provocó un aumento de la frecuencia cardiaca y secundariamente del gasto cardíaco de forma brusca. Dado que se ha descrito una relación inversamente propocional entre las concentraciones de propofol y el gasto cardíaco, pensamos que este aumento del gasto cardíaco pudo condicionar un descenso de las concentraciones de propofol y esto causar el episodio de despertar intraoperatorio.

Contribution of muscarinic receptors to in vitro and in vivo effects of Ruscus extract.

The objectives of this study were to evaluate, in vitro and in vivo, the contribution of muscarinic receptors to the effects of Ruscus extract. Ruscus extract was tested in competition binding experiments at recombinant human muscarinic receptors, heterologous expressed in Chinese Hamster Ovary (CHO) cells and in cellular assays measuring Ca2+ liberation and activator protein-1 (AP-1) reporter gene activation. The impact of muscarinic blockade on prolonged treatment outcome was evaluated using the hamster cheek pouch (HCP) microcirculation examining macromolecular permeability increase induced by histamine or ischemia/reperfusion (I/R), mean arteriolar and venular diameters, functional capillary density and I/R-induced leukocyte rolling and sticking. Ruscus extract exhibited affinities for muscarinic receptor subtypes at a range of 50-100µg/ml and behaved as partial agonist at human recombinant M1 and M3 receptors for Ca2+ liberation, confirmed in an AP-1 reporter gene assay. In the HCP model, topical application of atropine completely or partially blocked Ruscus extract-induced reductions of histamine- and I/R-induced increases of macromolecular permeability and leukocyte-endothelium interaction. Our results showed that Ruscus extract in vitro binds and activates different subtypes of muscarinic receptors and in vivo its anti-inflammatory effects are, at least partially, mediated via muscarinic receptors.

Efficacy of Ruscus extract, HMC and vitamin C, constituents of Cyclo 3 fort®, on improving individual venous symptoms and edema: a systematic review and meta-analysis of randomized double-blind placebo-controlled trials.

INTRODUCTION: Venoactive drugs (VADs) are considered an important component of the medical (conservative) treatment of chronic venous disorders (CVDs). However, the efficacy of certain VADs on one or more individual leg symptoms may have not been extensively studied to justify a high level or grade of recommendation in guidelines on CVD. The aim of the present systematic review and meta-analysis was to study the effectiveness of VADs containing Ruscus across the spectrum of defined venous symptoms. EVIDENCE ACQUISITION: On November 14 2016, a literature search of the databases MEDLINE and Scopus was performed, supplemented by hand searching, to identify randomized double-blind placebo-controlled trials on Ruscus extracts in patients with CVD. EVIDENCE SYNTHESIS: The main outcome measures were the effects of Ruscus on individual symptoms and leg edema, which were expressed as risk ratio (RR) or standardized mean difference (SMD) with 95% confidence interval (CI). Trial quality of evidence was graded using the GRADE system. We identified 10 trials, mostly with low risk of bias, on 719 patients. On qualitative analysis, Ruscus significantly improved seven defined leg symptoms, including pain, heaviness, fatigue, feeling of swelling, cramps, itching and paresthesia compared to placebo. On quantitative analysis, Ruscus compared with placebo, assessed as a categorical variable, reduced leg pain (RR=0.35, P=0.01, number needed to treat [NNT] 5, with no heterogeneity), heaviness (RR=0.26, P<0.00001, NNT=2.4, with a small amount of heterogeneity), feeling of swelling (RR=0.53, P<0.0001, NNT=4, with considerable heterogeneity, minimized after sensitivity analysis), paresthesia (RR=0.27, P<0.0001, NNT=1.8), global symptoms (RR=0.54, P<0.00001, NNT=4.3) and the total number of venous symptoms (RR 0.41, P=0.002). Similarly, Ruscus compared to placebo, assessed as a continuous variable reduced pain (SMD=-0.80, 95% CI: -1.21 to -0.39), heaviness (SMD=-1.23, 95% CI: -1.60 to -0.86), fatigue (SMD -1.16, 95% CI: -1.71 to -0.61), feeling of swelling (SMD=-2.27, 95% CI: -3.83 to -0.70), and paresthesia (SMD=-0.86, 95% CI: -1.51 to -0.21). Regarding objective assessments of leg edema, the use of Ruscus compared with placebo reduced ankle circumference (SMD=-0.74, 95% CI: -1.01 to -0.47) and leg or foot volume (SMD=-0.61, 95% CI: -0.91 to -0.31). The existing evidence, where sufficient, was mostly of high quality. CONCLUSIONS: Based on high quality evidence, Ruscus extracts are highly effective in reducing symptoms and edema of patients with CVD.

The place of Ruscus extract, hesperidin methyl chalcone, and vitamin C in the management of chronic venous disease.

Despite continuous improvement in our knowledge and management of chronic venous disease (CVD), certain areas, such as the role of muscarinic receptors in the pathology and treatment of CVD, remain unexplored. The symposium "The place of Ruscus extract, hesperidin methyl chalcone, and vitamin C in the management of CVD", held at the Annual Meeting of the European Venous Forum on 7-9 July 2016 in London, presented an update on the pathophysiology of CVD and highlighted how the combination of Ruscus extract, hesperidin methyl chalcone, and vitamin C (Ruscus/HMC/VitC; Cyclo 3® Fort), may counteract the deleterious processes underlying CVD. The data presented during this symposium are reported here. The pathophysiology of CVD is driven by a complex process involving numerous factors, with the two key players being venous hypertension and the inflammatory response. The cascade of reactions induced by disturbed venous flow, inflammation, and tissue alterations results in the early appearance of symptoms and progressive development of clinical signs of disease. Previous studies have shown that Ruscus extract acts at three levels: on the veins, capillaries and lymphatics, and has anti-inflammatory properties. A series of recent experiments has shed new light on the mechanism of action of the combination of Ruscus/HMC/VitC. The efficacy of Ruscus/HMC/VitC in CVD is supported by clinical studies, while two meta-analyses have confirmed a significant decrease of several symptoms and ankle circumference in response to treatment with this agent, leading to the conclusion that Ruscus/HMC/VitC deserves a Grade A rating.