Statin therapy and stroke prevention: what was known, what is new and what is next?

PURPOSE OF REVIEW: Randomized trials have shown that statins may reduce the risk of primary stroke. There is no evidence however that statins can reduce recurrent stroke incidence. RECENT FINDINGS: In the SPARCL trial, patients with a recent stroke or transient ischemic attack randomized to atorvastatin 80 mg/day had a significant 16% relative risk reduction of stroke, and a 35% reduction in major coronary events compared with placebo. This was obtained despite 25% of the placebo arm patients receiving a commercially-available statin outside of the trial. Post-hoc analysis used blinded LDL-cholesterol measurements as a marker of adherence to lipid-lowering therapy. Compared with the group with no change or an increase in LDL-cholesterol (the group adherent to placebo or not taking a statin), the group with over 50% reduction in LDL-cholesterol had a significant 31% reduction in stroke. The next step is to define whether achieving LDL-cholesterol below 70 mg/dl is better than a standard dose of statin (LDL around 100-110 mg/dl) in the secondary prevention of stroke. SUMMARY: Statins are effective in reducing both first-ever and recurrent stroke, and this effect seems driven by the extent of LDL-cholesterol lowering.     

Venous ulcer: what is new?

The pathophysiology of venous dermal abnormality in chronic venous ulcers is reflective of a complex interplay that involves sustained venous hypertension, inflammation, changes in the microcirculation, cytokine and matrix metalloproteinase activation, and altered cellular function. Red blood cells and macromolecules extravasate into the interstitium and activate endothelial cells. Endothelial expression of specific adhesion molecules recruits leukocytes and causes diapedesis of these cells into the dermal microvasculature, promoting an inflammatory response with activation of cytokines and proteinases. Altered cell function enhances a state of vulnerability in the surrounding tissues, initiating specific changes associated with venous disease. Ultimately, the persistent inflammatory-proteinase activity leads to advanced chronic venous insufficiency and ulcer formation. The mainstay of therapy in venous ulcer abnormality is correction of the underlying venous hypertension through compression therapy and/or surgery. Understanding the science involved in the pathophysiology of venous ulcer formation has led to the development of adjunctive treatment directed at the dysregulated molecular pathways. Randomized clinical trials are critical for determining the most effective evidence-based treatments for venous ulcer, and this review discusses important trials that have had a significant impact on venous ulcer healing. In addition, the authors have included subsections referred to as "Translational Implications for Therapy" in the basic science sections of the review to help bridge the basic science knowledge with clinical applications that may help to modulate the molecular abnormalities in the pathophysiologic cascade leading to venous ulcers.     

Phosphatidylserine receptors: what is the new RAGE?

The identification of RAGE as a phophatidylserine receptor—in this issue of EMBO reports by He et al—adds to the range of molecules that can sense this ‘eat-me'' signal, and suggests new potential therapeutic opportunities.EMBO Rep (2011) advance online publication. doi:10.1038/embor.2011.28The recognition of apoptotic cells by phagocytes is a complex, yet highly orchestrated event. Many receptors have been identified that recognize phosphatidylserine (PS; Fig 1)—which is exposed on early apoptotic cells—leading to downstream signalling and apoptotic cell engulfment. In a paper published this month in EMBO reports, the receptor for advanced glycation end-products (RAGE) is described as a new PS receptor on alveolar macrophages that participates in the clearance of apoptotic cells (He et al, 2011).…[RAGE] is described as a new phosphatidylserine receptor on alveolar macrophages that participates in the clearance of apoptotic cellsOpen in a separate windowFigure 1Phosphatidylserine-dependent apoptotic cell recognition.Schematic of the known PS receptors and downstream signalling to Rac. Dashed lines indicate unknown signalling mechanisms. PS, phosphatidylserine; RAGE, receptor for advanced glycation end-products; sRAGE, soluble RAGE.More than 200 billion cells undergo apoptosis every day in a human body, yet few apoptotic cells are detected in healthy tissue (Ravichandran, 2010). Apoptotic cells are generated during development, as part of normal homeostatic turnover and in disease states. The efficient clearance of apoptotic cells is crucial to prevent them from becoming secondarily necrotic, thereby limiting the immune response to apoptotic cell-derived self-antigens (Green et al, 2009). Disruptions to the clearance of apoptotic cells are linked to several diseases including atherosclerosis, chronic inflammation and autoimmunity (Elliott & Ravichandran, 2010).More than 200 billion cells undergo apoptosis every day in a human body, yet few apoptotic cells are detected in healthy tissueApoptotic cell engulfment can be divided into several steps. The first is the release of ‘find-me'' signals—such as triphosphate nucleotides (ATP and UTP), sphingosine-1-phosphate (S1P), lysophosphatidylcholine (LPC) and the chemokine CX₃CL1—by apoptotic cells (Ravichandran, 2010). Then, phagocytes sense the find-me signals and migrate toward the apoptotic cell. When they are in close proximity, recognition is mediated by the interaction between engulfment receptors on phagocytes and ligands, known as ‘eat-me'' signals, that are expressed on the dying cells (Ravichandran, 2010). The best-studied eat-me signal is PS, which is flipped from the inner leaflet to the outer leaflet of the plasma membrane during early apoptosis. Many receptors have been linked to the recognition of the exposed PS on apoptotic cells, and they are discussed below. The recognition of an apoptotic cell results in a downstream signalling cascade that leads to cytoskeletal rearrangement of the phagocytic membrane and subsequent engulfment of the apoptotic cell. Once the corpse is internalized, the phagocyte must process and digest the cellular contents.The exposure of PS on the outer leaflet of the membrane is the most-characteristic marker of an apoptotic cell. Phagocytes can recognize PS directly through receptors such as Bai1, TIM-4 and stabilin 2, or through soluble bridging molecules that bind to both PS and specific phagocyte receptors. For example, bridging molecules MFG-E8 and Gas6 interact with α_Vβ_3/5 and MER on the phagocytic membrane, respectively. Other eat-me signals and the molecules that bind to them have been characterized: thrombospondin is recognized by the vitronectin receptor, calreticulin by LRP1, oxidized LDL by scavenger receptors, ICAM3 might bind to CD14 and altered sugars bind to lectins (Lauber et al, 2004). Not all receptors need to be engaged for engulfment to occur, and different cell types have different receptor-expression levels.In a paper published this month in EMBO reports, the Yamamoto team identify RAGE as a new type of PS receptor on macrophages (He et al, 2011). There are two functional forms of RAGE, an abundant full-length transmembrane form that can initiate signalling through its intracellular tail, and a soluble isoform (sRAGE) that acts as a decoy receptor. RAGE is characteristically regarded as a pro-inflammatory receptor and has a variety of ligands, including advanced glycation end-products (AGEs) and many other damage-associated molecular patterns (DAMPs; Sims et al, 2010). One ligand in particular—high-mobility group protein B1 (HMGB1)—is released by cells undergoing necrosis and has been shown to bind to RAGE and induce inflammation (Sims et al, 2010). Therefore, RAGE might function during pro-inflammatory conditions and—as proposed by He and colleagues—during the anti-inflammatory process of apoptotic cell clearance. RAGE is mainly expressed in the lungs, but levels of it quickly increase at sites of inflammation, mostly on inflammatory and epithelial cells. Given the multitude of RAGE ligands and its inducible expression levels, RAGE is implicated in a variety of inflammation-related pathological states such as neurological and pulmonary disorders, vascular disease, cancer and diabetes (Sims et al, 2010).He and colleagues suggest that RAGE is a PS receptor during apoptotic cell engulfment in alveolar macrophages (He et al, 2011). Furthermore, sRAGE—which can bind to PS and apoptotic thymocytes—acts as a decoy and inhibits RAGE recognition of PS. By using PS liposomes as an artificial apoptotic target, the authors find RAGE in areas of the membrane in which a pseudopod forms to engulf a PS liposome. Additionally, sRAGE can compete with transmembrane RAGE to block the recognition of PS by the phagocyte and subsequently decrease the engulfment of apoptotic cells. Under homeostatic conditions, alveolar macrophages isolated from RAGE-deficient mice have defects in phagocytosis of apoptotic thymocytes. In a model of lung injury induced by lipopolysaccharide administration, RAGE-deficient mice accumulate neutrophils in the alveolar space and RAGE-deficient macrophages have defects in neutrophil engulfment. Previous works have implicated RAGE expression and/or upregulation in inflammatory conditions. In fact, genetic deletion of RAGE in mice can result in attenuated atherosclerosis, resistance to septic shock and reduced diabetic kidney disease (Ramasamy et al, 2010). Apoptotic cell clearance is generally an immunologically silent process and, therefore, if RAGE significantly contributes to engulfment, RAGE-deficient mice would be expected to have defects in cell clearance, leading to enhanced inflammation and disease. However, this does not seem to be the case. Thus, future studies should examine cell-type specific deletions of RAGE to clarify its apparently contradictory role in cell clearance and inflammation in these diseases.Given that several modes of PS recognition have been identified (Ravichandran, 2010), there must be some redundancy. The way in which RAGE contributes to this scenario remains to be investigated. Analysis of the expression levels of each PS receptor on different cell types will also help to define their relative importance in individual cells. As RAGE is highly expressed in the lung, it would be interesting to analyse its contribution to apoptotic cell engulfment in this tissue, in comparison with the other PS receptors. Furthermore, RAGE is induced by inflammation, suggesting that it is probably important during disease states to facilitate engulfment and reduce inflammation in the microenvironment.Another interesting question that remains is how RAGE signals to the phagocyte for engulfment. RAGE signalling results in pro-inflammatory cytokine production through activation of NF-κB (Yan et al, 1994), which seems to be different from the production of anti-inflammatory cytokines—such as IL-10 and TGFβ—by phagocytes during cell engulfment. However, as several RAGE ligands exist, the way in which they bind to RAGE could result in differential signalling. RAGE has also been shown to interact with mouse Dia1, leading to downstream activation of Rac1 and Cdc42, and cell migration (Hudson et al, 2008). Now, He and colleagues suggest that RAGE signals to Rac1 through Dia1 in the context of apoptotic cell clearance, as RAGE-deficient macrophages have decreased Rac1 activity in response to PS-liposome engulfment. Two evolutionarily conserved Rac-dependent pathways have been identified to mediate corpse internalization. Engagement of some engulfment receptors such as Bai1, results in Rac activation through the ELMO–Dock180–CrkII complex. ELMO and Dock180 mediate the exchange of GDP to GTP on Rac, whereas CrkII has been proposed to function as an adaptor protein. Another pathway involves signalling from the engulfment receptor LRP1 or stabilin 2, leading to Rac activation through the engulfment adaptor protein (GULP). Additional work is necessary to determine whether RAGE–mDia1 signalling constitutes a third intracellular signalling pathway for cell engulfment.Another interesting question that remains is how RAGE signals to the phagocyte for engulfmentThe study from the Yamamoto team identifies RAGE as a new PS-recognition molecule implicated in apoptotic cell-clearance in the lung. As each new receptor is identified, we are reminded of the redundancy and cell-type-specific expression of PS receptors. Defects in apoptotic cell-clearance lead to a variety of inflammatory diseases, including cardiovascular and autoimmune diseases. This study could also open an interesting therapeutic avenue; if sRAGE blocks the recognition of PS by RAGE and other PS receptors, it might be beneficial as a therapy by enhancing cell clearance and decreasing the severity of cell-clearance-associated diseases.     

Carotenoids and cardiovascular disease: what research gaps remain?

PURPOSE OF REVIEW: Dietary and blood carotenoids, including alpha-carotene, beta-carotene, lycopene, lutein/zeaxanthin, and beta-cryptoxanthin, have been examined in a number of epidemiological studies in recent years for the risk of cardiovascular disease. This review assimilated the existing and recent literature on carotenoids and cardiovascular disease and considered what research gaps may remain. RECENT FINDINGS: Numerous large cohort studies have been published in largely American men and women that have examined dietary intake or blood levels of total or individual carotenoids with the risk of various cardiovascular endpoints. Overall, early, promising results have grown increasingly inconsistent over time. More recently, studies examining lycopene and lutein/zeaxanthin have offered more promising data on a possible, but not yet established, inverse association with the risk of cardiovascular disease. Recent epidemiological data on beta-cryptoxanthin and cardiovascular disease are lacking. Primary and secondary prevention trials have extensively examined beta-carotene, but not other carotenoids, for the risk of cardiovascular disease as either the primary or secondary endpoint with largely null results. More recent studies have focused on individual carotenoids in relation to cardiovascular disease and require a more careful evaluation of potential mechanisms of effect. SUMMARY: The promise of early epidemiological studies on carotenoids and cardiovascular disease paved the way to largely disappointing results from several large prevention trials of beta-carotene. Emerging recent evidence of potential cardioprotective effects for lycopene and other carotenoids besides beta-carotene in the diet and blood suggest that there is more to be learned in the story of carotenoids and both atherosclerotic progression and clinically manifested cardiovascular disease.     

Blood pressure and cardiovascular risk: What about cocoa and chocolate?

Cocoa flavonoids are able to reduce cardiovascular risk by improving endothelial function and decreasing blood pressure (BP). Interest in the biological activities of cocoa is daily increasing. A recent meta-analysis shows flavanol-rich cocoa administration decreases mean systolic (−4.5 mm Hg; p < 0.001) and diastolic (−2.5 mm Hg; p < 0.001) BP. A 3-mm Hg systolic BP reduction has been estimated to decrease the risk of cardiovascular and all-cause mortality. This paper summarizes new findings concerning cocoa effects on cardiovascular health focusing on putative mechanisms of action and nutritional and “pharmacological” viewpoints. Cocoa consumption could play a pivotal role in human health.     

Aldosterone: A cardiovascular risk factor?

The hormone aldosterone has a well-recognized physiological role in epithelial fluid and electrolyte homeostasis, and more recently defined pathophysiological roles in the cardiovascular system. The term “risk factor” implies an active role in pathophysiology, with levels lower (e.g. HDL) or higher (e.g. LDL, BP) than normal contributing to an increased likelihood of morbidity and/or mortality. In this regard, primary aldosteronism represents a classic illustration of aldosterone as a cardiovascular risk factor. In this syndrome of (relatively) autonomous aldosterone secretion, the effects of elevated hormone levels are on a range of organs and tissues—the heart, blood vessels and brain, inter alia. In other cardiovascular disorders (e.g. CCF, EH) while an elevation of aldosterone levels is often regarded as a risk factor, it is more correctly a response to the severity of disease (or to treatment intervention), rather than necessarily a risk factor with a primary role in disease progression. An enduring enigma relevant to any discussion of aldosterone as a risk factor is that very high levels of aldosterone in response to chronic sodium deficiency have homeostatic (and protective of cardiovascular) functions, while the considerably lower levels commonly seen in primary aldosteronism are incontrovertibly damaging. A final section of the paper will thus propose a mechanism which might solve this enigma, based on the commonalities–and a single crucial difference–in the factors stimulating the secretion of aldosterone and endogenous ouabain from the zona glomerulosa of the adrenal gland.     

Phosphorothioate oligodeoxynucleotides: what is their origin and what is unique about them?

The development of nucleoside phosphorothioates is described in its historical context. Examples of the interaction of phosphorothioate groups, present either in oligodeoxynucleotides or in DNA, with nucleases are presented. The structural features responsible for the resistance of the phosphorothioates toward degradation by nucleases are discussed, as are the possible reasons for the high-affinity interaction of phosphorothioate oligodeoxynucleotides with certain proteins.     

Studying molecular motor-based cargo transport: what is real and what is noise?

Noise is a major problem in analyzing tracking data of cargos moved by molecular motors. We use Bayesian statistics to incorporate what is known about the noise in parsing the trajectory of a cargo into a series of constant velocity segments. Tracks with just noise and no underlying motion are fit with constant velocity segments to produce a calibration curve of fit quality versus average segment duration. Fits to tracks of moving cargos are compared to the calibration curves with similar noise. The fit with the optimum number of constant velocity states has the least number of segments needed to match the fit quality of the calibration curve. We have tested this approach using tracks with known underlying motion generated by computer simulations and with a specially designed in vitro experiment. We present the results of using this parsing approach to analyze transport of lipid droplets in Drosophila embryos.     

Sex and death: what is the connection?

A cost of reproduction, where lifespan and fecundity are negatively correlated, is of widespread occurrence. Mutations in insulin/IGF signaling (IIS) pathways and dietary restriction (DR) can extend lifespan in model organisms but do not always reduce fecundity, suggesting that the link between lifespan and fecundity is not inevitable. Understanding the molecular basis of the cost of reproduction will be informed by elucidation of the mechanisms by which DR and IIS affect these two traits.     

Autophagy and apoptosis: what is the connection?

The therapeutic potential of autophagy for the treatment cancer and other diseases is beset by paradoxes stemming from the complexity of the interactions between the apoptotic and autophagic machinery. The simplest question of how autophagy acts as both a protector and executioner of cell death remains the subject of substantial controversy. Elucidating the molecular interactions between the processes will help us understand how autophagy can modulate cell death, whether autophagy is truly a cell death mechanism, and how these functions are regulated. We suggest that, despite many connections between autophagy and apoptosis, a strong causal relationship wherein one process controls the other, has not been demonstrated adequately. Knowing when and how to modulate autophagy therapeutically depends on understanding these connections.     

Independent component analysis of functional MRI: what is signal and what is noise?

Many sources of fluctuation contribute to the functional magnetic resonance imaging (fMRI) signal, complicating attempts to infer those changes that are truly related to brain activation. Unlike methods of analysis of fMRI data that test the time course of each voxel against a hypothesized waveform, data-driven methods, such as independent component analysis and clustering, attempt to find common features within the data. This exploratory approach can be revealing when the brain activation is difficult to predict beforehand, such as with complex stimuli and internal shifts of activation that are not time-locked to an easily specified sensory or motor event. These methods can be further improved by incorporating prior knowledge regarding the temporal and spatial extent of brain activation.     

Early puberty: what is normal and when is treatment indicated?

Girls and boys who enter puberty before 8 and 9 years of age, respectively (corresponding to about -3 SDS), are arbitrarily considered to need referral for endocrine investigation. A recent report from the Lawson Wilkins Pediatric Endocrine Society suggested that the limit for investigation of girls and boys should be lowered to 7 and 8 years, respectively. For African-American girls, 6 years is the suggested age. This recommendation has been criticized. Although short stature is a common end result of precocious puberty, short- and long-term psychological symptoms may be more important, since several studies have indicated psychopathology in this patient group. Whether this can be prevented by gonadotropin releasing hormone agonist treatment remains to be shown. This review will highlight the psychological aspects of early puberty. In short, aspects other than height should also be evaluated when considering treatment of the early maturing child.     

Selenium and diabetes: an enigma?

In recent years diabetes has become one of the most common metabolic diseases in developed countries and it is closely related to supernutrition and obesity. Since untreated diabetes produces oxidative stress responsible for secondary complications of the disease, antioxidant supplements were considered as being favourable for the therapy of diabetes. However, the situation has changed recently, since large cross-sectional and interventional trials revealed a positive correlation between a high Se status and diabetes incidence in humans. Thus, currently available data on the role of Se in diabetes are inconsistent and an enigma appears to exist for the relation between selenium and diabetes. This review summarizes selected human and animal studies, pointing to beneficial and critical virtues of Se in diabetes. Moreover, the review discusses possible underlying mechanisms how Se may influence diabetes in both directions. From the current literature, the following information can be extracted: (1) In populations with a high Se status, with the single exception of pregnant women, Se supplements cannot be recommended for the prevention of diabetes; (2) Anti-diabetic effects of Se seem to be restricted to high and nearly toxic doses which cannot be used in humans; and (3) Future investigations should consider the stage of the disease.