Neuropathological changes in the brain of pigs with acute liver failure.

Abstract Objective. Cerebral edema is a serious complication of acute liver failure (ALF), which may lead to intracranial hypertension and death. An accepted tenet has been that the blood-brain barrier is intact and that brain edema is primarily caused by a cytotoxic etiology due to hyperammonemia. However, the neuropathological changes in ALF have been poorly studied. Using a well characterized porcine model we aimed to investigate ultrastructural changes in the brain from pigs suffering from ALF. Materials and methods. Sixteen female Norwegian Landrace pigs weighing 27-35 kg were randomised into two groups: ALF (n = 8) and sham operated controls (n = 8). ALF was induced with an end-to-side portacaval shunt followed by ligation of the hepatic arteries. Biopsies were harvested from three different areas of the brain (frontal lobe, cerebellum, and brain stem) following eight hours of ALF and analyzed using electron microscopy. Results. Profound perivascular and interstitial edema were found in all three areas. Disruption of pericytic and astrocytic processes were seen, reflecting breakdown/lesion of the blood-brain barrier in animals suffering from ALF. Furthermore, neurons and axons were edematous and surrounded by vesicles. Severe damage to Purkinje neuron (necrosis) and damaged myelin were seen in the cerebellum and brain stem, respectively. Biopsies from sham operated animals were normal. Conclusions. Our data support the concept that vasogenic brain edema plays an important role in the development of intracranial hypertension in pigs with ALF.

Mild hypothermia in the prevention of brain edema in acute liver failure: mechanisms and clinical prospects.

Mild hypothermia (32 degrees C-35 degrees C) reduces intracranial pressure in patients with acute liver failure and may offer an effective adjunct therapy in the management of these patients. Studies in experimental animals suggest that this beneficial effect of hypothermia is the result of a decrease in blood-brain ammonia transfer resulting in improvement in brain energy metabolism and normalization of glutamatergic synaptic regulation. Improvement in brain energy metabolism by hypothermia may result from a reduction in ammonia-induced decrease of brain glucose (pyruvate) oxidation. Restoration of normal glutamatergic synaptic regulation by hypothermia may be the consequence of the removal of ammonia-induced decreases in expression of astrocytic glutamate transporters resulting in normal glutamate neurotransmitter inactivation in brain. Randomized controlled clinical trials of hypothermia are required to further evaluate its clinical impact.

Hypothermia in acute liver failure.

The development of encephalopathy in patients with acute liver injury defines the occurrence of liver failure. The encephalopathy of acute liver failure is characterized by brain edema which manifests clinically as increased intracranial pressure. Despite the best available medical therapies a significant proportion of patients with acute liver failure die due to brain herniation. The present review explores the experimental and clinical data to define the role of hypothermia as a treatment modality for increased intracranial pressure in patients with acute liver failure.

Direct molecular and spectroscopic evidence for increased ammonia removal capacity of skeletal muscle in acute liver failure.

BACKGROUND/AIMS: It has been proposed that, in acute liver failure, skeletal muscle adapts to become the principle organ responsible for removal of blood-borne ammonia by increasing glutamine synthesis, a reaction that is catalyzed by the cytosolic ATP-dependent enzyme glutamine synthetase. To address this issue, glutamine synthetase expression and activities were measured in skeletal muscle of rats with acute liver failure resulting from hepatic devascularization. METHODS: Glutamine synthetase protein and gene expression were investigated using immunoblotting and semi-quantitative RT-PCR analysis. Glutamine synthetase activity and glutamine de novo synthesis were measured using, respectively, a standard enzymatic assay and [13C]-nuclear magnetic resonance spectroscopy. RESULTS: Glutamine synthetase protein (but not gene) expression and enzyme activities were significantly up-regulated leading to increased de novo synthesis of glutamine and increased skeletal muscle capacity for ammonia removal in acute liver failure. In contrast to skeletal muscle, expression and activities of glutamine synthetase in the brain were significantly decreased. CONCLUSIONS: These findings demonstrate that skeletal muscle adapts, through a rapid induction of glutamine synthetase, to increase its capacity for removal of blood-borne ammonia in acute liver failure. Maintenance of muscle mass together with the development of agents with the capacity to stimulate muscle glutamine synthetase could provide effective ammonia-lowering strategies in this disorder.

Effects of hypothermia on brain glucose metabolism in acute liver failure: a H/C-nuclear magnetic resonance study.

Mild hypothermia has a protective effect on brain edema and encephalopathy in both experimental and human acute liver failure. The goals of the present study were to examine the effects of mild hypothermia (35°C) on brain metabolic pathways using combined 1H and 13C-Nuclear Magnetic Resonance (NMR) spectroscopy, a technique which allows the study not only of metabolite concentrations but also their de novo synthesis via cell-specific pathways in the brain. :1H and 13C NMR spectroscopy using [1-13C] glucose was performed on extracts of frontal cortex obtained from groups of rats with acute liver failure induced by hepatic devascularization whose body temperature was maintained either at 37°C (normothermic) or 35°C (hypothermic), and appropriate sham-operated controls. At coma stages of encephalopathy in the normothermic acute liver failure animals, glutamine concentrations in frontal cortex increased 3.5-fold compared to sham-operated controls (P < 0.001). Comparable increases of brain glutamine were observed in hypothermic animals despite the absence of severe encephalopathy (coma). Brain glutamate and aspartate concentrations were respectively decreased to 60.9% ± 7.7% and 42.2% ± 5.9% (P < 0.01) in normothermic animals with acute liver failure compared to control and were restored to normal values by mild hypothermia. Concentrations of lactate and alanine in frontal cortex were increased to 169.2% ± 15.6% and 267.3% ± 34.0% (P < 0.01) respectively in normothermic rats compared to controls. Furthermore, de novo synthesis of lactate and alanine increased to 446.5% ± 48.7% and 707.9% ± 65.7% (P < 0.001), of control respectively, resulting in increased fractional 13C-enrichments in these cytosolic metabolites. Again, these changes of lactate and alanine concentrations were prevented by mild hypothermia. Mild hypothermia (35°C) prevents the encephalopathy and brain edema resulting from hepatic devascularization, selectively normalizes lactate and alanine synthesis from glucose, and prevents the impairment of oxidative metabolism associated with this model of ALF, but has no significant effect on brain glutamine. These findings suggest that a deficit in brain glucose metabolism rather than glutamine accumulation is the major cause of the cerebral complications of acute liver failure.

Mild hypothermia prevents cerebral edema and CSF lactate accumulation in acute liver failure.

Evidence from both clinical and experimental studies demonstrates that mild hypothermia prevents encephalopathy and brain edema in acute liver failure (ALF). As part of a series of studies to elucidate the mechanism(s) involved in this protective effect, groups of rats with ALF resulting from hepatic devascularization were maintained at either 37°C (normothermic) or 35°C (hypothermic), and neurological status was monitored in relation to cerebrospinal fluid (CSF) concentrations of ammonia and lactate. CSF was removed via implanted cisterna magna catheters. Mild hypothermia resulted in a delay in onset of encephalopathy and prevention of brain edema; CSF concentrations of ammonia and lactate were concomitantly decreased. Blood ammonia concentrations, on the other hand, were not affected by hypothermia in ALF rats. These findings suggest that brain edema and encephalopathy in ALF are the consequence of ammonia-induced impairment of brain energy metabolism and open the way for magnetic resonance spectroscopic monitoring of cerebral function in ALF. Mild hypothermia could be beneficial in the prevention of severe encephalopathy and brain edema in patients with ALF awaiting liver transplantation.

Mild hypothermia prevents brain edema and attenuates up-regulation of the astrocytic benzodiazepine receptor in experimental acute liver failure.

BACKGROUND/AIMS: Mild hypothermia has proven useful in the clinical management of patients with acute liver failure. Acute liver failure in experimental animals results in alterations in the expression of genes coding for astrocytic proteins including the "peripheral-type" (astrocytic) benzodiazepine receptor (PTBR), a mitochondrial complex associated with neurosteroid synthesis. To gain further insight into the mechanisms whereby hypothermia attenuates the neurological complications of acute liver failure, we investigated PTBR expression in the brains of hepatic devascularized rats under normothermic (37 degrees C) and hypothermic (35 degrees C) conditions. METHODS: PTBR mRNA was measured using semi-quantitative RT-PCR in cerebral cortical extracts and densities of PTBR sites were measured by quantitative receptor autoradiagraphy. Brain pregnenolone content was measured by radioimmunoassay. RESULTS: At coma stages of encephalopathy, animals with acute liver failure manifested a significant increase of PTBR mRNA levels. Brain pregnenolone content and [(3)H]PK 11195 binding site densities were concomitantly increased. Mild hypothermia prevented brain edema and significantly attenuated the increased receptor expression and pregnenolone content. CONCLUSIONS: These findings suggest that an attenuation of PTBR up-regulation resulting in the prevention of increased brain neurosteroid content represents one of the mechanisms by which mild hypothermia exerts its protective effects in ALF.

Systemic oxidative stress is implicated in the pathogenesis of brain edema in rats with chronic liver failure.

Chronic liver failure leads to hyperammonemia, a central component in the pathogenesis of hepatic encephalopathy (HE); however, a correlation between blood ammonia levels and HE severity remains controversial. It is believed oxidative stress plays a role in modulating the effects of hyperammonemia. This study aimed to determine the relationship between chronic hyperammonemia, oxidative stress, and brain edema (BE) in two rat models of HE: portacaval anastomosis (PCA) and bile-duct ligation (BDL). Ammonia and reactive oxygen species (ROS) levels, BE, oxidant and antioxidant enzyme activities, as well as lipid peroxidation were assessed both systemically and centrally in these two different animal models. Then, the effects of allopurinol (xanthine oxidase inhibitor, 100mg/kg for 10days) on ROS and BE and the temporal resolution of ammonia, ROS, and BE were evaluated only in BDL rats. Similar arterial and cerebrospinal fluid ammonia levels were found in PCA and BDL rats, both significantly higher compared to their respective sham-operated controls (p<0.05). BE was detected in BDL rats (p<0.05) but not in PCA rats. Evidence of oxidative stress was found systemically but not centrally in BDL rats: increased levels of ROS, increased activity of xanthine oxidase (oxidant enzyme), enhanced oxidative modifications on lipids, as well as decreased antioxidant defense. In PCA rats, a preserved oxidant/antioxidant balance was demonstrated. Treatment with allopurinol in BDL rats attenuated both ROS and BE, suggesting systemic oxidative stress is implicated in the pathogenesis of BE. Analysis of ROS and ammonia temporal resolution in the plasma of BDL rats suggests systemic oxidative stress might be an important "first hit", which, followed by increases in ammonia, leads to BE in chronic liver failure. In conclusion, chronic hyperammonemia and oxidative stress in combination lead to the onset of BE in rats with chronic liver failure.

Indirect Bonding Method: in vitro Comparison of the Shear Bond Strength between Metallic Orthodontic Brackets and Different Porcelain Surface Preparations

Introduction : La force d’adhésion à l'interface métal-céramique avec les résines auto-polymérisantes destinées au collage indirect des boîtiers orthodontiques n'a pas été évaluée à ce jour et un protocole clinique basé sur la littérature scientifique est inexistant. Objectifs : 1) Comparer la force de cisaillement maximale entre des boîtiers métalliques et des surfaces en porcelaine préparées selon différentes méthodes; 2) Suggérer un protocole clinique efficace et prévisible. Matériel et méthodes : Quatre-vingt-dix disques en leucite (6 groupes; n = 15/groupe) ont été préparés selon 6 combinaisons de traitements de surface : mécaniques (+ / - fraisage pour créer les rugosités) et chimiques (acide fluorhydrique, apprêt, silane). Des bases en résine composite Transbond XT (3M Unitek, Monrovia, California) faites sur mesure ont été collées avec le système de résine adhésive auto-polymérisante Sondhi A + B Rapid Set (3M Unitek, Monrovia, California). Les échantillons ont été préservés (H2O/24hrs), thermocyclés (500 cycles) et testés en cisaillement (Instron, Norwood, Massachusetts). Des mesures d’Index d’adhésif résiduel (IAR) ont été compilées. Des tests ANOVAs ont été réalisés sur les rangs étant donné que les données suivaient une distribution anormale et ont été ajustés selon Tukey. Un Kruskall-Wallis, U-Mann Whitney par comparaison pairée et une analyse de Weibull ont aussi été réalisés. Résultats : Les médianes des groupes varient entre 17.0 MPa (- fraisage + acide fluorhydrique) à 26.7 MPa (- fraisage + acide fluorhydrique + silane). Le fraisage en surface ne semble pas affecter l’adhésion. La combinaison chimique (- fraisage + silane + apprêt) a démontré des forces de cisaillement significativement plus élevées que le traitement avec (- fraisage + acide fluorhydrique), p<0,05, tout en possédant des forces similaires au protocole typiquement suggéré à l’acide fluorhydrique suivi d’une application de silane, l’équivalence de (- fraisage + acide fluorhydrique + silane). Les mesures d’IAR sont significativement plus basses dans le groupe (- fraisage + acide fluorhydrique) en comparaison avec celles des 5 autres groupes, avec p<0,05. Malheureusement, ces 5 groupes ont des taux de fracture élévés de 80 à 100% suite à la décimentation des boîtiers. Conclusion : Toutes les combinaisons de traitement de surface testées offrent une force d’adhésion cliniquement suffisante pour accomplir les mouvements dentaires en orthodontie. Une application de silane suivie d’un apprêt est forte intéressante, car elle est simple à appliquer cliniquement tout en permettant une excellente adhésion. Il faut cependant avertir les patients qu’il y a un risque de fracture des restorations en céramique lorsque vient le moment d’enlever les broches. Si la priorité est de diminuer le risque d’endommager la porcelaine, un mordançage seul à l’acide hydrofluorique sera suffisant.

Brain edema in acute liver failure and chronic liver disease: Similarities and differences.

Hepatic encephalopathy (HE) is a complex neuropsychiatric syndrome that typically develops as a result of acute liver failure or chronic liver disease. Brain edema is a common feature associated with HE. In acute liver failure, brain edema contributes to an increase in intracranial pressure, which can fatally lead to brain stem herniation. In chronic liver disease, intracranial hypertension is rarely observed, even though brain edema may be present. This discrepancy in the development of intracranial hypertension in acute liver failure versus chronic liver disease suggests that brain edema plays a different role in relation to the onset of HE. Furthermore, the pathophysiological mechanisms involved in the development of brain edema in acute liver failure and chronic liver disease are dissimilar. This review explores the types of brain edema, the cells, and pathogenic factors involved in its development, while emphasizing the differences in acute liver failure versus chronic liver disease. The implications of brain edema developing as a neuropathological consequence of HE, or as a cause of HE, are also discussed.

Carbon-carbon bond formation : from transition metal catalysis to base-promoted homolytic aromatic substitution

Cette thèse de doctorat porte sur la catalyse à partir de métaux de transition et sur la substitution homolytique aromatique favorisée par une base visant à former de nouvelles liaisons C–C, et à ainsi concevoir de nouvelles structures chimiques. Au cours des vingt dernières années, des nombreux efforts ont été réalisés afin de développer des méthodologies pour la fonctionnalisation de liens C–H, qui soient efficaces et sélectives, et ce à faible coût et en produisant le minimum de déchets. Le chapitre d'introduction donnera un aperçu de la fonctionnalisation directe de liens C–H sur des centres sp2 et sp3. Il sera également discuté dans cette partie de certains aspects de la chimie radicalaire reliés a ce sujet. Les travaux sur la fonctionnalisation d’imidazo[1,5-a]pyridines catalysée par des compleces de ruthénium seront présentés dans le chapitre 2. Malgré l'intérêt des imidazo[1,5-a]azines en chimie médicinale, ces composés n’ont reçu que peu d'attention dans le domaine de la fonctionnalisation de liens C–H. L'étendue de la réaction et l'influence des effets stériques et électroniques seront détaillés. Les cyclopropanes représentent les 10ème cycles carbonés les plus rencontrés dans les petites molécules d’intérêt pharmacologique. Ce sont aussi des intermédiaires de synthèse de choix pour la création de complexité chimique. Malgré de grands progrès dans le domaine de la fonctionnalisation de liens C(sp3)–H, l'étude des cyclopropanes comme substrats dans les transformations directes est relativement nouvelle. Le chapitre trois présentera l'arylation intramoléculaire directe de cyclopropanes. Cette réaction est réalisée en présence de palladium, en quantité catalytique, en combinaison avec des sels d’argent. Des études mécanistiques ont réfuté la formation d'un énolate de palladium et suggéreraient plutôt une étape de métallation - déprotonation concertée. En outre, les cycles de type benzoazepinone à sept chaînons ont été synthétisés par l'intermédiaire d'une séquence d'activation de cyclopropane/ouverture/cyclisation. Une arylation directe intermoléculaire des cyclopropanes a été réalisée en présence d'un auxiliaire de type picolinamide (Chapitre 4). Les deux derniers chapitres de ce mémoire de thèse décriront nos études sur la substitution homolytique aromatique favorisée par une base. Le mécanisme de la réaction de cyclisation intramoléculaire d'halogénures d'aryle, réalisée en présence de tert-butylate de potassium, a été élucidé et se produit via une voie radicalaire (Chapitre 5). La transformation, exempte de métaux de transition, ne nécessite que la présence d’une base et de pyridine comme solvant. Cette réaction radicalaire a été étendue à la cyclisation d'iodures d'alkyle non activés en présence d'un catalyseur à base de nickel et de bis(trimethylsilyl)amidure de sodium comme base (Chapitre 6). Des études de RMN DOSY ont démontré une association entre le catalyseur, la base et le matériel de départ.

Association of reduced extracellular brain ammonia, lactate, and intracranial pressure in pigs with acute liver failure.

We previously demonstrated in pigs with acute liver failure (ALF) that albumin dialysis using the molecular adsorbents recirculating system (MARS) attenuated a rise in intracranial pressure (ICP). This was independent of changes in arterial ammonia, cerebral blood flow and inflammation, allowing alternative hypotheses to be tested. The aims of the present study were to determine whether changes in cerebral extracellular ammonia, lactate, glutamine, glutamate, and energy metabolites were associated with the beneficial effects of MARS on ICP. Three randomized groups [sham, ALF (induced by portacaval anastomosis and hepatic artery ligation), and ALF+MARS] were studied over a 6-hour period with a 4-hour MARS treatment given beginning 2 hours after devascularization. Using cerebral microdialysis, the ALF-induced increase in extracellular brain ammonia, lactate, and glutamate was significantly attenuated in the ALF+MARS group as well as the increases in extracellular lactate/pyruvate and lactate/glucose ratios. The percent change in extracellular brain ammonia correlated with the percent change in ICP (r(2) = 0.511). Increases in brain lactate dehydrogenase activity and mitochondrial complex activity for complex IV were found in ALF compared with those in the sham, which was unaffected by MARS treatment. Brain oxygen consumption did not differ among the study groups. Conclusion: The observation that brain oxygen consumption and mitochondrial complex enzyme activity changed in parallel in both ALF- and MARS-treated animals indicates that the attenuation of increased extracellular brain ammonia (and extracellular brain glutamate) in the MARS-treated animals reduces energy demand and increases supply, resulting in attenuation of increased extracellular brain lactate. The mechanism of how MARS reduces extracellular brain ammonia requires further investigation.

L-ornithine phenylacetate attenuates increased arterial and extracellular brain ammonia and prevents intracranial hypertension in pigs with acute liver failure.

Hyperammonemia is a feature of acute liver failure (ALF), which is associated with increased intracranial pressure (ICP) and brain herniation. We hypothesized that a combination of L-ornithine and phenylacetate (OP) would synergistically reduce toxic levels of ammonia by (1) L-ornithine increasing glutamine production (ammonia removal) through muscle glutamine synthetase and (2) phenylacetate conjugating with the ornithine-derived glutamine to form phenylacetylglutamine, which is excreted into the urine. The aims of this study were to determine the effect of OP on arterial and extracellular brain ammonia concentrations as well as ICP in pigs with ALF (induced by liver devascularization). ALF pigs were treated with OP (L-ornithine 0.07 g/kg/hour intravenously; phenylbutyrate, prodrug for phenylacetate; 0.05 g/kg/hour intraduodenally) for 8 hours following ALF induction. ICP was monitored throughout, and arterial and extracellular brain ammonia were measured along with phenylacetylglutamine in the urine. Compared with ALF + saline pigs, treatment with OP significantly attenuated concentrations of arterial ammonia (589.6 +/- 56.7 versus 365.2 +/- 60.4 mumol/L [mean +/- SEM], P= 0.002) and extracellular brain ammonia (P= 0.01). The ALF-induced increase in ICP was prevented in ALF + OP-treated pigs (18.3 +/- 1.3 mmHg in ALF + saline versus 10.3 +/- 1.1 mmHg in ALF + OP-treated pigs;P= 0.001). The value of ICP significantly correlated with the concentration of extracellular brain ammonia (r(2) = 0.36,P< 0.001). Urine phenylacetylglutamine levels increased to 4.9 +/- 0.6 micromol/L in ALF + OP-treated pigs versus 0.5 +/- 0.04 micromol/L in ALF + saline-treated pigs (P< 0.001).Conclusion:L-Ornithine and phenylacetate act synergistically to successfully attenuate increases in arterial ammonia, which is accompanied by a significant decrease in extracellular brain ammonia and prevention of intracranial hypertension in pigs with ALF.

Thumb-bangers : exploring the cultural bond between video games and heavy metal

« Heavy Metal Generations » is the fourth volume in the series of papers drawn from the 2012 Music, Metal and Politics international conference (http://www.inter-disciplinary.net/publishing/product/heavy-metal-generations/).