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Raikes AC, Hernandez GD, Mullins VA, Wang Y, Lopez C, Killgore WDS, Chilton FH, Brinton RD. Effects of docosahexaenoic acid and eicosapentaoic acid supplementation on white matter integrity after repetitive sub-concussive head impacts during American football: Exploratory neuroimaging findings from a pilot RCT. Front Neurol 2022; 13:891531. [PMID: 36188406 PMCID: PMC9521411 DOI: 10.3389/fneur.2022.891531] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Context Repetitive sub-concussive head impacts (RSHIs) are common in American football and result in changes to the microstructural integrity of white matter. Both docosahexaenoic acid (DHA) and eicosapentaoic acid (EPA) supplementation exerted neuroprotective effects against RSHIs in animal models and in a prior study in football players supplemented with DHA alone. Objective Here, we present exploratory neuroimaging outcomes from a randomized controlled trial of DHA + EPA supplementation in American football players. We hypothesized that supplementation would result in less white matter integrity loss on diffusion weighted imaging over the season. Design setting participants We conducted a double-blind placebo-controlled trial in 38 American football players between June 2019 and January 2020. Intervention Participants were randomized to the treatment (2.442 g/day DHA and 1.020 g/day EPA) or placebo group for five times-per-week supplementation for 7 months. Of these, 27 participants were included in the neuroimaging data analysis (n = 16 placebo; n = 11 DHA + EPA). Exploratory outcome measures Changes in white matter integrity were quantified using both voxelwise diffusion kurtosis scalars and deterministic tractography at baseline and end of season. Additional neuroimaging outcomes included changes in regional gray matter volume as well as intra-regional, edge-wise, and network level functional connectivity. Serum neurofilament light (NfL) provided a peripheral biomarker of axonal damage. Results No voxel-wise between-group differences were identified on diffusion tensor metrics. Deterministic tractography using quantitative anisotropy (QA) revealed increased structural connectivity in ascending corticostriatal fibers and decreased connectivity in long association and commissural fibers in the DHA+EPA group compared to the placebo group. Serum NfL increases were correlated with increased mean (ρ = 0.47), axial (ρ = 0.44), and radial (ρ = 0.51) diffusivity and decreased QA (ρ = -0.52) in the corpus callosum and bilateral corona radiata irrespective of treatment group. DHA + EPA supplementation did preserve default mode/frontoparietal control network connectivity (g = 0.96, p = 0.024). Conclusions These exploratory findings did not provide strong evidence that DHA + EPA prevented or protected against axonal damage as quantified via neuroimaging. Neuroprotective effects on functional connectivity were observed despite white matter damage. Further studies with larger samples are needed to fully establish the relationship between omega-3 supplementation, RSHIs, and neuroimaging biomarkers. Trial registration ClinicalTrials.gov-NCT04796207.
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Affiliation(s)
- Adam C. Raikes
- Center for Innovation in Brain Science, University of Arizona, Tucson, AZ, United States
| | - Gerson D. Hernandez
- Center for Innovation in Brain Science, University of Arizona, Tucson, AZ, United States
| | - Veronica A. Mullins
- Department of Nutritional Sciences, University of Arizona, Tucson, AZ, United States
| | - Yiwei Wang
- Center for Innovation in Brain Science, University of Arizona, Tucson, AZ, United States
| | - Claudia Lopez
- Center for Innovation in Brain Science, University of Arizona, Tucson, AZ, United States
| | - William D. S. Killgore
- Social, Cognitive, and Affective Neuroscience Lab, Department of Psychiatry, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Floyd H. Chilton
- Department of Nutritional Sciences, University of Arizona, Tucson, AZ, United States
| | - Roberta D. Brinton
- Center for Innovation in Brain Science, University of Arizona, Tucson, AZ, United States
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Mullins VA, Graham S, Cummings D, Wood A, Ovando V, Skulas-Ray AC, Polian D, Wang Y, Hernandez GD, Lopez CM, Raikes AC, Brinton RD, Chilton FH. Effects of Fish Oil on Biomarkers of Axonal Injury and Inflammation in American Football Players: A Placebo-Controlled Randomized Controlled Trial. Nutrients 2022; 14:2139. [PMID: 35631280 PMCID: PMC9146417 DOI: 10.3390/nu14102139] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 11/27/2022] Open
Abstract
There are limited studies on neuroprotection from repeated subconcussive head impacts (RSHI) following docosahexaenoic acid (DHA) + eicosapentaenoic acid (EPA) supplementation in contact sports athletes. We performed a randomized, placebo-controlled, double-blinded, parallel-group design trial to determine the impact of 26 weeks of DHA+EPA supplementation (n = 12) vs. placebo (high-oleic safflower oil) (n = 17) on serum concentrations of neurofilament light (NfL), a biomarker of axonal injury, and inflammatory cytokines (interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-a)) in National Collegiate Athletic Association Division I American football athletes. DHA+EPA supplementation increased (p < 0.01) plasma DHA and EPA concentrations throughout the treatment period. NfL concentrations increased from baseline to week 26 in both groups (treatment (<0.001); placebo (p < 0.05)), with starting players (vs. non-starters) showing significant higher circulating concentrations at week 26 (p < 0.01). Fish oil (DHA+EPA) supplementation did not mitigate the adverse effects of RSHI, as measured by NfL levels; however, participants with the highest plasma DHA+EPA concentrations tended to have lower NfL levels. DHA+EPA supplementation had no effects on inflammatory cytokine levels at any of the timepoints tested. These findings emphasize the need for effective strategies to protect American football participants from the effects of RSHI.
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Affiliation(s)
- Veronica A. Mullins
- School of Nutritional Sciences and Wellness, University of Arizona, 1230 N Cherry Avenue, Tucson, AZ 85719, USA; (V.A.M.); (S.G.); (D.C.); (A.W.); (V.O.); (A.C.S.-R.)
| | - Sarah Graham
- School of Nutritional Sciences and Wellness, University of Arizona, 1230 N Cherry Avenue, Tucson, AZ 85719, USA; (V.A.M.); (S.G.); (D.C.); (A.W.); (V.O.); (A.C.S.-R.)
| | - Danielle Cummings
- School of Nutritional Sciences and Wellness, University of Arizona, 1230 N Cherry Avenue, Tucson, AZ 85719, USA; (V.A.M.); (S.G.); (D.C.); (A.W.); (V.O.); (A.C.S.-R.)
| | - Alva Wood
- School of Nutritional Sciences and Wellness, University of Arizona, 1230 N Cherry Avenue, Tucson, AZ 85719, USA; (V.A.M.); (S.G.); (D.C.); (A.W.); (V.O.); (A.C.S.-R.)
| | - Vanessa Ovando
- School of Nutritional Sciences and Wellness, University of Arizona, 1230 N Cherry Avenue, Tucson, AZ 85719, USA; (V.A.M.); (S.G.); (D.C.); (A.W.); (V.O.); (A.C.S.-R.)
| | - Ann C. Skulas-Ray
- School of Nutritional Sciences and Wellness, University of Arizona, 1230 N Cherry Avenue, Tucson, AZ 85719, USA; (V.A.M.); (S.G.); (D.C.); (A.W.); (V.O.); (A.C.S.-R.)
| | - Dennis Polian
- Baylor Athletics, Baylor University, 1500 South University Parks Drive, Waco, TX 76706, USA;
| | - Yiwei Wang
- Center for Innovation in Brain Science, University of Arizona, 1230 N. Cherry Avenue, Tucson, AZ 85719, USA; (Y.W.); (G.D.H.); (C.M.L.); (A.C.R.); (R.D.B.)
| | - Gerson D. Hernandez
- Center for Innovation in Brain Science, University of Arizona, 1230 N. Cherry Avenue, Tucson, AZ 85719, USA; (Y.W.); (G.D.H.); (C.M.L.); (A.C.R.); (R.D.B.)
| | - Claudia M. Lopez
- Center for Innovation in Brain Science, University of Arizona, 1230 N. Cherry Avenue, Tucson, AZ 85719, USA; (Y.W.); (G.D.H.); (C.M.L.); (A.C.R.); (R.D.B.)
| | - Adam C. Raikes
- Center for Innovation in Brain Science, University of Arizona, 1230 N. Cherry Avenue, Tucson, AZ 85719, USA; (Y.W.); (G.D.H.); (C.M.L.); (A.C.R.); (R.D.B.)
| | - Roberta D. Brinton
- Center for Innovation in Brain Science, University of Arizona, 1230 N. Cherry Avenue, Tucson, AZ 85719, USA; (Y.W.); (G.D.H.); (C.M.L.); (A.C.R.); (R.D.B.)
| | - Floyd H. Chilton
- School of Nutritional Sciences and Wellness, University of Arizona, 1230 N Cherry Avenue, Tucson, AZ 85719, USA; (V.A.M.); (S.G.); (D.C.); (A.W.); (V.O.); (A.C.S.-R.)
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N-3 Polyunsaturated Fatty Acids Ameliorate Neurobehavioral Outcomes Post-Mild Traumatic Brain Injury in the Fat-1 Mouse Model. Nutrients 2021; 13:nu13114092. [PMID: 34836347 PMCID: PMC8620437 DOI: 10.3390/nu13114092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022] Open
Abstract
Concussions and mild traumatic brain injury (m-TBI) have been identified as a consequential public health concern because of their potential to cause considerable impairments in physical, cognitive, behavioral, and social functions. Given their prominent structural and functional roles in the brain, n-3 polyunsaturated fatty acids (PUFA) have been identified as a potentially viable prophylactic agent that may ameliorate the deleterious effects of m-TBI on brain function. The purpose of the present pilot study was to investigate the effect of n-3 PUFA on neurologic function using a weight drop injury (WDI) model. Fat-1 mice, capable of synthesizing n-3 PUFA endogenously from n-6 PUFA, and their wild-type (WT) counterparts, were subjected to a mild low-impact WDI on the closed cranium, and recovery was evaluated using the neurological severity score (NSS) to assess the motor and neurobehavioral outcomes. In comparison to the WT mice, the fat-1 mice had a significantly (p ≤ 0.05) lower NSS at all time points post-WDI, and significantly greater neurological restoration measured as the time to first movement. Overall, these findings demonstrate the protective effect of n-3 PUFA against mild brain injury.
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Kunces LJ, Keenan J, Schmidt CM, Schmidt MA. Molecular Deficits Relevant to Concussion Are Prevalent in Top-Ranked Football Players Entering the National Football League Draft. J Strength Cond Res 2021; 35:3139-3144. [PMID: 34533486 DOI: 10.1519/jsc.0000000000004131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
ABSTRACT Kunces, LJ, Keenan, J, Schmidt, CM, and Schmidt, MA. Molecular deficits relevant to concussion are prevalent in top-ranked football players entering the National Football League draft. J Strength Cond Res XX(X): 000-000, 2021-Characterization of blood variants in athletes entering the highly competitive contact environment of professional football can help us understand the risk for brain injury. When coupled with longitudinal follow-up of future concussion incidence and trajectory, it may provide additional insight into factors that influence brain injury. We observed the metabolic phenotype of collegiate football players entering the 2016 National Football League (NFL) draft. The principal aims were to characterize the molecular status of individual athletes and quantify the prevalence of athletes with multiple concurrent molecular deficits. Blood was taken from 30 elite American collegiate football players 7 weeks before the NFL scouting combine and 15 weeks before entering the NFL draft. Average results revealed suboptimal values in Omega-3 Index (avg ± std, 4.66 ± 1.16%), arachidonic acid:eicosapentaenoic acid fatty acid ratio (29.13 ± 10.78), homocysteine (11.4 ± 3.4 µmol·L-1), vitamin D (30 ± 11.4 ng·ml-1), and red blood cell magnesium (4.1 ± 0.8 mg·dl-1). Using sport-optimized reference ranges from previously published research, 10% presented with 3, 40% presented with 4, and 50% of athletes presented with 5 suboptimal values at once. We conclude molecular deficits in this cohort entering the NFL draft were common, with a significant number of athletes presenting with multiple suboptimal levels. The significant commonality of the suboptimal biomarkers is relevance to brain health and function. This data warrant extensive metabolic phenotyping and consideration of prophylactic precision nutrition countermeasures by the multidisciplinary staff for athletes entering contact environments.
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Affiliation(s)
- Laura J Kunces
- Onegevity Health, New York, New York; Thorne HealthTech, Summerville, South Carolina; EXOS, Phoenix, Arizona; and Advanced Pattern Analysis & Countermeasures Group, Boulder, Colorado
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Postolache TT, Wadhawan A, Can A, Lowry CA, Woodbury M, Makkar H, Hoisington AJ, Scott AJ, Potocki E, Benros ME, Stiller JW. Inflammation in Traumatic Brain Injury. J Alzheimers Dis 2021; 74:1-28. [PMID: 32176646 DOI: 10.3233/jad-191150] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
There is an increasing evidence that inflammation contributes to clinical and functional outcomes in traumatic brain injury (TBI). Many successful target-engaging, lesion-reducing, symptom-alleviating, and function-improving interventions in animal models of TBI have failed to show efficacy in clinical trials. Timing and immunological context are paramount for the direction, quality, and intensity of immune responses to TBI and the resulting neuroanatomical, clinical, and functional course. We present components of the immune system implicated in TBI, potential immune targets, and target-engaging interventions. The main objective of our article is to point toward modifiable molecular and cellular mechanisms that may modify the outcomes in TBI, and contribute to increasing the translational value of interventions that have been identified in animal models of TBI.
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Affiliation(s)
- Teodor T Postolache
- Mood and Anxiety Program, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA.,Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Veterans Integrated Service Network (VISN) 19, Aurora, CO, USA.,Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, CO, USA.,Mental Illness Research, Education and Clinical Center (MIRECC), Veterans Integrated Service Network (VISN) 5, VA Capitol Health Care Network, Baltimore, MD, USA
| | - Abhishek Wadhawan
- Mood and Anxiety Program, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA.,Saint Elizabeths Hospital, Department of Psychiatry, Washington, DC, USA
| | - Adem Can
- School of Medicine, University of Maryland Baltimore, Baltimore, MD, USA
| | - Christopher A Lowry
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Veterans Integrated Service Network (VISN) 19, Aurora, CO, USA.,Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, CO, USA.,Department of Integrative Physiology and Center for Neuroscience, University of Colorado Boulder, Boulder, CO, USA.,Department of Physical Medicine and Rehabilitation and Center for Neuroscience, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Margaret Woodbury
- Mood and Anxiety Program, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA.,VA Maryland Healthcare System, Baltimore VA Medical Center, Baltimore, MD, USA
| | - Hina Makkar
- Mood and Anxiety Program, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew J Hoisington
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Veterans Integrated Service Network (VISN) 19, Aurora, CO, USA.,Systems Engineering and Management, Air Force Institute of Technology, Wright-Patterson AFB, OH, USA
| | - Alison J Scott
- Department of Microbial Pathogenesis, University of Maryland School of Dentistry, Baltimore, MD, USA
| | - Eileen Potocki
- VA Maryland Healthcare System, Baltimore VA Medical Center, Baltimore, MD, USA
| | - Michael E Benros
- Copenhagen Research Center for Mental Health-CORE, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - John W Stiller
- Mood and Anxiety Program, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA.,Maryland State Athletic Commission, Baltimore, MD, USA.,Saint Elizabeths Hospital, Neurology Consultation Services, Washington, DC, USA
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McCarty MF, Lerner A. The second phase of brain trauma can be controlled by nutraceuticals that suppress DAMP-mediated microglial activation. Expert Rev Neurother 2021; 21:559-570. [PMID: 33749495 DOI: 10.1080/14737175.2021.1907182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION A delayed second wave of brain trauma is mediated in large part by microglia that are activated to a pro-inflammatory M1 phenotype by DAMP proteins released by dying neurons. These microglia can promote apoptosis or necrosis in neighboring neurons by producing a range of pro-inflammatory cytokines and the deadly oxidant peroxynitrite. This second wave could therefore be mitigated with agents that blunt the post-traumatic M1 activation of microglia and that preferentially promote a pro-healing M2 phenotype. AREAS COVERED The literature on nutraceuticals that might have clinical potential in this regard. EXPERT OPINION The chief signaling pathway whereby DAMPs promote M1 microglial activation involves activation of toll-like receptor 4 (TLR4), NADPH oxidase, NF-kappaB, and the stress activated kinases JNK and p38. The green tea catechin EGCG can suppress TLR4 expression. Phycocyanobilin can inhibit NOX2-dependent NADPH oxidase, ferulate and melatonin can oppose pro-inflammatory signal modulation by NADPH oxidase-derived oxidants. Long-chain omega-3 fatty acids, the soy isoflavone genistein, the AMPK activator berberine, glucosamine, and ketone bodies can down-regulate NF-kappaB activation. Vitamin D activity can oppose JNK/p38 activation. A sophisticated program of nutraceutical supplementation may have important potential for mitigating the second phase of neuronal death and aiding subsequent healing.
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Affiliation(s)
- Mark F McCarty
- Department of research, Catalytic Longevity Foundation, San Diego, California, USA
| | - Aaron Lerner
- Chaim Sheba Medical Center, The Zabludowicz Research Center for Autoimmune Diseases, Tel Hashomer, Israel
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Concussion in the Athletic Training Room: a Team Physician Narrative. Curr Pain Headache Rep 2021; 25:24. [PMID: 33738547 DOI: 10.1007/s11916-021-00937-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF THE REVIEW Concussion evaluation and management has changed significantly. Understanding proper recognition, evaluation, and management allows for improved provision of care to patients. This paper will approach this topic from a sideline to training room management versus the traditional clinic evaluation RECENT FINDINGS: Research is continuing to refine and examine tools to assist in proper concussion evaluation. Concussion recovery protocols are becoming more conservative as patients are taking longer to recover than previously thought. Treatment of concussion is becoming more sophisticated and patient involved. Concussion research has increased dramatically over the last 30 years changing our approach to diagnosis and treatment. The area of concussion will continue to evolve as research continues to look at effective tools and markers for diagnosis and effective treatment protocols become substantiated through research.
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McCarty MF, Lerner A. Nutraceutical induction and mimicry of heme oxygenase activity as a strategy for controlling excitotoxicity in brain trauma and ischemic stroke: focus on oxidative stress. Expert Rev Neurother 2020; 21:157-168. [PMID: 33287596 DOI: 10.1080/14737175.2021.1861940] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Ischemic stroke and traumatic brain injury are leading causes of acute mortality, and in the longer run, major causes of significant mental and physical impairment. Most of the brain neuronal cell death in the minutes and hours following an ischemic stroke or brain trauma is mediated by the process of excitotoxicity, in which sustained elevations of extracellular glutamate, reflecting a failure of ATP-dependent mechanism which sequester glutamate in neurons and astrocytes, drive excessive activation of NMDA receptors. Areas covered: A literature search was undertaken to clarify the molecular mechanisms whereby excessive NMDA activation leads to excitotoxic neuronal death, and to determine what safe nutraceutical agents might have practical potential for rescuing at-risk neurons by intervening in these mechanisms. Expert opinion: Activation of both NADPH oxidase and neuronal nitric oxide synthase in the microenvironment of activated NMDA receptors drives production of superoxide and highly toxic peroxynitrite. This leads to excessive activation of PARP and p38 MAP kinase, mitochondrial dysfunction, and subsequent neuronal death. Heme oxygenase-1 (HO-1) induction offers protection via inhibition of NADPH oxidase and promotion of cGMP generation. Phase 2-inductive nutraceuticals can induce HO-1, and other nutraceuticals can mimic the effects of its products biliverdin and carbon monoxide.
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Affiliation(s)
| | - Aaron Lerner
- Technion Israel Institute of Technology Ruth and Bruce Rappaport Faculty of Medicine- Research, Haifa, Israel (Retired)
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McGeown JP, Hume PA, Theadom A, Quarrie KL, Borotkanics R. Nutritional interventions to improve neurophysiological impairments following traumatic brain injury: A systematic review. J Neurosci Res 2020; 99:573-603. [PMID: 33107071 DOI: 10.1002/jnr.24746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/02/2020] [Accepted: 10/07/2020] [Indexed: 12/25/2022]
Abstract
Traumatic brain injury (TBI) accounts for significant global health burden. Effects of TBI can become chronic even following mild injury. There is a need to develop effective therapies to attenuate the damaging effects of TBI and improve recovery outcomes. This literature review using a priori criteria (PROSPERO; CRD42018100623) summarized 43 studies between January 1998 and July 2019 that investigated nutritional interventions (NUT) delivered with the objective of altering neurophysiological (NP) outcomes following TBI. Risk of bias was assessed for included studies, and NP outcomes recorded. The systematic search resulted in 43 of 3,748 identified studies met inclusion criteria. No studies evaluated the effect of a NUT on NP outcomes of TBI in humans. Biomarkers of morphological changes and apoptosis, oxidative stress, and plasticity, neurogenesis, and neurotransmission were the most evaluated NP outcomes across the 43 studies that used 2,897 animals. The risk of bias was unclear in all reviewed studies due to poorly detailed methodology sections. Taking these limitations into account, anti-oxidants, branched chain amino acids, and ω-3 polyunsaturated fatty acids have shown the most promising pre-clinical results for altering NP outcomes following TBI. Refinement of pre-clinical methodologies used to evaluate effects of interventions on secondary damage of TBI would improve the likelihood of translation to clinical populations.
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Affiliation(s)
- Joshua P McGeown
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand.,Traumatic Brain Injury Network, Auckland University of Technology, Auckland, New Zealand
| | - Patria A Hume
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand.,Traumatic Brain Injury Network, Auckland University of Technology, Auckland, New Zealand.,National Institute of Stroke and Applied Neuroscience (NISAN), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand
| | - Alice Theadom
- Traumatic Brain Injury Network, Auckland University of Technology, Auckland, New Zealand.,National Institute of Stroke and Applied Neuroscience (NISAN), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand
| | | | - Robert Borotkanics
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand
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Peng R, Li H, Yang L, Chen X, Zeng L, Bo Z, Zhang L. Immunonutrition for traumatic brain injury in children and adolescents: protocol for a systematic review and meta-analysis. BMJ Open 2020; 10:e037014. [PMID: 32883725 PMCID: PMC7473625 DOI: 10.1136/bmjopen-2020-037014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is the leading cause of paediatric trauma death and disability worldwide. The 'Guidelines for the Management of Severe Traumatic Brain Injury (Fourth Edition)' recommend that nutritional goals should be achieved within 5-7 days of injury. Immune-enhancing nutrition or immunonutrition, referring to the addition of specialised nutrients, including glutamine, alanine, omega-3 fatty acids and nucleotides, to standard nutrition formulas, may improve surgical outcomes in the perioperative period. However, the role of immune-enhancing nutritional supplements for patients with paediatric TBI remains unclear. We will conduct a systematic review to determine the efficacy and safety of immunonutrition for patients with paediatric TBI and provide evidence for clinical decision-making. METHODS AND ANALYSIS Studies reporting immune-enhancing nutrition treatments for patients with paediatric TBI will be included. Outcomes of interest include the length of hospital stay, wound infections, all-cause mortality, non-wound infection, including pneumonia, urinary tract infection and bacteraemia, and the reports adverse events. Duration of follow-up has no restriction. Primary studies consisting of randomised controlled trials (RCTs) and non-RCTs will be eligible for this review, and only studies published in English will be included. We will search the Medline, Embase and Cochrane Library databases from their inception dates to January 2020. We will also search clinicaltrials.gov and the WHO International Clinical Trials Registry Platform for additional information. Two reviewers will independently select studies and extract data. Risk-of-bias will be assessed with tools based on the Cochrane risk-of-bias criteria and Newcastle-Ottawa Quality Assessment Scale. A meta-analysis will be used to pool data when there are sufficient studies with homogeneity. Heterogeneity of the estimates across studies will be assessed; if necessary, a subgroup analysis will be performed to explore the source of heterogeneity. The Grades of Recommendation, Assessment, Development and Evaluation method will be applied to assess the level of evidence obtained from this systematic review. ETHICS AND DISSEMINATION The proposed systematic review and meta-analysis will be based on published data, and thus ethical approval is not required. The results of this review will be published. PROSPERO REGISTRATION NUMBER CRD42020154814.
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Affiliation(s)
- Rong Peng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
- Department of Clinical Nutrition, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Hailong Li
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lijun Yang
- Department of General Practice Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Xinwei Chen
- Department of Critical Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Zhenyan Bo
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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Ritz PP, Rogers MB, Zabinsky JS, Hedrick VE, Rockwell JA, Rimer EG, Kostelnik SB, Hulver MW, Rockwell MS. Dietary and Biological Assessment of the Omega-3 Status of Collegiate Athletes: A Cross-Sectional Analysis. PLoS One 2020; 15:e0228834. [PMID: 32348305 PMCID: PMC7190167 DOI: 10.1371/journal.pone.0228834] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/07/2020] [Indexed: 01/07/2023] Open
Abstract
Omega-3 fatty acids (ω-3 FA) are associated with cardiovascular health, brain function, reduction of inflammation, and several other physiological roles of importance to competitive athletes. The ω-3 FA status of National Collegiate Athletic Association (NCAA) Division I athletes has not been well-described. The purpose of this study was to evaluate the ω-3 FA status of NCAA Division I athletes using dietary and biological assessment methodology. Athletes from nine NCAA Division I institutions from throughout the U.S. (n = 1,528, 51% male, 34 sports represented, 19.9 ± 1.4 years of age) completed a food frequency questionnaire (FFQ) to assess ω-3 FA from diet and supplements. Omega-3 Index (O3i) was evaluated in a sub-set of these participants (n = 298, 55% male, 21 sports represented, 20.0 ± 1.3 years of age) using dried blood spot sampling. Only 6% (n = 93) of athletes achieved the Academy of Nutrition & Dietetics’ recommendation to consume 500 mg DHA+EPA per day. Use of ω-3 FA supplements was reported by 15% (n = 229) of participants. O3i was 4.33 ± 0.81%, with no participants meeting the O3i benchmark of 8% associated with the lowest risk of cardiovascular disease. Every additional weekly serving of fish or seafood was associated with an absolute O3i increase of 0.27%. Overall, sub-optimal ω-3 FA status was observed among a large, geographically diverse group of male and female NCAA Division I athletes. These findings may inform interventions aimed at improving ω-3 FA status of collegiate athletes. Further research on athlete-specific ω-3 FA requirements is needed.
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Affiliation(s)
- Peter P. Ritz
- Athletics Department, Virginia Tech, Blacksburg, VA, United States of America
| | - Mark B. Rogers
- Athletics Department, Virginia Tech, Blacksburg, VA, United States of America
- Edward Via College of Osteopathic Medicine, Blacksburg, VA, United States of America
| | - Jennifer S. Zabinsky
- Athletics Department, Virginia Tech, Blacksburg, VA, United States of America
- Department of Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VA, United States of America
| | - Valisa E. Hedrick
- Department of Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VA, United States of America
| | - John A. Rockwell
- Department of Medicine, Carilion Clinic, Roanoke, VA, United States of America
| | - Ernest G. Rimer
- Department of Exercise & Sport Science, College of Health, University of Utah, Salt Lake City, UT, United States of America
- Athletics Department, University of Utah, Salt Lake City, UT, United States of America
| | - Samantha B. Kostelnik
- Department of Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VA, United States of America
| | - Matthew W. Hulver
- Department of Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VA, United States of America
- Center for Transformative Research on Health Behaviors, Fralin Biomedical Research Institute Roanoke, Roanoke, VA, United States of America
- Fralin Life Sciences Institute, Virginia Tech, Blacksburg, VA, United States of America
| | - Michelle S. Rockwell
- Department of Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VA, United States of America
- Center for Transformative Research on Health Behaviors, Fralin Biomedical Research Institute Roanoke, Roanoke, VA, United States of America
- * E-mail:
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12
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Yamakawa GR, Eyolfson E, Weerawardhena H, Mychasiuk R. Administration of diphenyl diselenide (PhSe)2 following repetitive mild traumatic brain injury exacerbates anxiety-like symptomology in a rat model. Behav Brain Res 2020; 382:112472. [DOI: 10.1016/j.bbr.2020.112472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/05/2020] [Accepted: 01/05/2020] [Indexed: 02/07/2023]
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13
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Dokalis N, Prinz M. Resolution of neuroinflammation: mechanisms and potential therapeutic option. Semin Immunopathol 2019; 41:699-709. [PMID: 31705317 DOI: 10.1007/s00281-019-00764-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/12/2019] [Indexed: 01/01/2023]
Abstract
The central nervous system (CNS) is comprised by an elaborate neural network that is under constant surveillance by tissue-intrinsic factors for maintenance of its homeostasis. Invading pathogens or sterile injuries might compromise vitally the CNS integrity and function. A prompt anti-inflammatory response is therefore essential to contain and repair the local tissue damage. Although the origin of the insults might be different, the principles of tissue backlashes, however, share striking similarities. CNS-resident cells, such as microglia and astrocytes, together with peripheral immune cells orchestrate an array of events that aim to functional restoration. If the acute inflammatory event remains unresolved, it becomes toxic leading to progressive CNS degeneration. Therefore, the cellular, molecular, and biochemical processes that regulate inflammation need to be on a fine balance with the intrinsic CNS repair mechanisms that influence tissue healing. The purpose of this review is to highlight aspects that facilitate the resolution of CNS inflammation, promote tissue repair, and functional recovery after acute injury and infection that could potentially contribute as therapeutic interventions.
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Affiliation(s)
- Nikolaos Dokalis
- Institute of Neuropathology, Medical Faculty, University of Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Marco Prinz
- Institute of Neuropathology, Medical Faculty, University of Freiburg, Freiburg, Germany. .,Signalling Research Centres BIOSS and CIBSS, University of Freiburg, Freiburg, Germany. .,Center for Basics in NeuroModulation (NeuroModulBasics), Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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14
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Yu J, Zhu H, Taheri S, Monday WL, Perry S, Kindy MS. Reduced Neuroinflammation and Improved Functional Recovery after Traumatic Brain Injury by Prophylactic Diet Supplementation in Mice. Nutrients 2019; 11:nu11020299. [PMID: 30708954 PMCID: PMC6412510 DOI: 10.3390/nu11020299] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 02/08/2023] Open
Abstract
Currently, there are no approved therapeutic drugs for the treatment of traumatic brain injury (TBI), and new targets and approaches are needed to provide relief from the long-term effects of TBI. Recent studies suggest that nutrition plays a critical role in improving the outcome from TBI in both civilians and military personnel. We have previously shown that GrandFusion® (GF) diets improved recovery from cerebral ischemia and enhanced physical activity and endurance in rodent models. We, therefore, sought to determine the impact of a prophylactic diet enriched in fruits and vegetables on recovery from TBI in the controlled cortical impact rodent model. Results demonstrated that mice fed the diets had improved neuromotor function, reduced lesion volume, increased neuronal density in the hippocampus and reduced inflammation. As previously shown, TBI increases cathepsin B as part of the inflammasome complex resulting in elevated inflammatory markers like interleukin-1β (IL-1β). Consumption of the GF diets attenuated the increase in cathepsin B levels and prevented the increase in the proapoptotic factor Bax following TBI. These data suggest that prior consumption of diets enriched in fruits and vegetables either naturally or through powdered form can provide protection from the detrimental effects of TBI.
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Affiliation(s)
- Jin Yu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL 33620, USA.
| | - Hong Zhu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL 33620, USA.
| | - Saeid Taheri
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL 33620, USA.
| | - William L Monday
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL 33620, USA.
| | | | - Mark S Kindy
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL 33620, USA.
- Departments of Molecular Medicine, Molecular Pharmacology, Physiology and Pathology and Cell Biology, and Neurology, College of Medicine, University of South Florida, Tampa, FL 33620, USA.
- James A. Haley VA Medical Center, Tampa, FL 33612, USA.
- Shriners Hospital for Children, Tampa, FL 33612, USA.
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Abstract
Although concussions are common, they are complex, variable, and not entirely understood in terms of pathophysiology and treatment. The incidence of concussion is expected to continue to rise with the increased participation of youth in sports and improved awareness. The role of orthopedic surgeons in concussion management is murky. However, the existing literature does provide a foundation from which orthopedic surgeons who are exposed to concussed patients can function. [Orthopedics. 2019; 42(1):12-21.].
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Polokowski AR, Shakil H, Carmichael CL, Reigada LC. Omega-3 fatty acids and anxiety: A systematic review of the possible mechanisms at play. Nutr Neurosci 2018; 23:494-504. [PMID: 30264663 DOI: 10.1080/1028415x.2018.1525092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Introduction: Anxiety is prevalent, costly, and associated with significant adverse outcomes. The importance of nutrition is underestimated in the management of mental health disorders. In particular, omega-3 fatty acids (ω-3 FAs) are a critical component for healthy development and have been shown to reduce anxiety symptoms. Objective: This paper reviews the current state of the research to identify potential mechanisms underlying the relationship between ω-3 FAs and anxiety reduction. Method: Studies were identified using PubMed, PsycINFO, and CINAHL databases. Results: Of the 197 full-text studies screened, six met criteria for inclusion. Four mechanisms were identified based on primary outcomes reported by each study, Inflammatory Response, Brain-Derived Neurotrophic Factor (BDNF), Cortisol, and Cardiovascular Activity. Conclusion: Five key recommendations are provided to guide future research examining ω-3 FAs and anxiety. They include: (1) standardization of dosage and duration of ω-3 supplementation, (2) more rigorous measurement of variables, (3) effective blinding of participants, (4) designing experiments that test mediation, and (5) increasing sample diversity.
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Affiliation(s)
- Ashley R Polokowski
- The Graduate Center, City University of New York, New York, NY, USA.,Brooklyn College, City University of New York, Brooklyn, NY, USA
| | - Haque Shakil
- Brooklyn College, City University of New York, Brooklyn, NY, USA
| | - Cheryl L Carmichael
- The Graduate Center, City University of New York, New York, NY, USA.,Brooklyn College, City University of New York, Brooklyn, NY, USA
| | - Laura C Reigada
- The Graduate Center, City University of New York, New York, NY, USA.,Brooklyn College, City University of New York, Brooklyn, NY, USA
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Huun MU, Garberg H, Løberg EM, Escobar J, Martinez-Orgado J, Saugstad OD, Solberg R. DHA and therapeutic hypothermia in a short-term follow-up piglet model of hypoxia-ischemia: Effects on H+MRS biomarkers. PLoS One 2018; 13:e0201895. [PMID: 30086156 PMCID: PMC6080779 DOI: 10.1371/journal.pone.0201895] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/24/2018] [Indexed: 12/22/2022] Open
Abstract
Background Therapeutic hypothermia has become the standard of care for newborns with hypoxic-ischemic encephalopathy in high and middle income countries. Docosahexaenoic acid (DHA) has neuroprotective properties of reducing excitotoxicity, neuroinflammation and apoptosis in rodent models. We aim to study whether post hypoxic administration of i.v. DHA will reduce H+MRS biomarkers and gene expression of inflammation and apoptosis both with and without hypothermia in a large animal model. Methods Fifty-five piglets were randomized to severe global hypoxia (N = 48) or not (Sham, N = 7). Hypoxic piglets were further randomized by factorial design: Vehicle (VEH), DHA, VEH + Hypothermia (HT), or DHA + HT. 5 mg/kg DHA was given intravenously 210 min after end of hypoxia. Two-way ANOVA analyses were performed with DHA and hypothermia as main effects. Results Cortical lactate/N-acetylaspartate (Lac/NAA) was significantly reduced in DHA + HT compared to HT. DHA had significant main effects on increasing N-acetylaspartate and glutathione in hippocampus. Therapeutic hypothermia significantly reduced the Lac/NAA ratio and protein expression of IL-1β and TNFα in hippocampus and reduced Troponin T in serum. Neuropathology showed significant differences between sham and hypoxia, but no differences between intervention groups. Conclusion DHA and therapeutic hypothermia significantly improve specific H+MRS biomarkers in this short-term follow up model of hypoxia-ischemia. Longer recovery periods are needed to evaluate whether DHA can offer translational neuroprotection.
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Affiliation(s)
- Marianne Ullestad Huun
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
- * E-mail:
| | - Håvard Garberg
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Else Marit Løberg
- Department of Pathology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Javier Escobar
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Neonatal Research Unit, Health Research Institute Hospital La Fe, Valencia, Spain
| | | | - Ola Didrik Saugstad
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Rønnaug Solberg
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Pediatrics, Vestfold Hospital Trust, Tønsberg, Norway
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18
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Galán-Arriero I, Serrano-Muñoz D, Gómez-Soriano J, Goicoechea C, Taylor J, Velasco A, Ávila-Martín G. The role of Omega-3 and Omega-9 fatty acids for the treatment of neuropathic pain after neurotrauma. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2017; 1859:1629-1635. [PMID: 28495596 DOI: 10.1016/j.bbamem.2017.05.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 12/22/2022]
Abstract
Omega-3 polyunsaturated fatty acids (PUFAs), such as docosaexaenoic acid (DHA) and eicosapentaenoic acid (EPA), mediate neuroactive effects in experimental models of traumatic peripheral nerve and spinal cord injury. Cellular mechanisms of PUFAs include reduced neuroinflammation and oxidative stress, enhanced neurotrophic support, and activation of cell survival pathways. Bioactive Omega-9 monounsaturated fatty acids, such as oleic acid (OA) and 2-hydroxy oleic acid (2-OHOA), also show therapeutic effects in neurotrauma models. These FAs reduces noxious hyperreflexia and pain-related anxiety behavior following peripheral nerve injury and improves sensorimotor function following spinal cord injury (SCI), including facilitation of descending inhibitory antinociception. The relative safe profile of neuroactive fatty acids (FAs) holds promise for the future clinical development of these molecules as analgesic agents. This article is part of a Special Issue entitled: Membrane Lipid Therapy: Drugs Targeting Biomembranes edited by Pablo V. Escribá.
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Affiliation(s)
- Iriana Galán-Arriero
- Sensorimotor Function Group, Hospital Nacional de Parapléjicos, SESCAM, 45071 Toledo, Spain.
| | - Diego Serrano-Muñoz
- Sensorimotor Function Group, Hospital Nacional de Parapléjicos, SESCAM, 45071 Toledo, Spain.
| | - Julio Gómez-Soriano
- GIFTO, Nursing and Physiotherapy Faculty, Universidad de Castilla la Mancha, 45072 Toledo, Spain.
| | - Carlos Goicoechea
- Pharmacology and Nutrition Department, Health Sciences Faculty, Universidad Rey Juan Carlos, 28922 Alcorcón, Madrid, Spain.
| | - Julian Taylor
- Sensorimotor Function Group, Hospital Nacional de Parapléjicos, SESCAM, 45071 Toledo, Spain; Stoke Mandeville Spinal Research, National Spinal Injuries Centre, Buckinghamshire Healthcare NHS Trust, HP21 8AL Aylesbury, UK; Harris Manchester College, OX1 3TD University of Oxford, UK.
| | - Ana Velasco
- Instituto de Neurociencias de Castilla y León, 37007 Salamanca, Spain.
| | - Gerardo Ávila-Martín
- Sensorimotor Function Group, Hospital Nacional de Parapléjicos, SESCAM, 45071 Toledo, Spain.
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