Chia-Wei Liou

Increased Oxidative Damage with Altered Antioxidative Status in Type 2 Diabetic Patients Harboring the 16189 T to C Variant of Mitochondrial DNA

Abstract: A transition of T to C at nucleotide position 16189 in mitochondrial DNA (mtDNA) has attracted biomedical researchers for its probable correlation with the development of diabetes mellitus in adult life. In diabetes, persistent hyperglycemia may cause high production of free radicals. Reactive oxygen species are thought to play a role in a variety of physiologic and pathophysiologic processes in which increased oxidative stress may play an important role in disease mechanisms. The aim of the present study was to clarify the degree of oxidative damage and plasma antioxidant status in diabetic patients and to see the potential influence of the 16189 variant of mtDNA on the oxidative status in these patients. An indicative parameter of lipid peroxidation, malondialdehyde (MDA), and total free thiols were measured from plasma samples of 165 type 2 diabetic patients with or without this variant and 168 normal subjects. Here we report an increase in the plasma levels of MDA and total thiols in type 2 diabetic patients compared with control subjects. The levels of plasma thiols in diabetic patients with the 16189 variant of mtDNA were not different from those in controls. These results suggest an increase in the oxidative damage and a compensatory higher antioxidative status in patients with type 2 diabetes. Harboring the 16189 mtDNA variant may impair the ability of a cell to respond properly to oxidative stress and oxidative damage.

2017 Taiwan lipid guidelines for high risk patients

In Taiwan, the prevalence of hyperlipidemia increased due to lifestyle and dietary habit changes. Low density lipoprotein cholesterol (LDL-C) and non-high density lipoprotein cholesterol (non-HDL-C) are all significant predicting factors of coronary artery disease in Taiwan. We recognized that lipid control is especially important in patients with existed atherosclerotic cardiovascular diseases (ASCVD), including coronary artery disease (CAD), ischemic stroke and peripheral arterial disease (PAD). Because the risk of ASCVD is high in patients with diabetes mellitus (DM), chronic kidney disease (CKD) and familial hypercholesterolemia (FH), lipid control is also necessary in these patients. Lifestyle modification is the first step to control lipid. Weight reduction, regular physical exercise and limitation of alcohol intake all reduce triglyceride (TG) levels. Lipid-lowering drugs include HMG-CoA reductase inhibitors (statins), cholesterol absorption inhibitors (ezetimibe), proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, nicotinic acids (niacin), fibric acids derivatives (fibrates), and long-chain omega-3 fatty acids. Statin is usually the first line therapy. Combination therapy with statin and other lipid-lowering agents may be considered in some clinical settings. For patients with acute coronary syndrome (ACS) and stable CAD, LDL-C < 70 mg/dL is the major target. A lower target of LDL-C <55 mg/dL can be considered in ACS patients with DM. After treating LDL-C to target, non-HDL-C can be considered as a secondary target for patients with TG ≥ 200 mg/dL. The suggested non-HDL-C target is < 100 mg/dL in ACS and CAD patients. For patients with ischemic stroke or transient ischemic attack presumed to be of atherosclerotic origin, statin therapy is beneficial and LDL-C < 100 mg/dL is the suggested target. For patients with symptomatic carotid stenosis or intracranial arterial stenosis, in addition to antiplatelets and blood pressure control, LDL-C should be lowered to < 100 mg/dL. Statin is necessary for DM patients with CV disease and the LDL-C target is < 70 mg/dL. For diabetic patients who are ≥ 40 years of age, or who are < 40 years of age but have additional CV risk factors, the LDL-C target should be < 100 mg/dL. After achieving LDL-C target, combination of other lipid-lowering agents with statin is reasonable to attain TG < 150 mg/dL and HDL-C >40 in men and >50 mg/dL in women in DM. LDL-C increased CV risk in patients with CKD. In adults with glomerular filtration rate (GFR) < 60 mL/min/1.73m2 without chronic dialysis (CKD stage 3-5), statin therapy should be initiated if LDL-C ≥ 100 mg/dL. Ezetimibe can be added to statin to consolidate the CV protection in CKD patients. Mutations in LDL receptor, apolipoprotein B and PCSK9 genes are the common causes of FH. Diagnosis of FH usually depends on family history, clinical history of premature CAD, physical findings of xanthoma or corneal arcus and high levels of LDL-C. In addition to conventional lipid lowering therapies, adjunctive treatment with mipomersen, lomitapide, or PCSK9 inhibitors become necessary to further reduce LDL-C in patients with FH. Overall, these recommendations are to help the health care professionals in Taiwan to treat hyperlipidemia with current scientific evidences. We hope the prescription rate of lipid lowering drugs and control rate of hyperlipidemia in high risk patients could be increased by implementation of the clinical guidelines. The major purpose is to improve clinical outcomes of these high risk patients through the control of hyperlipidemia.

Predicting 3-month Mortality Among Patients Hospitalized for First-ever Acute Ischemic Stroke

BACKGROUNDnThe clinical course of patients with acute ischemic stroke tends to be unstable. Understanding the factors contributing to the progression of stroke is important for the appropriate management of patients. This study investigated the factors related to 3-month mortality at admission in patients with first-ever acute ischemic stroke.nnnMETHODSnPatients with first-ever acute ischemic stroke consecutively admitted to a medical center in Taiwan within 48 hours after stroke onset were prospectively followed-up for 3 months. All deaths during this 3-month post-stroke period were analyzed. We evaluated only those characteristics that could be assessed at admission. Multivariate logistic regression analysis was used to identify the main predictors of 3-month stroke-related mortality.nnnRESULTSnIn the 360 enrolled patients, the inhospital mortality rate was 7.8% (28 deaths), and the 3-month mortality rate was 9.7% (35 deaths). Twenty-seven deaths (77%) were stroke-related. Risk factors for mortality at 3 months included sex (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.08-9.41; p=0.036), National Institutes of Health Stroke Scale (NIHSS) at admission (per unit increase: OR, 1.17; 95% CI, 1.12-1.22; p<0.001), history of cardiac disease (OR, 2.73; 95% CI, 1.04-7.16; p=0.042), and posterior circulation stroke (OR, 5.25; 95% CI, 1.92-14.36; p=0.001).nnnCONCLUSIONnThis study of hospital-based data on patients with first-ever acute ischemic stroke in Taiwan found that initial NIHSS, posterior circulation stroke and history of cardiac disease were risk factors for 3-month mortality.

Association of the mitochondrial DNA 16189 T to C variant with lacunar cerebral infarction: evidence from a hospital-based case-control study.

Abstract: A transition of T to C at nucleotide position 16189 in the hypervariable D‐loop region of mitochondrial DNA (mtDNA) has attracted research interest for its probable correlation with increasing insulin resistance and development of diabetes mellitus (DM) in adult life. In this article, we present our observations of the positive relationship between this variant and cerebral infarction. Six hundred and one subjects in two groups—one with cerebral infarction (307 cases), the other with no cerebral infarction (294 cases)—were recruited. Their clinical features, fasting blood sugar and insulin levels, and insulin resistance index, were recorded. Patients with cerebral infarction were further categorized into four different subgroups according to the TOAST criteria for stroke classification. The results showed the occurrence of the mtDNA 16189 variant in 34.2% of patients with cerebral infarction and in 26.5% of normal controls. The difference in the occurrence rates between the two groups was statistically significant (P= 0.041). Further studies of the occurrence rate in each stroke subgroup revealed that the variant occurred at the highest frequency in the small vessel subgroup (41.5%). The difference in occurrence rate between this subgroup and the normal controls is highly significant (P= 0.006). These results correlated well with the findings of significantly increased levels of average fasting blood insulin and a higher index of average insulin resistance in the small vessel subgroup of patients harboring this mtDNA variant. Taken together, we suggest that the mtDNA 16189 variant is a predisposing genetic factor for the development of insulin resistance and may be related to various phenotypic expressions in adult life such as development of DM and vascular pathologies involved in stroke and cardiovascular diseases.

Preferential involvement of mitochondria in Toll-like receptor 3 agonist-induced neuroblastoma cell apoptosis, but not in inhibition of cell growth

Double-stranded RNA (dsRNA) can mediate its therapeutic effect through Toll-like receptor 3 (TLR3) expressed on tumor cells including neuroblastoma. We used synthetic dsRNA polyinosinic-polycytidylic acid [Poly(I:C)] as a TLR3 agonist to treat TLR3-expressing SK-N-AS neuroblatoma (NB) cells. We found up-regulation of endoplasmic reticulum (ER) stress proteins glucose-regulated protein 78 and inositol-requiring enzyme 1. Bafilomycin A1, an inhibitor of ER function, effectively blocked poly(I:C)-induced activation of caspase-8, -9, and -3, MnSOD and glutathione peroxidase 1 and reduced poly(I:C)-induced SK-N-AS apoptosis. Pan caspase inhibitor and inhibitor of caspase-9, but not of caspase-8, inhibited poly(I:C)-induced activated caspase-3 expression. Rho zero (ρ0)-SK-N-AS cells were resistant to poly(I:C)-induced mitochondrial reactive oxygen species production and apoptosis, but not to inhibition of cell growth, as compared to parent SK-N-AS cells. Taking together, these findings suggest that mitochondria are preferentially involved in poly(I:C)-induced NB cell apoptosis, but not in inhibition of cell growth. A crosstalk between mitochondria and ER is implicated.

Prognosis of symptomatic patients with the A3243G mutation of mitochondrial DNA

BACKGROUND/PURPOSEnThe clinical analyses and prognoses of mitochondrial diseases with A3243G mutation are rarely documented in Taiwan. Our study investigated the clinical phenotypes and thexa0outcomes of patients with mitochondrial disease and the A3243G mutation of mtDNA in a Taiwanese population, and compared these with previous reports.nnnMETHODSnWe retrospectively studied 22 consecutive patients with mitochondrial disease and the A3243G mutation of mtDNA in Chang Gung Memorial Hospital between 1988 and 2009. All patients underwent a detailed demographic registration, neurological examinations, a muscle biopsy, and mitochondrial DNA analysis. Modified Rankin scale, the presence of recurrent strokes or seizures, critical medical complications, and death were monitored during the follow-up period.nnnRESULTSnOf the 22 patients, seizures and stroke-like episodes were found in 12 (55%). Visceral involvement, including cardiomyopathy, nephropathy, and pulmonary hypertension, were noted in five patients (23%). Patients with seizures had a high frequency of status epilepticus (92%) and a younger age of onset (21.3±7.2 years). Both the Kaplan-Meier survival analysis and the Cox-regression model showed a marked deterioration in patients with seizures after 7 years of follow-up.nnnCONCLUSIONnOur study found that seizures and status epilepticus are the most important predictive values for a poor outcome in patients with the mtA3243G mutation of mtDNA. Age of onset and visceral organ involvement had no prominent influence on the prognosis. Some medical complications could be well controlled or even reversed after management.

Lack of Relation Between Severity of Stroke and Severity of Extracranial Internal Carotid Artery Lesions in Taiwanese First-Ever Ischemic Stroke Patients

Background and Purpose. The authors attempt to determine whether hemodynamically significant extracranial internal carotid artery (ICA) lesions correlate with the severity of first‐ever hemispheric ischemic stroke. Methods. Carotid duplex was used to evaluate carotid arteries. The National Institutes of Health Stroke Scale was used to describe the severity of the stroke and was stratified as follows: 1–6 = mild, 7–15 = moderate, >15 = severe. Duplex findings were categorized according to velocity criteria into <50% stenosis if ICA peak systolic velocity (PSV) (cm/s) <140 and >50% stenosis if ICA PSV >140 or ratio of ICA and common carotid artery in PSV >2. No detectable flow at ICA was considered occlusion. Stroke subtype was classified according to TOAST criteria. Results. Two hundred nineteen consecutive patients were enrolled, including 127 with mild, 65 with moderate, and 27 with severe stroke. The prevalence of ICA stenosis >50% in each group was 3.6%, 1.4%, 0.9%, respectively. Two patients in the severe group had total ICA occlusion. The overall prevalence of significant ICA lesions was 6.8%. Conclusions. There is no positive correlation of stroke severity with the severity of duplex findings, which may be due to low prevalence of significant ICA lesions or other stroke mechanisms. Most of the patients had mild stroke, and the majority had ICA stenosis <50%. Small‐vessel occlusion tended to have mild severity of stroke. Intracranial artery lesions or other factors causing stroke in Taiwanese should be investigated. Given the low incidence of significant extracranial carotid disease in symptomatic Taiwanese stroke patients, routine screening of symptomatic Taiwanese for extracranial carotid artery disease does not provide enough information to determine stroke mechanism, and transcranial Doppler should be added to the screening tests.

Low Antioxidant Content and Mutation Load in Mitochondrial DNA A3243G Mutation-Related Diabetes Mellitus

BACKGROUND AND PURPOSEnDiabetes mellitus (DM) is a common clinical manifestation in patients harboring mitochondrial encephalomyopathy, lactic acidosis with stroke-like episodes (MELAS)-specific A3243G mitochondrial DNA (mtDNA) mutation. However, in some MELAS family members, the presence of mtDNA mutation in the blood is not always associated with DM, and the relationship between development of DM and A3243G mtDNA mutation is not fully understood. This study evaluated the relationship between A3243G mtDNA mutation and DM in a Taiwanese family.nnnMETHODSnWe analyzed the relation of genotypic and phenotypic characteristics in a 2-generation DM family associated with the A3243G mtDNA mutation. The contents of mutant mtDNA in various tissue samples of 11 family members and their serum levels of antioxidants, including protein thiols and alpha-tocopherol (vitamin E) were determined and correlated with their past history and various clinical manifestations.nnnRESULTSnDM in 4 members of the first and second generations was associated with age and decreased serum levels of antioxidant protein thiols. In a series of studies of mutant mtDNA content in various tissues, a relatively low proportion of A3243G mutant mtDNA was noted in the elderly proband and her elderly symptomatic siblings. A low proportion of mutant mtDNA was also noted in a younger family member presenting with DM. Moreover, a significantly lower average level of protein thiols was found in the symptomatic family members compared to the asymptomatic members (2.3 +/- 0.2 vs 3.5 +/- 0.54 nmol/mg protein, p < 0.05).nnnCONCLUSIONSnThe finding of relatively lower levels of mutant mtDNA in the elderly proband and her elderly symptomatic family members indicates that DM may be a late phenotypic expression in patients harboring MELAS-specific mtDNA mutation. Decreased serum protein thiols, suggestive of increased oxidative stress, also appear to be an early sign associated with subsequent development of DM.

Association of the Mitochondrial DNA 16189 T to C Variant with Lacunar Cerebral Infarction

A transition of T to C at nucleotide position 16189 in the hypervariable D-loop region of mitochondrial DNA (mtDNA) has attracted research interest for its probable correlation with increasing insulin resistance and development of diabetes mellitus (DM) in adult life. In this article, we present our observations of the positive relationship between this variant and cerebral infarction. Six hundred and one subjects in two groups-one with cerebral infarction (307 cases), the other with no cerebral infarction (294 cases)-were recruited. Their clinical features, fasting blood sugar and insulin levels, and insulin resistance index, were recorded. Patients with cerebral infarction were further categorized into four different subgroups according to the TOAST criteria for stroke classification. The results showed the occurrence of the mtDNA 16189 variant in 34.2% of patients with cerebral infarction and in 26.5% of normal controls. The difference in the occurrence rates between the two groups was statistically significant (P = 0.041). Further studies of the occurrence rate in each stroke subgroup revealed that the variant occurred at the highest frequency in the small vessel subgroup (41.5%). The difference in occurrence rate between this subgroup and the normal controls is highly significant (P = 0.006). These results correlated well with the findings of significantly increased levels of average fasting blood insulin and a higher index of average insulin resistance in the small vessel subgroup of patients harboring this mtDNA variant. Taken together, we suggest that the mtDNA 16189 variant is a predisposing genetic factor for the development of insulin resistance and may be related to various phenotypic expressions in adult life such as development of DM and vascular pathologies involved in stroke and cardiovascular diseases.