Microvascular diseases: is a new era coming?

The microvascular bed is an anatomical entity which comprises myriads of small arterioles, capillaries and venules. Microvessels and surrounding tissue metabolism are tightly coupled; consequently they are equipped with many, very specific and fine-tuned mechanisms allowing permanent, precise regulation of nutrient delivery. The review thoroughly describes the structure and physiology of arterioles and capillaries as well as the specialized means to investigate them. Microcirculation has been largely neglected for decades, mainly because of lack of technical possibilities for visualization and quantitation. However the past years have completely renewed the scientific interest, due to the combination of the availability of new techniques in human research and the recognition that the microcirculation is autonomically and causally involved in diseases previously thought to be essentially a question of macrocirculation. Today we start to see that microangiopathy is not only a consequence of large vessel diseases but can be the source of many pathologies in both cardiovascular and metabolic disorders, the best example -developed here- being the cardiometabolic syndrome or prediabetes. With very few exceptions, pentoxifylline and the antidiabetic metformin, no specific treatments have been developed for treating disorders at the microcirculatory level. Metformin has unique, intrinsic actions specifically at the level of terminal arterioles, which are completely independent of its antidiabetic effect. Other drugs are shortly described which have revealed a potential interest in this field. Our review aims at showing that microcirculation is entering a new era, starting with rapidly increasing knowledge of its intimate functioning and worth specific pharmacological developments.

Mild acute renal failure potentiates metformin accumulation in the diabetic rat kidney without further impairment of renal function.

OBJECTIVES: To analyze, in acute renal failure (ARF) in diabetic rats, how moderate functional ARF would modify metformin (MET) pharmacokinetics and if plasma and renal tissue MET accumulation could aggravate renal insufficiency and/or elicit plasma lactate accumulation. METHODS: Streptozotocin-induced diabetic rats were allocated to four groups: control, MET, ARF, ARF-MET (6-7 rats per group). MET (100 mg/kg/day) was given per os for two weeks before ARF was induced by drinking restriction and enalapril treatment. The effects of MET and/or ARF were examined in vivo on renal function in conscious rats (metabolic cages) and ex vivo on renal vascular reactivity (isolated kidney). RESULTS: MET treatment (plasma level: 5.3 +/- 1.4 microg/ml, mean+/-SEM), resulted in biguanide accumulation in cortex and medulla (53 +/- 17 and 80 +/- 40 microg/g respectively). MET was devoid of any effect on creatinine clearance, mean blood pressure or renal vascular resistance, but moderately increased plasma lactate (3.8 +/- 0.5 vs 3.2 +/- 0.2 mM, P<0.05) and decreased angiotensin II-induced renal vasoconstriction. ARF, although mild, decreased renal MET clearance (0.29 +/- 0.05 vs 1.01 +/- 0.31 ml/min/100 g, P<0.05) and increased plasma and renal tissue MET levels (x 2-4). MET however did not worsen the fall in glomerular filtration rate, nor modify renal vascular reactivity. ARF did not change the MET-elicited moderate increase in plasma lactate. CONCLUSION: Despite the increase in MET plasma and renal tissue levels subsequent to moderate ARF, no harmful metabolic effect on plasma lactate and no further impairment of renal function was observed in MET-treated diabetic rats subjected to ARF.

Effect of the extract of Ginkgo biloba (EGb 761) on the circulating and cellular profiles of polyunsaturated fatty acids: correlation with the anti-oxidant properties of the extract.

Ginkgo biloba extract (EGb 761) has beneficial effects on cognitive functions in aging patients, and on various pathologies, including cardiovascular diseases. Although the extract is known to have antioxidant properties and improve membrane fluidity, the cellular mechanisms underlying these effects have not been determined. Here, we examined the in vivo effects of EGb 761 on circulating and cellular lipids. EGb 761 treatment induced significant increases in the levels of circulating polyunsaturated fatty acids (PUFAs), and a decrease in the saturation index SI (saturated/polyunsaturated species). Plasma triglycerides and cholesterol were not affected, while phospholipids were slightly increased at the higher dose of EGb 761. EGb 761 treatment also induced a significant increase in the levels of PUFAs in erythrocyte membranes, especially for the eicosapentaenoic acid (EPA omega 3), and a decrease in the saturation index. Moreover, the response of erythrocytes to oxidative stress was improved in EGb 761-treated animals (H(2)O(2)-induced cell lysis decreased by 50%). Considering that PUFAs are known to improve membrane fluidity and response to oxidative damage, and are precursors of signaling molecules such as prostaglandins, the effects of EGb 761 on circulating and cellular PUFAs may explain some of the pharmacological properties of Ginkgo biloba.

Hyperglycaemia modifies the reaction of microvessels to insulin in rat skeletal muscle.

The role played by glucose and/or insulin in local vascular regulation of tissue glucose uptake is largely unknown. Thus, the aim of this study was to examine microvascular changes induced either by hyperinsulinaemia alone or in combination with hyperglycaemia. The effects of insulin or glucose on the diameter and periodic vasomotion of precapillary arterioles (diameter < 20 microm) were determined by using the spinotrapezius muscle preparation in fasted, anaesthetized rats. Ten minutes after s.c. insulin administration, the blood insulin level was greatly increased whereas plasma glucose remained unchanged. This was associated with a marked and durable vasodilation of terminal arterioles without significant changes in vasomotion. When similar plasma insulin levels were attained by glucose infusion, tissue glucose uptake was increased in spite of a partial constriction and increased vasomotion of precapillary arterioles. Importantly, local tissue blood flow was not reduced despite the diminution in microvascular diameters. These results indicate that hyperinsulinaemia alone produces an increase in the diameter of terminal arterioles. This effect seems to be offset when the same level of hyperinsulinaemia is associated with hyperglycaemia (such as occurs postprandially), as illustrated by vasoconstriction of the muscle terminal arterioles. Our data suggest that the vasoconstriction of precapillary arterioles may be part of an active regulation for optimal glucose supply to the tissue in acute hyperglycaemic episodes. These data provide the first direct evidence that insulin and glucose can act as regulators of microflow in the skeletal muscle, as illustrated by changes in precapillary haemodynamics.

Tetanie latente: action d'une eau minerale naturelle magnesienne (hydroxydase) / Tetany: action of natural magnesian mineral water (hydroxydase)

Chez un groupe de 10 sujets dont la tetanie latente a ete verifiee par une echelle specifique validee, appelee echelle de spasmophilie, un traitement par deux cures d'eau d'Hydroxydase a ete mis en place. Cette... (AU)

Metformin induces an agonist-specific increase in albumin production by primary cultured rat hepatocytes.

Metformin (MET) is known to increase several biological effects of insulin (INS), but there is no information concerning its direct effects on protein synthesis. We studied the action of MET on albumin production by primary cultures of freshly isolated rat hepatocytes, alone or in combination with various agonists: INS, IGF-1, EGF, thyroxin, and dexamethasone. While having no effect alone, MET in vitro potentiates the effects of INS, IGF-1, and EGF. When this increasing effect toward INS was studied over a broad concentration range, MET appeared to improve low-acting INS levels and to intensify the maximal INS effects. In contrast, MET did not change the production of albumin stimulated by thyroxin or dexamethasone. Animals chronically pretreated with MET in vivo showed a higher yield of isolated hepatocytes, better attachment, and especially higher viability after liver perfusion and during cell culture. This may largely explain why basal albumin rates were higher than in in vitro-treated cells. The effect of MET in the presence of the agonists exhibited the same agonist-specificity as in vitro. Our data provide new insights into the pharmacology of MET by showing that hepatic protein synthesis is increased by MET and INS. From the specificity of action of MET towards INS, IGF-1, and EGF (but not thyroxin or dexamethasone), we hypothesize that this biguanide may act on intracellular pathways located between membrane receptors and sites of branching in the signaling cascades shared by these agonists.

Metabolic and drug distribution studies do not support direct inhibitory effects of metformin on intestinal glucose absorption.

In an attempt to clarify the question of an involvement of the inhibition of intestinal glucose absorption in the mechanism of action of Metformin, we used several experimental approaches: 1 glucose/lactate measurement in rat portal blood in vivo and 2 in the venous effluent of an isolated perfused rat intestinal segment; 3 metabolism of freshly isolated enterocytes in vitro and tissue distribution of 3H-labeled Metformin was investigated both in vivo and in vitro. Metformin applied intraluminally had no significant effect on portal glycaemia after a glucose load, but lactate increased, whereas in vivo only a high Metformin dosage reduced portal glucose appearance significantly. Although high Metformin concentrations were found in gut biopsies, precise histological analysis in the isolated intestine revealed that it was absent from enterocytes; however the drug accumulated in villous lacteals. Intrarterially applied Metformin decreased glucose absorption in the isolated perfused ileo-jejunal segment. These data suggested that vascular Metformin boosted intestinal anaerobic glucose metabolism. Biochemical measurements performed on freshly isolated enterocytes showed that even high Metformin levels did not interfere with cell respiration or with Na+/K+ ATPase activity. Thus, our data agree with other recent reports, suggesting that even at nontherapeutic concentrations Metformin has no relevant inhibitory effect on intestinal glucose absorption. The data are discussed in the frame of previous divergent observations. The results suggest however that Metformin of vascular origin stimulates glucose consumption by the intestine, which then increases lactate output from the gut.

Demonstration of the "anti-stress" activity of an extract of Ginkgo biloba (EGb 761) using a discrimination learning task.

1. Young (4-month-old) and old (20-month-old) rats, maintained under water restriction, were trained to discriminate to obtain a small amount of drinking water as a reward. Each animal had to learn to press a lever corresponding to a light that was randomly distributed on the left or right. 2. Introduction of an auditory perturbation ("stress") during the discriminative phase of learning modified the capacity and rate of acquisition in both young and old animals, changes that were correlated with increases in plasma concentrations of epinephrine, norepinephrine and corticosterone. 3. Stress-induced detrimental changes in both discrimination learning and plasma hormones were suppressed by 20 days of oral treatment with an extract of Ginkgo biloba leaves (EGb 761; 50 or 100 mg/kg/day) in both young and old rats, effects that became statistically significant by the third day of learning (time of maximal acquisition rate). 4. EGb 761 treatment was less effective in increasing the percentage of efficient lever presses in old than in young rats, but more effective in decreasing the number of inefficient lever presses and reaction time in the older animals. 5. These results indicate that EGb 761 can facilitate behavioral adaptation despite adverse environmental influences, a property that supports its clinical use in treating cognitive impairment, especially in elderly patients.

Demonstration of defective glucose uptake and storage in erythrocytes from non-insulin dependent diabetic patients and effects of metformin.

1. Red blood cells can store glucose and may thus participate in blood glucose homeostasis. We investigated if a defect in this process exists in non-insulin dependent diabetes (NIDD). 2. Blood was obtained in fasting conditions from 10 normal and 10 newly diagnosed NIDD patients (before and after 4 weeks Metformin therapy). Washed erythrocytes were resuspended in media containing various glucose concentrations (4.4, 6.6, 8.8 and 13.2 mmol/L). Total glucose uptake was calculated as the sum of the measurements of lactate as well as free glucose, the latter being determined before and after addition of amyloglucosidase to the pellet. 3. Cells from diabetics showed a pronounced reduction in glucose uptake, particularly in their capacity to store glucose as glycogen (reactive to amyloglucosidase). Metformin treatment almost normalized glycogen levels, whereas lactate declined concomitantly in the pellet. 4. Our data demonstrate that a defect in glucose uptake exists in erythrocytes from NIDD patients, affecting both free and stored glucose, and that this defect is reversed by Metformin treatment, indicating that this drug can increase glycogen levels even in insulin-insensitive cells. 5. Thus, in view of their total mass, erythrocytes may be important in the impaired glucose homeostasis in NIDD, in particular in marked hyperglycaemia such as after a meal.

Postischemic breakdown in hippocampal protein synthesis and mnesic deficits in rats: pharmacological improvement by curative naftidrofuryl treatment.

This work was designed to investigate the effects of brain ischemia on mnesic retention in the model of unilateral microsphere embolization in rats. Using various radioactive tracers as well as a learning/memory test, we could correlate following parameters: regional blood flow, protein synthesis and memory retention. All were severely impaired by the hemispheric multi-infarction. A curative treatment with naftidrofuryl (15 mg/kg i.p.) for 3 consecutive days strongly improved the mnesic capacities of the animals, and this effect was corroborated by a marked protective drug action on protein synthesis in the hippocampus. Indeed, studies on valine incorporation into proteins revealed that, despite having no quantitative effect on regional blood flow, naftidrofuryl allowed an almost normal functioning of protein synthesis. As naftidrofuryl had also no direct effect on protein synthesis in the intact contralateral hemisphere, this effect was consequently attributed to the metabolic and/or antiserotoninergic effects of the drug.

Erythrocyte glucose consumption in insulin-dependent diabetes: effect of metformin in vitro.

Erythrocyte glucose consumption in red blood cells from healthy donors or insulin-dependent diabetics with stable glycemia was measured using the 2-deoxyglucose technique. Data showed that the formation of glucose-6P was severely impaired in diabetic red blood cells in both normo- and hyperglycemic incubation conditions. This defect seems to be inherent to the disease. Coincubation with Metformin (6.4 ug/ml) did not modify the G6P levels in RBCs from healthy donors and in RBCs from diabetics when incubated in normoglycemic conditions. However, when diabetics RBCs were incubated in a hyperglycemic medium, addition of Metformin strongly improved the intracellular levels of G6P. The underlying mechanism for the defect and the correction by Metformin remains to be determined. This study shows that also red blood cells may be involved in the failure of glucose homeostasis in diabetes and thus this may represent an additional target for therapy.

[Changes in erythrocyte deformability in Alzheimer's disease]. / Modification de la déformabilité érythrocytaire dans la maladie d'Alzheimer.

In a previous work we showed an alteration of erythrocyte filtration ability in patients with Alzheimer's disease according to their age and illness duration. This study has for aim to find a criteria of deformability that would be constant in all Alzheimer patients and would show a modification of red cell membranes. The erythrocyte filterability was studied in this present paper, in accord to Reid and Dormandy method using two values of depression (5 and 0 cm of water). These depressions correspond to the physiological values of blood pressure at the level of precapillary and capillary systems. The ratio between the result obtained at 5 cm and the result at 0 cm is constant in normal patient without organic disease and it is independent of age. At the opposite, this ratio increase very significantly in all Alzheimer patients, and this is not correlated to the initial value of filtrability. This ratio could be an index of the alteration of red cell membranes.

Models of hypoxia and cerebral ischemia.

Most models of hypoxia and ischemia are used for evaluating the metabolic consequences of cerebral insult. They have also been used for inducing cognitive disturbance. The pathological cascade after severe hypoxia or ischemia includes decreased ATP, influx of Ca2+ and Na+ with decrease in intracellular K+ leading to depolarization, release of glutamate, noradrenaline and acetylcholine, changes in neuronal plasticity, cell death, and cognitive impairment. Possible pharmacological mechanisms for protecting brain function include blockade of Ca2+ influx, inhibition of cell swelling, regulation of membrane potential, inhibition of neurotransmitter release and inhibition of excitatory amino-acid receptors. Among the existing models, many suffer from poor reproducibility and standardization. Two models which are more satisfactory in this respect are global transient ischemia in gerbils induced by bilateral carotid occlusion and focal ischemia in rats induced by occlusion of the middle cerebral artery. Although clear protective effects have been observed in both kinds of model (e.g., with NMDA antagonists, Ca2+ antagonists, PAF antagonists) it is frequently difficult to extrapolate these effects to disorders associated with memory impairment.

National Alzheimer's disease program.

The psycho-behavioral troubles of patients with an Alzheimer's Disease (AD) are such that it is very difficult to keep those patients within the normal family environment, and that it therefore proves necessary to have them placed in a specially adapted residence manned by a highly specialised medical and para-medical staff. Within the frame of such an approach, a new type of residence has been devised "Asclepios Gardens", a one-level ranch-type residence, including 44 individual apartments, each opening, on the one hand, on a little private garden opening itself on a large, strictly enclosed and protected, 5-acre park, and, on the other hand, on a collective living structure conceived for social activities under attentive medical care, to help the patients restore their social structures. In a such residences, besides the special training given to the staff (medical, para-medical), aimed at developing as much as possible the patients' autonomy and self-reliance in every aspect of everyday life, you find a psychometric computerized "activation" program, devised both on a collective basis with differentiated subprograms, for groups of patients that have been classified according to the degree of seriousness of their problem, and-whenever possible, with individual attention programs; the whole of this "activation" method has thus clearly a double target; first to develop what is left of the patients' autonomy, for instance by psychometric exercises, and moreover, to have them start new activities, which they had never practised before--this latter action with a view to developing their neuroplasticity resources. And finally, a new chemical therapy is proposed. This substance induced a significant improvement in 40% of cases and a slight improvement in 20%. These results were observed through a series of specific psychometric tests (Visuo Retention Test of Benton, Mnesic profile of Rey), a global scale (Mini Mental State), and a general evaluation of the patients' daily activities by the General Practitioner and by the family. These preliminary data very interesting yet must be confirmed in a larger Alzheimer population.

Memory complaints in the elderly: a study of 367 community-dwelling individuals from 50 to 80 years old.

State of memory was evaluated by a Memory Clinic in 367 community-dwelling patients aged from 50 to 80. They performed an exhaustive subjective evaluation including: severity of memory complaint, social status, activity scale, subjective Memory score, Zung's anxiety and depression scales and Well Being Questionnaire. Objective memory performance was evaluated by a complete memory scanning leading to a Global Objective Memory Score. No relationship was found between severity of memory complaints and age, sex, educational level, marital status, living alone or in family, and memory tests performance. More severe complaints were reported in people with poor social network, negative stereotypes on aging, and poor affective status. A strong correlation was found between severity of memory complaints and scores in self-reporting depression questionnaire, even in people with low depression scores.

Amines for brain tomoscintigraphy.

Amines like N-isopropyl-p-123I-iodoamphetamine (IMP) and hydroxy 123I-iodobenzyl propyl diamine (HIPDM) associated with brain tomoscintigraphy have proved their worth for detecting ischaemic abnormalities. Even though the chemistry of their metabolism and their biodistribution are not fully understood, their application in the study of parenchymal impairment in stroke and reversible ischaemia yields additional information compared to the other methods of imaging like CT or MRI. The concept of a steady state in brain with a wash in/wash out model has been considered especially with IMP, to explain the evolution of the activity pattern with time when comparing early and delayed images. (This review leads to foresee the prognosis of of ischaemic diseases when redistribution is taken into account.)

Temporal evolution of brain distribution of IMP and HIPDM. Concise communication.

Early and late brain distribution of iodine-labelled N,N,N'-trimethyl-N'-(2-hydroxy-3-methyl-5-iodobenzyl)-1,3-propanediamine (HIPDM) and iodine labelled N-isopropyl-p-iodoamphetamine (IMP) were compared in rat and one human patient with a recent stroke in the right middle cerebral artery area. In rat, an important 'redistribution' of cerebral activity was observed in various areas of the brain, mainly white matter, whereas no such observation was made with HIPDM. In the patient, the right area was hypoactive during the early SPECT with IMP and HIPDM, and redistribution was observed in the late SPECT only with IMP. We suggest that while HIPDM appears to reflect regional cerebral perfusion, IMP distribution is dependent upon metabolic brain activity.

[Cerebral glucose consumption. The effect of Ginkgo biloba extract]. / Consommation cérébrale du glucose. Effet de l'extrait de Ginkgo biloba.

Deoxyglucose is transported under the same conditions as glucose from blood to cerebral tissue. Deoxyglucose-6-phosphate, which cannot be neither metabolized nor eliminated, accumulates in cells. This accumulation is correlated with glucose consumption. In this study, two parameters, transfer rate of deoxyglucose and glucose consumption were measured by means of quantitative autoradiography in two experimental models: normobaric hypoxia and carotid clamping in rats. Normobaric hypoxia induced a decrease in both transfer rate and glucose consumption. Ligature of the carotid artery induced a diminution of glucose consumption greater than that of transfer rate. After administration of Ginkgo biloba extract, glucose consumption was partly reestablished in both experimental models, but the transfer rate of deoxyglucose was increased only in normobaric hypoxia.