A protocol update for the Selenium Treatment and Chagasic Cardiomyopathy (STCC) trial.

Several studies evaluating clinical forms of chronic Chagas disease show that about one-third of patients present cardiac involvement. Heart failure, sudden death and cardioembolic stroke are the main mechanisms of death in Chagas heart disease. The impact of specific etiologic treatment on the prognosis of patients with chronic Chagas heart disease is very limited regardless of the presence or absence of heart failure. Patients with symptomatic Chagas heart disease present serum selenium (Se) levels lower than patients without Chagas heart disease. Moreover, Se supplementation in animal models showed promising results. The aim of this trial is to estimate the effect of Se treatment on prevention of heart disease progression in patients with Chagas cardiomyopathy. However, we had to introduce some protocol modifications in order to keep trial feasibility, as follows: the primary outcome was restricted to left ventricular ejection fraction as a continuous variable, excluding disease progression; the follow-up period was decreased from 5 years to 1 year, an adjustment that might increase the participation rate of our study; the superior age limit was increased from 65 to 75 years; and diabetes mellitus was no longer considered an exclusion criterion. All of these protocol modifications were extensively debated by the research team enrolled in the design, recruitment and conduction of the clinical trial to guarantee a high scientific quality. TRIAL REGISTRATION: Clinical Trials.gov, NCT00875173 . Registered on 20 October 2008.

Pharmaconutrition with selenium in critically ill patients: what do we know?

Selenium is a component of selenoproteins with antioxidant, anti-inflammatory, and immunomodulatory properties. Systemic inflammatory response syndrome (SIRS), multiorgan dysfunction (MOD), and multiorgan failure (MOF) are associated with an early reduction in plasma selenium and glutathione peroxidase activity (GPx), and both parameters correlate inversely with the severity of illness and outcomes. Several randomized clinical trials (RCTs) evaluated selenium therapy as monotherapy or in antioxidant cocktails in intensive care unit (ICU) patient populations, and more recently several meta-analyses suggested benefits with selenium therapy in the most seriously ill patients. However, the largest RCT on pharmaconutrition with glutamine and antioxidants, the REducing Deaths due to Oxidative Stress (REDOXS) Study, was unable to find any improvement in clinical outcomes with antioxidants provided by the enteral and parenteral route and suggested harm in patients with renal dysfunction. Subsequently, the MetaPlus study demonstrated increased mortality in medical patients when provided extra glutamine and selenium enterally. The treatment effect of selenium may be dependent on the dose, the route of administration, and whether administered with other nutrients and the patient population studied. Currently, there are few small studies evaluating the pharmacokinetic profile of intravenous (IV) selenium in SIRS, and therefore more data are necessary, particularly in patients with MOD, including those with renal dysfunction. According to current knowledge, high-dose pentahydrate sodium selenite could be given as an IV bolus injection (1000-2000 µg), which causes transient pro-oxidant, cytotoxic, and anti-inflammatory effects, and then followed by a continuous infusion of 1000-1600 µg/d for up to 10-14 days. Nonetheless, the optimum dose and efficacy still remain controversial and need to be definitively established.

Selenium Treatment and Chagasic Cardiopathy (STCC): study protocol for a double-blind randomized controlled trial.

BACKGROUND: Heart disease progression occurs in 30% of patients with chronic Trypanosoma cruzi infection. Supplementation with selenium (Se) in animal model of T. cruzi infection produced promising results. There is evidence that patients with Chagas heart disease have lower Se levels than healthy individuals and patients with T. cruzi infection without of cardiac disease. The aim of this investigation is to estimate the effect of Se treatment on prevention of heart disease progression in patients with chagasic cardiopathy. METHODS: The Selenium Treatment and Chagasic Cardiopathy trial is a superiority, double-blind, placebo-controlled, randomized clinical trial. The eligibility criteria are as follows: (1) a Chagas disease diagnosis confirmed by serology; (2) segmental, mild or moderate global left ventricular systolic dysfunction; and (3) age between 18 and 65 years. The exclusion criteria are as follows: (1) pregnancy, (2) diabetes mellitus, (3) tobacco use, (4) alcohol abuse, (5) evidence of nonchagasic heart disease, (6) depression, (7) dysphagia with evidence of food residues in the esophagus, (8) dysphagia with weight loss higher than 15% of usual weight in the last four months and/or (9) conditions that may result in low protocol adherence. The intervention will be 100 µg of sodium selenite once daily for 365 consecutive days compared to placebo. The following are the primary outcomes to be measured: (1) the trajectories of the left ventricular ejection fraction in the follow-up period; (2) reduction of heart disease progression rates, with progression defined as a 10% decrease in left ventricular ejection fraction; and (3) rate of hospital admissions attributable to dysrhythmia, heart failure or stroke due to Chagas disease. One hundred thirty patients will be randomly allocated into either the intervention or placebo group at a ratio of 1:1. The sequence allocation concealment and blinding were planned to be conducted with the strategy of numbered boxes. Both patients and health-care providers will remain blinded to the intervention groups during the 5 years of follow-up. DISCUSSION: If Se treatment reduces the progression of Chagas cardiopathy, the inclusion of this micronutrient in the daily diet can improve the therapeutic regimen for this neglected tropical disease at low cost. TRIAL REGISTRATION: Clinical Trials.gov ID: NCT00875173 (registered 20 October 20 2008).

Diminazene aceturate associated with sodium selenite and vitamin E in the treatment of Trypanosoma evansi infection in rats.

The aim of this study was to evaluate the utilization of a standard treatment with diminazene aceturate against the infection caused by Trypanosoma evansi, associated to sodium selenite and vitamin E. In vitro tests showed trypanocidal effect related to the treatment with diminazene aceturate and sodium selenite, but vitamin E had no harmful effect on the trypanosomes. In vivo experiments utilized a total of 72 adult outbreed females rats, separated into 9 groups (A, B, C, D, E, F, G, H and I), 8 animals each. Group A was the uninfected group; groups B to I were infected with 0.2mL of blood containing 10(6) trypanosomes. Parasitemia was estimated daily by microscopic examination of blood smears. Group B served as positive control; group C was treated with diminazene aceturate; group D with sodium selenite; group E with vitamin E; group F received an association of diminazene aceturate and sodium selenite; group G received an association of diminazene aceturate and vitamin E; group H received an association of diminazene aceturate, sodium selenite and vitamin E, and group I received an association of sodium selenite and vitamin E. Diminazene aceturate was administrated in a single dose on the 3rd day post infection (PI). Sodium selenite and vitamin E were administered at the 3rd and 23rd day PI. In vivo tests showed increase of longevity in groups treated with diminazene aceturate associated with sodium selenite (groups F and H). No difference was found between groups C and E, thus the vitamin E did not increase the efficacy of treatment against T. evansi when associated to diminazene aceturate. The curative efficacy of treatments was 37.5, 87.7, 37.7 and 75% to the groups C, F, G and H, respectively. Other treatments showed no efficacy. The sodium selenite when combined with chemotherapy may represent an alternative in the treatment of trypanosomosis.

Ultrastructural assessment of the radioprotective effects of sodium selenite on parotid glands in rats.

The aim of this study was to assess the radioprotective effects of sodium selenite on parotid glands in rats by ultrastructural analysis of acinar cells. Four experimental groups were assessed; control, irradiated, selenium, and selenium/irradiated. The sodium selenite dose was 0.5 mg/kg, administered intraperitoneally 24 h before irradiation in the head and neck region with a single 15-Gy dose of gamma radiation. At 4, 8, 12, 48 and 72 h after irradiation, all animals were sacrificed and the parotid glands were removed. Radiation caused cellular changes from 4 h, and the organelles that presented the greatest alterations were the mitochondria and the secretion glands; nuclear alterations were also observed. Sodium selenite was found to have a radioprotective action, as the selenium/irradiated group presented with less damage when compared to the irradiated group. However, sodium selenite caused cellular alterations that were evident after 8 h, but with less damage when compared to those caused by radiation, which demonstrates a favorable risk-benefit for its use as a radioprotector. Thus, this research shows that sodium selenite has an effective radioprotective action in the parotid gland, which may contribute to the reduction of the adverse effects brought by the radiotherapy.

Effect of selenium and vitamin E on oxidative stress in lambs experimentally infected with Haemonchus contortus.

The objective of this study was to evaluate oxidative stress in lambs experimentally infected with Haemonchus contortus and supplemented with selenium and vitamin E. Twenty male Corriedale lambs were divided into four experimental groups with five animals each: G1 consisted of animals infected and supplemented with 0.2 mg/kg of live weight (LW) sodium selenite by intramuscular injection (IM); G2 consisted of animals infected with larvae and supplemented with 0.2 mg/kg LW sodium selenite IM and 2000 IU per animal of Vitamin E IM; G3 consisted of animals infected with larvae and supplemented with 2000 IU per animal of Vitamin E IM; and G4 consisted of animals infected with larvae. The animals were infected orally with 500 H. contortus larvae (L3) every 48 hours for 20 days. For biochemical analyses and eggs per grams of feces (EPG) evaluation, blood and feces were both collected at zero (T0), 20 (T1), 40 (T2) and 60 (T3) days. The weight of the animals was also measured at these times. Lower TBARS values were observed in the supplemented animals compared to the control group. The groups supplemented with Selenium exhibited blood GSH-Px activity higher than that of non-supplemented animals. Supplementation with selenium provided greater antioxidant protection against oxidative stress generated from experimental infection of lambs with H. contortus.

Neutrophil oxidative metabolism and haemogram of sheep experimentally infected with Haemonchus contortus and supplemented with selenium and vitamin E.

The objective of this study was to evaluate neutrophil oxidative metabolism and haemogram in sheep experimentally infected with Haemonchus contortus and supplemented with selenium and vitamin E. Twenty male Corriedale sheep were utilised and distributed into four experimental groups each with five animals infected with larvae: G1--supplemented with sodium selenite, 0.2 mg/kg body weight (bw) given intramuscularly (IM); G2--supplemented with sodium selenite and vitamin E, 0.2 mg/kg bw and 2000 IU per animal, respectively, both IM; G3--supplemented with vitamin E, 2000 IU per animal IM; G4--not supplemented. A haemogram and the number of parasite eggs were determined in samples of blood and faeces, respectively, on days zero (T0), 20 (T1), 40 (T2) and 60 (T3) and nitroblue tetrazolium (NBT) assays were performed on heparinized blood samples taken on days zero, 30 and 60. A lower total leucocyte count was detected in G1 in relation to G4 at T4. Lymphocytes were reduced in G1 in relation to G3 and G4 at T3. In both non-stimulated (NBT-NS) and stimulated (NBT-S) dye reduction assays, there was reduced activity at 60 days, in relation to other times in the groups treated with selenium (G1 and G2). On the basis of results obtained, we conclude that supplementation with selenium provides better antioxidant protection to neutrophils.

High-dose selenium for critically ill patients with systemic inflammation: pharmacokinetics and pharmacodynamics of selenious acid: a pilot study.

OBJECTIVE: Systemic inflammatory response syndrome is characterized by increased urinary excretion of selenium and low serum concentration. Repletion by parenteral selenite is the most efficacious form of supplementation. However, the optimum safe dose and mode of administration remain controversial. We aimed to determine pharmacokinetic and pharmacodynamic profiles of selenite and estimate a safe dose to optimize selenium status. METHODS: A prospective, randomized, pilot study in 20 patients with systemic inflammatory response syndrome compared a high-dose (HD) group that received a loading dose of selenium as selenite 15.18 micromol over 2 h and thereafter 10.12 micromol/d as a continuous intravenous infusion (CIV) for 10 d with a very-high-dose (VHD) group that received a loading dose of 25.30 micromol over 2 h and thereafter 20.24 micromol as a CIV for 10 d. Clinical outcome was evaluated by length of stay in the intensive care unit, incidence of ventilator-associated pneumonia, and Sequential Organ Failure Assessment score. RESULTS: Patients in group HD (n = 10, age 54 +/- 23 y) had an Acute Physiology and Chronic Health Evaluation II score of 23 +/- 5 and a Sequential Organ Function Assessment score of 10 +/- 2. Those in group VHD (n = 10, age 41 +/- 19 y) had scores of 21 +/- 7 and 8 +/- 3, respectively. Pharmacokinetic concentration/time curves for serum selenium overlapped but were independent of dose, whereas the pharmacodynamics were different, showing maximum glutathione peroxidase activity only with VHD. Glutathione peroxidase decreased after day 7 independently of the selenium dose. Clinical outcomes were similar in both groups. CONCLUSION: A bolus loading dose of selenite providing 2000 microg of selenium (25.30 micromol) followed by a CIV of 1600 microg/d (20.24 micromol/d) for 10 d is most effective at returning serum selenium to physiologic levels and safely maximizing glutathione peroxidase activity.

Effects of mercury and selenite on delta-aminolevulinate dehydratase activity and on selected oxidative stress parameters in rats.

The present study evaluates the effects of Na(2)SeO(3) and HgCl(2) on kidney and liver of adult rats. In vivo, HgCl(2) (17 micromol/kg, sc) reduced ascorbic acid levels in liver ( approximately 15%), whereas in kidney it reduced ALA-D activity ( approximately 60%) and ascorbic acid levels ( approximately 35%) and increased TBARS content ( approximately 50%). Na(2)SeO(3) (17 micromol/kg, sc) exposure increased the content of nonprotein thiol groups in liver (35-60%) and kidney ( approximately 50-160%), partially prevented mercury-induced ALA-D inhibition in kidney, and completely prevented a mercury-induced increase of TBARS content and decrease of ascorbic acid levels in kidney. In vitro, HgCl(2) and Na(2)SeO(3) inhibited renal and hepatic ALA-D, while HgCl(2) increased TBARS in renal and hepatic tissue preparations. Na(2)SeO(3) increased the rate of glutathione oxidation in vitro. Results indicated that Na(2)SeO(3) protected against HgCl(2) effects in vivo (prevention of mercury interaction with thiol groups and of mercury-induced oxidative damage). In vitro, Na(2)SeO(3) did not prevent mercury effects, but potentiated ALA-D inhibition by mercury, probably due to its ability to oxidize thiol groups.

Protective effects of the antioxidant selenium on quinolinic acid-induced neurotoxicity in rats: in vitro and in vivo studies.

Quinolinic acid (QUIN), a well known excitotoxin that produces a pharmacological model of Huntington's disease in rats and primates, has been shown to evoke degenerative events in nerve tissue via NMDA receptor (NMDAr) overactivation and oxidative stress. In this study, the antioxidant selenium (as sodium selenite) was tested against different markers of QUIN-induced neurotoxicity under both in vitro and in vivo conditions. In the in vitro experiments, a concentration-dependent effect of selenium was evaluated on the regional peroxidative action of QUIN as an index of oxidative toxicity in rat brain synaptosomes. In the in vivo experiments, selenium (0.625 mg per kg per day, i.p.) was administered to rats for 5 days, and 2 h later animals received a single unilateral striatal injection of QUIN (240 nmol/ micro L). Rats were killed 2 h after the induction of lesions with QUIN to measure lipid peroxidation and glutathione peroxidase (GPx) activity in striatal tissue. In other groups, the rotation behavior, GABA content, morphologic alterations, and the corresponding ratio of neuronal damage were all evaluated as additional markers of QUIN-induced striatal toxicity 7 days after the intrastriatal injection of QUIN. Selenium decreased the peroxidative action of QUIN in synaptosomes both from whole rat brain and from the striatum and hippocampus, but not in the cortex. A protective concentration-dependent effect of selenium was observed in QUIN-exposed synaptosomes from whole brain and hippocampus. Selenium pre-treatment decreased the in vivo lipid peroxidation and increased the GPx activity in QUIN-treated rats. Selenium also significantly attenuated the QUIN-induced circling behavior, the striatal GABA depletion, the ratio of neuronal damage, and partially prevented the morphologic alterations in rats. These data suggest that major features of QUIN-induced neurotoxicity are partially mediated by free radical formation and oxidative stress, and that selenium partially protects against QUIN toxicity.