Targeting Oxidative Stress Research Articles

Targeting oxidative stress attenuates trinitrobenzene sulphonic acid induced inflammatory bowel disease like symptoms in rats: role of quercetin.

Objective:This study was aimed to investigate the beneficial effects of quercetin (QCT) against trinitrobenzene sulfonic acid (TNBS) induced clinical, morphological, and biochemical alterations in rats.Materials and Methods:Colitis in rats was induced by administration of TNBS (25 mg dissolved in 0.25 ml of 30% ethanol) 8 cm into the rectum of the rat using a catheter. The animals were divided into six experimental groups (n = 6); naive (saline only without TNBS administration), control (saline + TNBS), standard (sulfasalazine 25 mg/kg + TNBS), QCT (25) (QCT 25 mg/kg + TNBS), QCT (50) (QCT 50 mg/kg + TNBS), QCT (100) (QCT 100 mg/kg + TNBS). Sulfasalazine (25 mg/kg) and QCT (25, 50 and 100 mg/kg) were administered per oral for 11 days and the colonic damage was evaluated in terms of macroscopical (body weight, stool consistency, rectal bleeding, and ulcer index) and biochemical parameters (myeloperoxidase activity, lipid peroxidation, nitrite, and glutathione).Results:Treatment with QCT (50, 100 mg/kg) for 10 days following TNBS administration significantly attenuated the clinical, morphological, and biochemical alterations induced by TNBS, whereas it was found to be not effective at its lower dose (25 mg/kg) throughout the experimental protocol.Conclusion:QCT attenuates the clinical, morphological and biochemical alterations induced by TNBS possibly via its antioxidant mechanism.

Targeting Oxidative Stress in Embryonal Rhabdomyosarcoma

Rhabdomyosarcoma is a soft-tissue sarcoma with molecular and cellular features of developing skeletal muscle. Rhabdomyosarcoma has two major histologic subtypes, embryonal and alveolar, each with distinct clinical, molecular, and genetic features. Genomic analysis shows that embryonal tumors have more structural and copy number variations than alveolar tumors. Mutations in the RAS/NF1 pathway are significantly associated with intermediate- and high-risk embryonal rhabdomyosarcomas (ERMS). In contrast, alveolar rhabdomyosarcomas (ARMS) have fewer genetic lesions overall and no known recurrently mutated cancer consensus genes. To identify therapeutics for ERMS, we developed and characterized orthotopic xenografts of tumors that were sequenced in our study. High-throughput screening of primary cultures derived from those xenografts identified oxidative stress as a pathway of therapeutic relevance for ERMS.

Targeting Inflammation and Oxidative Stress in Atrial Fibrillation: Role of 3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase Inhibition with Statins

Atrial fibrillation (AF) is a burgeoning health-care problem, and the currently available therapeutic armamentarium is barely efficient. Experimental and clinical evidence implicates inflammation and myocardial oxidative stress in the pathogenesis of AF. Local and systemic inflammation has been found to both precede and follow the new onset of AF, and NOX2-dependent generation of reactive oxygen species in human right atrial samples has been independently associated with the occurrence of AF in the postoperative period in patients undergoing cardiac surgery. Anti-inflammatory and antioxidant agents can prevent atrial electrical remodeling in animal models of atrial tachypacing and the new onset of AF after cardiac surgery, suggesting a causal relationship between inflammation/oxidative stress and the atrial substrate that supports AF. Statin therapy, by redressing the myocardial nitroso-redox balance and reducing inflammation, has emerged as a potentially effective strategy for the prevention of AF. Evidence indicates that statins prevent AF-induced electrical remodeling in animal models of atrial tachypacing and may reduce the new onset of AF after cardiac surgery. However, whether statins have antiarrhythmic properties in humans has yet to be conclusively demonstrated, as data from randomized controlled trials specifically addressing the relevance of statin therapy for the primary and secondary prevention of AF remain scanty. A better understanding of the mechanisms underpinning the putative antiarrhythmic effects of statins may afford tailoring AF treatment to specific clinical settings and patient's subgroups. Large-scale randomized clinical trials are needed to support the indication of statin therapy solely on the basis of AF prevention.

Aging aggravates long-term renal ischemia-reperfusion injury in a rat model

AimIschemia-reperfusion injury (IRI) has been considered as the major cause of acute kidney injury and can result in poor long-term graft function. Functional recovery after IRI is impaired in the elderly. In the present study, we aimed to compare kidney morphology, function, oxidative stress, inflammation, and development of renal fibrosis in young and aged rats after renal IRI. Materials and methodsRat models of warm renal IRI were established by clamping left pedicles for 45 min after right nephrectomy, then the clamp was removed, and kidneys were reperfused for up to 12 wk. Biochemical and histologic renal damage were assessed at 12 wk after reperfusion. The immunohistochemical staining of monocyte macrophage antigen-1 (ED-1) and transforming growth factor beta 1 (TGF-β1) and messenger RNA level of TGF-β1 in the kidney were analyzed. ResultsRenal IRI caused significant increases of malondialdehyde and 8-hydroxydeoxyguanosine levels and a decrease of superoxide dismutase activity in young and aged IRI rats; however, these changes were more obvious in the aged rats. IRI resulted in severe inflammation and tubulointerstitial fibrosis with decreased creatinine (Cr) clearance and increased histologic damage in aged rats compared with young rats. Moreover, we measured the ratio of Cr clearance between young and aged IRI rats. It demonstrated that aged IRI rats did have poor Cr clearance compared with the young IRI rats. ED-1 and TGF-β1 expression levels in the kidney were significantly higher in aged rats than in young rats after IRI. ConclusionAged rats are more susceptible to IRI-induced renal failure, which may associate with the increased oxidative stress, increased histologic damage, and increased inflammation and tubulointerstitial fibrosis. Targeting oxidative stress and inflammatory response should improve the kidney recovery after IRI.

Abstract 107: Apocynin Attenuates Isoproterenol-induced Myocardial Injury: Implications For Targeting Nadph Oxidase In Myocardial Fibrogenesis

Myocardial fibrosis results from cardiac injuries caused by various pathophysiological mechanisms including myocardial infarction, leading to destruction of myocardial architecture and progressive cardiac dysfunction. Oxidative stress is likely involved in myocardial ischemic injury and the subsequent tissue remodeling mediated by myocardial fibrogenesis. Our current study aimed to evaluate the implication of NADPH oxidase in overproduction of reactive oxygen species and its contribution to the pathogenesis of myocardial fibrogenesis after ischemic injuries. The effects of Apocynin, a selective NADPH oxidase inhibitor, were evaluated in the mouse model of isoproterenol-induced myocardial injury by histopathological approaches and whole-genome gene expression profiling. The results demonstrated that Apocynin was able to inhibit the development of ISO-induced myocardial necrotic lesions and fibrogenesis in a dose-dependent manner. Moreover, the preventive effects of Apocynin on myocardial injuries were associated with suppressed expression of genes implicated in inflammation responses and extracellular matrix, which were remarkably upregulated by isoproterenol administration. In summary, o ur study provides proof-of-concept for the involvement of NADPH oxidase-mediated ROS generation in myocardial ischemic injuries and fibrogenesis, which will benefit the mechanism-based therapeutic development targeting NADPH oxidase and oxidative stress in treating myocardial fibrosis and related disorders.

Pediatric non alcoholic fatty liver disease: more on novel treatment targets

The mainstay treatment of non alcoholic fatty liver disease (NAFLD) based on weight loss and/or lifestyle changes is most often unsuccessful at all ages, thus requiring the implementation of pharmacological strategies. Targeting insulin resistance and oxidative stress has recently proven unsatisfactory. Among a number of proposed innovative approaches targeting novel pathomechanisms, probiotics appear an interesting and reasonable option acting on gut-liver axis malfunction through the modulation of diet-driven, obesogenic, and inflammatory intestinal microbiota.A combined multiple pharmacological therapy directed simultaneously towards novel and old pathomechanisms (including, e.g., insulin resistance, oxidative stress, gut-liver axis, apoptosis) along with lifestyle interventions however might be necessary both in adult and pediatric NAFLD therapy.

Vitexin Inhibits Inflammatory Pain in Mice by Targeting TRPV1, Oxidative Stress, and Cytokines

The flavonoid vitexin (1) is a flavone C-glycoside (apigenin-8-C-β-D-glucopyranoside) present in several medicinal and other plants. Plant extracts containing 1 are reported to possess antinociceptive, anti-inflammatory, and antioxidant activities. However, the only evidence that 1 exhibits antinociceptive activity was demonstrated in the acetic acid-induced writhing model. Therefore, the analgesic effects and mechanisms of 1 were evaluated. In the present investigation, intraperitoneal treatment with 1 dose-dependently inhibited acetic acid-induced writhing. Furthermore, treatment with 1 also inhibited pain-like behavior induced by phenyl-p-benzoquinone, complete Freund's adjuvant (CFA), capsaicin (an agonist of transient receptor potential vanilloid 1, TRPV1), and both phases of the formalin test. It was also observed that inhibition of carrageenan-, capsaicin-, and chronic CFA-induced mechanical and thermal hyperalgesia occurred. Regarding the antinociceptive mechanisms of 1, it prevented the decrease of reduced glutathione levels, ferric-reducing ability potential, and free-radical scavenger ability, inhibited the production of hyperalgesic cytokines such as TNF-α, IL-1β, IL-6, and IL-33, and up-regulated the levels of the anti-hyperalgesic cytokine IL-10. These results demonstrate that 1 exhibits an analgesic effect in a variety of inflammatory pain models by targeting TRPV1 and oxidative stress and by modulating cytokine production.

Abstract TMP113: Oxidative stress and Extracellular Signal-regulated Kinase (ERK) Play a Key Role in Impairment of Receptor Desensitization and Prolongation of Vascular Reactivity in the Cerebral Artery after Subarachnoid Hemorrhage

Cerebral vasospasm is a critical determinant in the prognosis of subarachnoid hemorrhage (SAH). The vasospasm is characterized by not only enhanced but also prolonged contraction. The enhanced response is attributable to an increased receptor expression, while a prolonged response is attributable to impaired receptor desensitization. This study addressed this hypothesis and investigated the mechanism underlying a prolonged contraction, using a rabbit SAH model and A7r5 smooth muscle cells. A thrombin receptor (PAR 1 )-activating peptide (PAR 1 AP) induced a transient contraction in the basilar arteries of the control rabbits. The subsequent second stimulation produced 8% of the first response. PAR 1 AP induced an enhanced and prolonged contraction in SAH, and the second stimulation produced a 75% response. Thrombin induced an enhanced and prolonged contraction in SAH. This contraction irreversibly persisted even after terminating thrombin stimulation. The enhancement and prolongation of the contractile response after SAH was further observed with angiotensin II, vasopressin and PGF 2 α. The heparinization of autologous blood or the intrathecal application of a thrombin inhibitor, argatroban, prevented the enhancement of contraction, while they had no effect on the prolongation of the contraction. The addition of vitamin C or tempol to argatroban restored the transient response, tachyphylactic attenuation of the second response and reversibility of thrombin contraction. The amount of malondialdehyde, an indicator of oxidative stress, in the brain tissues increased after SAH, and this increase was prevented by either argatroban or vitamin C. The Ca 2+ responses to thrombin and PAR 1 AP in A7r5 cells exhibited a phenomenon similar to those seen with the contractile response in an SAH model. ERK inhibitors restored the transient response, tachyphylactic attenuation and reversibility of thrombin response, while the inhibitors of JNK, p38 kinase or Rho kinase had no effect. In conclusion, oxidative stress and ERK activation play a key role in the impaired receptor desensitization and prolonged vascular reactivity after SAH. Targeting oxidative stress and ERK could provide a novel strategy to normalize vascular reactivity after SAH.

Future Treatment for COPD: Targeting Oxidative Stress and its Related Signal

Future Treatment for COPD: Targeting Oxidative Stress and its Related Signal

Targeting oxidative stress injury after ischemic stroke in conscious rats: limited benefits with apocynin highlight the need to incorporate long term recovery.

NADPH oxidase is a major source of superoxide anion following stroke and reperfusion. This study evaluated the effects of apocynin, a known antioxidant and inhibitor of Nox2 NADPH, on neuronal injury and cell-specific responses to stroke induced in the conscious rat. Apocynin treatment (50 mg/kg i.p.) commencing 1 hour prior to stroke and 24 and 48 hours after stroke significantly reduced infarct volume in the cortex by ~ 60%, but had no effect on striatal damage or neurological deficits. In situ detection of reactive oxygen species (ROS) using dihydroethidium fluorescence revealed that increased ROS detected in OX-42 positive cells following ischemia was reduced in apocynin-treated rats by ~ 51%, but surprisingly increased in surrounding NeuN positive cells of the same rats by ~ 27%, in comparison to the contralateral hemisphere. Reduced ROS from activated microglia/macrophages treated with apocynin was associated with reduced Nox2 immunoreactivity without change to the number of cells. These findings confirm the protective effects of apocynin and indicate a novel mechanism via reduced Nox2 expression. We also reveal compensatory changes in neuronal ROS generation as a result of Nox2 inhibition and highlight the need to assess long term individual cell responses to inhibitors of oxidative stress.

Oxidative DNA damage of peripheral blood polymorphonuclear leukocytes, selectively induced by chronic arsenic exposure, is associated with extent of arsenic-related skin lesions

There is increasing evidence that oxidative stress is an important risk factor for arsenic-related diseases. Peripheral blood leukocytes constitute an important defense against microorganisms or pathogens, while the research on the impact of chronic arsenic exposure on peripheral blood leukocytes is much more limited, especially at low level arsenic exposure. The purpose of the present study was to explore whether chronic arsenic exposure affects oxidative stress of peripheral blood leukocytes and possible linkages between oxidative stress and arsenic-induced skin lesions. 75 male inhabitants recruited from an As-endemic region of China were investigated in the present study. The classification of arsenicosis was based on the degree of skin lesions. Arsenic levels were measured in drinking water and urine by Atomic Fluorescence Spectroscopy. Urinary 8-hydroxy-2′-deoxyguanosine (8-OHdG) was tested by Enzyme-Linked Immunosorbent Assay. 8-OHdG of peripheral blood leukocytes was evaluated using immunocytochemical staining. 8-OHdG-positive reactions were only present in polymorphonuclear leukocytes (PMNs), but not in monocytes (MNs). The 8-OHdG staining of PMN cytoplasm was observed in all investigated populations, while the 8-OHdG staining of PMN nuclei was frequently found along with the elevated amounts of cell debris in individuals with skin lesion. Urinary arsenic levels were increased in the severe skin lesion group compared with the normal group. No relationship was observed between drinking water arsenic or urine 8-OHdG and the degree of skin lesions. These findings indicated that the target and persistent oxidative stress in peripheral blood PMNs may be employed as a sensitive biomarker directly to assess adverse health effects caused by chronic exposure to lower levels of arsenic.

Future Treatment for COPD: Targeting Oxidative Stress and its Related Signal

COPD is pathogenically associated with oxidative stress, which originates not only from cigarette smoke, but also from hypoxia, infection, inflammation, and ageing. It is the reason that therapeutic strategies aim at attenuation of oxidative stress, its sources, or intracellular signals and pro-inflammatory network of its downstream. This review discusses the pathogenesis of COPD and its current therapy in viewpoint of oxidative stress and further provides the perspectives for new treatment strategies in COPD and recent patents that could develop into novel therapeutics. Keywords: Arachidonic acid, COPD, inflammation, neutrophil, oxidative stress, CORTICOSTEROID RESISTANCE, NEUTROPHILIC INFLAMMAION, CIGARETTE SMOKE, INFLAMM-AGEING, HYPOXIA

Future Treatment for COPD: Targeting Oxidative Stress and its Related Signal

COPD is pathogenically associated with oxidative stress, which originates not only from cigarette smoke, but also from hypoxia, infection, inflammation, and ageing. It is the reason that therapeutic strategies aim at attenuation of oxidative stress, its sources, or intracellular signals and pro-inflammatory network of its downstream. This review discusses the pathogenesis of COPD and its current therapy in viewpoint of oxidative stress and further provides the perspectives for new treatment strategies in COPD and recent patents that could develop into novel therapeutics.

Oxidative stress in hypertensive children before and after 1 year of antihypertensive therapy

BackgroundThe relation between primary hypertension (PH), target organ damage (TOD) and oxidative stress (SOX) is not known.MethodsWe assessed SOX in 86 children with PH before and after 12 months of standard non-pharmacological and pharmacological therapy based on renin-angiotensin system blockade.ResultsPatients with left ventricular hypertrophy (LVH) and with carotid intima-media thickness (cIMT) >2SDS had higher thiobarbituric acid reactive substances (TBARS) concentrations in comparison to patients without LVH or with normal cIMT. Patients with metabolic syndrome (MS) had lower activity of gluthatione peroxidase, higher asymmetric dimethyloarginine (ADMA) and oxidized LDL cholesterol (oxyLDL) in comparison to patients without MS. TBARS correlated with left ventricular concentric hypertrophy, cIMT, albuminuria and SBP/24 h. ADMA and oxyLDL correlated with CRP and TG/HDL ratio. After 1 year of antihypertensive treatment blood pressure, TOD and prevalence of MS decreased. TBARS decreased and glutathione concentrations increased. The decrease of TBARS concentration correlated with the decrease of body mass index (BMI). Decrease of oxyLDL and ADMA correlated with increased insulin sensitivity, however markers of SOX did not correlate with BP decrease.ConclusionSOX in children with PH correlates with TOD, metabolic abnormalities, changes in fat amount and improvement of insulin sensitivity, but not with BP decrease.

A Transdermal Delivery System to Enhance Quercetin Nanoparticle Permeability

Targeting oxidative stress with inhibiting or boosting the endogenous levels of antioxidants potentially has an outstanding effect in the treatment of oxidative-stress-related diseases. The present work demonstrates the synthesis of quercetin nanoemulsion as one of the potential antioxidants for the treatment of oxidative- stress-related diseases. A quercetin nanoemulsion was prepared using poly(lactic-co-glycolic acid) (PLGA), hyaluronic acid (HA) and emulsifier (Tween-20) through a solvent evaporation technique. The efficiency of the nanoemulsion was evaluated with and without chemical permeation enhancer (CPE). The FT-IR result shows no interaction between quercetin and polymer that proves excellent compatibility. The transdermal delivery ability was evaluated using in vitro release and ex vivo permeation analysis. The transdermal drug-release mechanism was studied by the mathematical model and was found to obey a zero-order, diffusion-controlled mechanism. In vitro toxicity and cell behavior, including cell adhesion, proliferation and cell death of quercetin-nanoemulsion-treated L929 cells, were elucidated by the electrical cell-substrate impedance sensing (ECIS) technique. The produced nanoemulsion showed a high encapsulation efficiency, less toxicity, controlled delivery with enhanced transdermal drug permeation and effective scavenging of free radicals.

Targeting Oxidative Stress Component in the Therapeutics of Epilepsy

The role of free radical-mediated reactions in human neuropathology continues to attract significant interest. Oxidative injury produced by free radicals may play a role in the initiation and progression of epilepsy and, therapies aimed at reducing oxidative stress may ameliorate tissue damage and favorably alter the clinical course. The prevalence of epilepsy increases with age, and mitochondrial oxidative stress is a leading mechanism of aging and age-related degenerative disease, signifying a further involvement of mitochondrial dysfunction in seizure generation. Oxidative stress occurs when the generation of reactive oxygen species in a system exceeds the body's ability to neutralize and eliminate them, thus creating an imbalance or over abundance of free radicals. Therefore, it is imperative to maintain oxidative balance and control in the brain, and this is tightly regulated by antioxidants. In the last two decades, there has been an explosive interest in the role of antioxidants or neuroprotectants in clinical as well as experimental models of epilepsy. In this regard, the present review is intended to discuss the current state of knowledge pertaining to neuroprotection in epileptic conditions by employing diverse chemical agents including conventional as well as novel anti-epileptic drugs, and to highlight the efficacy of distinct neuroprotective strategies for preventing or treating epilepsy.

Targeting Neuro-Inflammatory Cytokines and Oxidative Stress by Minocycline Attenuates Quinolinic-Acid-Induced Huntington’s Disease-Like Symptoms in Rats

Recent experimental and clinical reports support the fact that the minocycline exhibits significant neuroprotective activity in neurodegenerative diseases. However, its mechanism of neuroprotection is still far from our understanding. Besides, minocycline does not always produce neuroprotective effect. Therefore, this study has been designed to explore the possible mechanism of minocycline in experimental model of HD in rats. Intrastriatal administration of quinolinic acid caused a significant reduction in body weight, motor dysfunction (impaired locomotor activity, rotarod performance, and beam walk test), oxidative damage (as evidenced by increase in lipid peroxidation, nitrite concentration, and depletion of super oxide dismutase and catalase), increased TNF-α and IL-6 levels as compared to the sham-treated animals. Minocycline (25, 50, and 100mg/kg) treatment (for 21days) significantly improved body weight, locomotor activity, rotarod performance, balance beam walk performance, oxidative defense, attenuated TNF-α and IL-6 levels as compared to quinolinic-acid (QA)-treated animals. This study provides evidence that minocycline might have neuroprotective effect against QA-induced Huntington-like behavioral, biochemical alterations, and neuroinflammation in rats.

Targeting Oxidative Stress in Epilepsy: Study of Effect of Antioxidants on Anticonvulsant Profile of Jatamansone

Nardostachys jatamansi, commonly known as Indian nard or spike nard or nardus root, is an indigenous Indian drug used in treatment of epilepsy, hysteria, syncope and mental weakness. It has been reported to possess anticonvulsant, neuroprotective activity and antioxidant activity. In the present paper, Jatamansone, a major component of volatile oil was isolated and characterized by spectral analysis. It was evaluated for anticonvulsant activity by MES and scPTZ tests alone and in combination with well known antioxidants like alcoholic extract of Bacopa monnieri, volatile oil of Syzygium aromaticum and pure gallic acid. Results obtained have shown significant change (reduction) in the recovery time in MES screen for Bacopa monnieri and Syzygium aromaticum (39.33s and 6.66s at 1.0 h and 4.0 h) compared to (113.66s and 123.33s at 1.0 h and 4.0 h time interval) of control while gallic acid was found to show insignificant effect (126.66s and 96s) respectively. These data are compared with standard anticonvulsant drug, Phenytoin. Antioxidant data for Jatamansone and its combinations was evaluated by DPPH model. In this screen, Jatamansone has shown IC50 value of 14.80 mg/ml alone and 6.1 μg/ml in combination.

Strategies to Target Mitochondria and Oxidative Stress by Antioxidants: Key Points and Perspectives

For several decades, many antioxidants studies have emphasized the marked disparity between the beneficial effect of the antioxidants shown in preclinical studies and their inability to show beneficial effects in clinical trials. Besides, it is not uncommon to find highly contradictory clinical results, which may explain why consumers are less enthusiastic for antioxidant uses. This perspective article aims to highlights the critical role of Reactive Oxygen Species (ROS) and antioxidants, the potential mechanisms that might account for these discrepancies in clinical trials and some strategies to target oxidative stress and mitochondria by antioxidants. We need urgently to set up standard methods to evaluate antioxidants and oxidative stress in human and in particular at mitochondria level. The determination of what the basal level of ROS is in normal human may be used to identify pathologic ROS levels in patients and ultimately guide antioxidants treatment.

Targeting oxidative stress, mitochondrial dysfunction and neuroinflammatory signaling by selective cyclooxygenase (COX)-2 inhibitors mitigates MPTP-induced neurotoxicity in mice

Several studies have pointed towards the role of oxidative stress, mitochondrial dysfunction and neuroinflammation in Parkinson's disease (PD). The present study was focused on the possible neuroprotective effect of selective cyclooxygenase (COX)-2-inhibitors: valdecoxib and NS-398 in 1-methyl-4-phenyl-1,2,3,6-tertahydropyridine (MPTP)-induced neurotoxicity in mice. MPTP administration in dose of 40 mg/kg, i.p (four injections of 10mg/kg, i.p. at an interval of 1h each) significantly induced the Parkinson-like symptoms in mice as indicated by change in locomotor activity, inability to correct posture (bar test), and oxidative stress (increased levels of lipid peroxidation, nitrite concentration, and depletion of antioxidant enzyme). MPTP administration significantly impaired mitochondrial complex-I activity and redox activity, upregulated the caspase-3 and NF-κB levels as compared to vehicle group. Treatment with valdecoxib (5 or 10 mg/kg, p.o.) or NS-398 (5 or 10mg/kg, p.o.) for 7 days significantly reversed behavioral, biochemical, mitochondrial complex alterations as well as attenuated the induction of proinflammatory mediators in MPTP-treated groups. The findings of the present study substantiate the neuroprotective role of selective COX-2 inhibitors in ameliorating MPTP-induced neurodegeneration in mice and suggest the possible therapeutic potential of these drugs in the management of PD.