An evidence-based review on urate-lowering treatments: implications for optimal treatment of chronic hyperuricemia

Several studies suggest that chronic hyperuricemia, the main precursor of gout, is involved in the pathogenesis of different systemic disorders that affect cardiovascular and renal systems, such as hypertension, obesity, hypercholesterolemia, atherosclerosis, metabolic syndrome, chronic heart failure, and chronic kidney disease. Recent epidemiological evidence has shown an increasing trend in the prevalence of hyperuricemia and gout in the Western world: a number of population-based studies estimate a prevalence of up to 21% for hyperuricemia and 1%–4% for gout. As such, early detection and careful management of this pathological condition is required, starting from lifestyle changes (mainly based on a diet low in red meat, sugars, and alcoholic beverages, with increased intake of vegetables, water, and vitamin C sources), adding specific drugs to lead serum uric acid (SUA) levels under the target value of 7 mg/dL. In particular, nonselective and selective XO inhibitors (allopurinol, oxypurinol, febuxostat) reduce SUA levels and the overproduction of reactive oxygen species, mainly related to XO overactivity that often causes inflammatory damage to the vascular endothelium. The effect of lowering SUA levels via XO inhibition includes an attenuation of oxidative stress and related endothelial dysfunction that largely contribute to the pathophysiology of metabolic syndrome and cardiovascular diseases. Therefore, the inhibition of XO overactivation seems to be an excellent therapeutic option to limit the harmful effects of excess UA and reactive oxygen species. In conclusion, rapid diagnosis and correct therapy for hyperuricemia may also improve the prevention and/or treatment of serious and multifactorial diseases. The available evidence supports the importance of promoting new experimental clinical trials to confirm the emerging antioxidant role of XO inhibitors, which could effectively contribute to cardiovascular and chronic kidney disease prevention.

Grade of eosinophilia versus symptoms in patients with dysphagia and esophageal eosinophilia

The aim of this study was to assess whether the symptom severity and health-related quality of life (HRQL) of patients with dysphagia and esophageal eosinophilia correlate with disease activity as expressed by the number of eosinophils in the esophageal mucosa. This study included newly diagnosed (n = 58) or relapsed patients (n = 7), where 40% were diagnosed in connection with esophageal bolus impaction. The mean age was 45 years (19-88), and 74% were men. Symptoms and HRQL were recorded using the Watson Dysphagia Scale (WDS), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Oesophageal Module 18 and the Short Form-36 Questionnaire. Histological samples gathered from the proximal and distal esophageal mucosa were stained using both hematoxylin and eosin (HE) and an immunohistochemical (IHC) technique against 'Eosinophil Major Basic Protein,' and the peak number of eosinophils per high-power field was assessed. More eosinophils were detected after IHC staining than HE staining (P < 0.001). No correlation was found between symptoms or the HRQL and the number of eosinophils. However, higher numbers of eosinophils at the proximal esophagus were found in patients with concomitant bolus impaction (IHC P < 0.05 and HE P < 0.05) and could serve as a risk marker.

Additional therapy for cholesterol lowering in ezetimibe-treated, statin-intolerant patients in clinical practice: results from an internal audit of a university lipid clinic

OBJECTIVE

The aim of our study was to evaluate the tolerability and efficacy of alternative approaches to improve cholesterolemia control in patients with statin-related myalgia treated with ezetimibe.

RESEARCH DESIGN AND METHODS

We retrospectively evaluated 3534 Clinical Report Forms (CRFs) filled in the period June 2012-June 2015 for first visits to the lipid clinic of the University of Bologna. For this study, we selected 252 CRFs based on the following criteria: statin-related myalgia, previous failed treatment with at least two low-dosed statins, well tolerated treatment with ezetimibe. Then, the following lipid-lowering treatments were added in order to improve the ezetimibe low density lipoprotein cholesterol (LDL-C) lowering efficacy, based on clinical judgment: fenofibrate 145 mg, rosuvastatin 5 mg 1 tablet/week, rosuvastatin 5 mg 2 tablets/week, red yeast rice (standardized in monacolin K 3 mg) + berberine 500 mg, berberine 500 mg b.i.d., phytosterols 900 mg + psyllium fiber 3.5 g b.i.d. Patients continuing to claim a tolerable myalgia were then treated with coenzyme Q10 nanoemulsions 200 mg/day.

RESULTS

The treatment with standard lipid-lowering diet plus ezetimibe alone was associated with a mean LDL-C reduction of 17 ± 2%. The additive LDL-lowering effect with the various tested treatment was: -16 ± 2% with fenofibrate 145 mg/day, -13 ± 1% with rosuvastatin 5 mg 1 tablet/week, -17 ± 3% with rosuvastatin 5 mg 2 tablets/week, -19 ± 4% with red yeast rice + berberine, -17 ± 4% with berberine b.i.d. and -10 ± 3% with phytosterols + psyllium b.i.d.; 11% of the patients treated with fenofibrate required treatment modification because of myalgia recurrence, while the percentage was negligible for the other tested treatments. In patients with residual tolerable myalgia, treatment with coenzyme Q10 for 8 weeks was associated with a mean improvement of the graduated myalgia score from 4.8 ± 1.9 to 2.9 ± 1.3 (p = 0.013).

CONCLUSIONS

Some alternative treatments seems to be effective and well tolerated, thus improving the ezetimibe effect on cholesterolemia.

The NADPH oxidase NOX2 as a novel biomarker for suicidality: evidence from human post mortem brain samples

Recent evidence points towards a role of oxidative stress in suicidality. However, few studies were carried out on the sources of reactive oxygen species (ROS) in subjects with suicidal behaviour. We have previously demonstrated that the NADPH oxidase NOX2-derived oxidative stress has a major role in the development of neuropathological alterations observed in an animal model of psychosis. Here, we investigated the possible increase in NOX2 in post mortem brain samples of subjects who died by asphyctic suicide (AS) compared with controls (CTRL) and subjects who died by non-suicidal asphyxia (NSA). We found that NOX2 expression was significantly higher in the cortex of AS subjects than in the other two experimental groups. NOX2 immunostaining was mainly detected in GABAergic neurons, with a minor presence of NOX2-positive-stained cells in glutamatergic and dopaminergic neurons, as well as astrocytes and microglia. A sustained increase in the expression of 8-hydroxy-2'-deoxyguanosine, an indirect marker of oxidative stress, was also detected in the cortex of AS subjects, compared with CTRL and NSA subjects. A significant elevation in cortical interleukin-6 immunoreactivity in AS subjects suggested an involvement of cytokine-associated molecular pathways in NOX2 elevations. Our results suggest that the increase in NOX2-derived oxidative stress in the brain might be involved in the neuropathological pathways leading to suicidal behaviour. These results may open innovative insights in the identification of new pathogenetic and necroscopic biomarkers, predictive for suicidality and potentially useful for suicide prevention.

SHORT-TERM IMPACT OF A COMBINED NUTRACEUTICAL ON COGNITIVE FUNCTION, PERCEIVED STRESS AND DEPRESSION IN YOUNG ELDERLY WITH COGNITIVE IMPAIRMENT: A PILOT, DOUBLE-BLIND, RANDOMIZED CLINICAL TRIAL

Background: The prevalence of senile dementia is increasing worldwide, especially in the developed countries. Nevertheless, drug therapy isn’t often enough to treat this condition. Researchers are evaluating the possible impact of a preventive approach, based on an improvement of lifestyle and the intake of micronutrients. Moreover, there is an increasing interest for combined nutraceuticals that can act as memory and learning enhancers, with a significant and beneficial potential on the cognitive disorders. Objective: To evaluate the effects of a rational assemblage of nutraceuticals on cognitive functions in a sample of 30 elderly subjects. Design: Double bind, cross-over designed trial versus placebo Setting: outpatient clinical practice Participants: 30 elderly subjects with basal Mini-Mental State Examination score between 20 and 27 and self-perceived cognitive decline. Intervention: Treatment with a combination of nutraceuticals based on Bacopa monnieri, L-theanine, Crocus sativus, copper, folate and vitamins of B and D group. After2 months of treatment or placebo. Measurements: Patients were evaluated with Mini-Mental State Examination (MMSE), Perceived Stress Questionnaire (PSQ) and Index and Self-Rating Depression Scale (SRDS). Results: MMSE and PSQ Index significantly improved in the active treatment arm, both versus baseline and versus the parallel arm. Both groups experienced a significant improving in the SRDS scores. Conclusions: We obtained a good and significant improvement of the cognitive functions tested with the MMSE, PSQ-Index and SRDS score, after 2 months of combined therapy of nutraceuticals. Further confirmation will be needed to verify these observations on the middle and long term in a larger number of subjects.

[Acute liver failure due to human herpesvirus 6 in an infant]

We report a case of a 4-months infant with fever in the absence of other specific symptoms that has rapidly and unexpectedly developed acute liver failure (ALF) with coagulopathy and complicated with bone marrow failure without encephalopathy. The main viral infection agents (hepatitis virus A, B, C, Citomegalovirus, Ebstain Barr virus, Parvovirus B19, Adenovirus), drug-induced hepatotoxicity and metabolic disorders associated to ALF were excluded. Quantitative determination of Human Herpesvirus 6 (HHV6) genome was positive with a significant number of copies for mL. A favorable evolution of the clinical symptoms and a progressive hematochemical resolution were obtained. Plasma and Vitamin K were administrated as a support therapy for treating coagulopathy. The present case report and the cases' review from the literature, evidence the importance of always including screening for HHV6 infection in the diagnostic approach to acute onset of liver failure. HHV6 is a common virus in the pediatric population with a greater number of cases of fulminant viral non-A, non-B, non-C hepatitis in immunocompetent patients due to this virus: these forms have often a high mortality rate and maybe necessitate liver transplantation; for this reason correct etiological agent identification is mandatory for the prognosis and it has to be based on the quantitative search of the virus's genome. Pathogenesis of liver-induced damage associated to HHV6 remains unclear; however in vitro studies demonstrate the potential hepatotoxicity effects of this virus.

Bacterial flora of the human oral cavity, and the upper and lower esophagus

This reference study aims to survey the bacterial flora of the healthy lower human esophagus and to compare it with that of the upper esophagus and oral mucosa. The use of biopsies, in addition to brush samples, allows inclusion of not only transient bacteria present on the surface but also bacteria residing in the epithelia, and the yield of the two methods can be compared. Forty patients scheduled for surgery for reasons with no known influence on esophageal flora and with no symptoms or endoscopic signs of esophageal disease were included. Samples were collected from the oral, upper esophageal, and lower esophageal mucosa using sealed brushes and biopsy forceps. Colonies cultivated on agar plates were classified and semiquantified. Twenty-three different bacterial species were identified, with similar strains present at the three sites. The most common group of bacteria was viridans streptococci, with an occurrence rate in brush samples and biopsies of 98% and 95%, respectively. The median number of species occurring in the oral cavity, upper esophagus, and lower esophagus was between 3 and 4 (range 0-7). The total number of species in the oral cavity was significantly higher when compared with either level in the esophagus, while the yields obtained by brush and biopsy sampling were highly correlated. Hence, the normal human esophagus is colonized with a resident bacterial flora of its own, which has similarities to that of the oral mucosa. There are diverse species that make up this flora, although in relatively low amounts. The most frequent inhabitants of the esophagus are streptococci, with an occurrence rate in brush samples and biopsies of 95-98%. Comparative studies of patients with eosinophilic esophagitis and gastroesophageal reflux disease are warranted.

Functional effect of short-term immobilization: kinematic changes and recovery on reaching-to-grasp

Although previous investigations agree in showing significant cortical modifications related to short-term limb immobilization, little is known about the functional changes induced by non-use. To address this issue, we studied the kinematic effect of 10h of hand immobilization. In order to prevent any movement, right handed healthy participants wore on their dominant hand a soft bandage. They were requested to perform the same reaching-to-grasping task immediately after immobilization, 1 day before (baseline 1) and in other two following days without non-use (baseline 2 and baseline 3). While no differences were found among baseline conditions, an increase of the total duration of reaching movement together with an anticipation of the time to peak velocity were observed in the first trial after immobilization. Interestingly, these initial effects decreased quickly trial-by-trial, following an exponential function till reaching values equal to those observed in the control conditions. The present findings show firstly that the transport phase of the reaching-to-grasp task was affected by a temporary reduction of sensory and motor information. Secondly, a trial-by-trial recovery of the immobilization-related changes, likely driven by the sensory inputs and motor outputs associated to the repetition of the movement has been observed. All together these results confirm a fundamental role of a continuous stream of sensorimotor signals in maintaining motor efficiency and in driving recovery process.

Psychosocial factors and metabolic parameters: is there any association in elderly people? The Massa Lombarda Project

OBJECTIVE

Several studies claim that psychophysical stress and depression contribute significantly to cardiovascular disease (CVD) development. The aim of our research is to discover and analyse a possible relationship between two psychosocial disorders (depression and perceived mental stress) and traditional cardiovascular risk markers.

METHODS

We selected 106 subjects (58 males and 48 females), mean age 79.5 +/- 3.8-years old, from the Massa Lombarda Project, an epidemiological study, including 7000 north Italian adult subjects. We carried out anamnesis, clinical and blood tests. Then, we administered the Perceived Stress Questionnaire (PSQ range score 0-1) and the Self-Rating Depression Scale (SRDS range score 50-70 Z), as validated instruments for depression and stress evaluation, which focus on the individual's subjective perception and emotional response. Statistical descriptive and inferential analyses of data collected were performed.

RESULTS

The multiple linear regression analysis showed a negative correlation between PSQ index score and uric acid, low-density lipoprotein cholesterol (LDL-c), body mass index (BMI), systolic and diastolic blood pressure values, a positive and statistically significant correlation between PSQ index score and triglycerides (p < 0.05). We found an inverse relationship between Zung SRDS score and LDL-c, uric acid, glucose waist circumference values, this correlation was significant only for uric acid (p < 0.01). Besides, a positive and significant correlation between Zung SRDS and triglycerides (p < 0.05) was observed.

CONCLUSION

We suppose that psycho-emotional stress and depression disorder, often diagnosed in elderly people, may influence different metabolic parameters (triglycerides, uric acid and BMI) that are involved in the complex process of metabolic syndrome.

Omega 3 polyunsaturated fatty acids supplementation and blood pressure levels in hypertriglyceridemic patients with untreated normal-high blood pressure and with or without metabolic syndrome: a retrospective study

Recent evidence suggests that at least a part of the polyunsaturated fatty acids (PUFAs) heart protective effect is mediated by a relatively small but significant decrease in blood pressure level. We retrospectively evaluated the long-term effect of a PUFA supplementation on the blood pressure level of 111 hypertriglyceridemic subjects with untreated normal-high blood pressure that were prescribed a 2 grams PUFA supplementation in order to improve their plasma lipid pattern. After 12 months of treatment, systolic blood pressure (SBP) meanly decreased by 2.7 +/- 2.5 mmHg (p = 0.001) and diastolic blood pressure (DBP) by 1.3 +/- 3.3 mmHg (p < 0.001), while basal heart rate decreased by 4.0 +/- 4.4 bpm (p < 0.001). Both SBP and DBP reduction were significantly related to the baseline SBP (p < 0.001) and DBP (p < 0.001), respectively. Diastolic blood pressure change was also inversely related to the patient's age (p = 0.004). No significant difference was perceived in the metabolic syndrome subgroup. In our retrospective study, highly purified omega-3 PUFA long-term supplementation is associated with a significant reduction in SBP, DBP, Pulse pressure (PP), and basal heart rate in hypertriglyceridemic patients with normal-high blood pressure. No significant difference was perceived in the metabolic syndrome subgroup. The main determinants of the PUFA anti-hypertensive effect appear to be the basal blood pressure level and age.

Effect of a sequential training programme on inflammatory, prothrombotic and vascular remodelling biomarkers in hypertensive overweight patients with or without metabolic syndrome

BACKGROUND

It is not known whether serum level of vascular remodelling parameters, such as matrix metalloproteinases could be modulated by physical activity and whether the eventual change could be influenced by metabolic syndrome (MS) diagnosis.

DESIGN

Open, intervention study to evaluate the effects of a sequential physical activity training on inflammatory, prothrombotic and vascular remodelling biomarkers in overweight patients with and without MS.

METHODS

We enrolled 80 overweight patients (mean age: 62.9+/-8.3 years; male : female = 36 : 44) with newly diagnosed hypertension, with or without MS. After 3 months of American Heart Association step 2 diet, they followed a sequential training programme including 56 days of added three metabolic equivalent tasks/week and 56 days of six metabolic equivalent tasks/week.

RESULTS

All patients experienced a significant decrease in body mass index, waist circumference and blood pressure after both the training phases. High-density lipoprotein-cholesterolemia, triglycerides, and glycaemia significantly improved only after the intensive training phase compared with the baseline in MS patients. Prothrombotic parameters improved irrespectively from the MS diagnosis. High-sensitivity C-reactive protein P level significantly decreased towards baseline and towards the previous phase, after exercise intensification, but only in MS patients. The plasma level of matrix metalloproteinase 2 and 9, and their activated forms improved significantly when compared with the baseline both after the first and the second training period, independently from the MS diagnosis.

CONCLUSION

Diagnosis of MS is a determinant of changes in metabolic and inflammatory biomarkers, but not of the prothrombotic and vascular remodelling ones in a sample of overweight hypertensive patients.

[Earthquake in Abruzzo, public health interventions. Preliminary report]

On 6th April 2009, at 3.32 AM, there was in L'Aquila and in some neighbouring villages, after an earthquake swarm last some months, an earthquake of M(L) = 5.8 (Richter magnitude scale) on depth of 8.8 km. The event was sensed in a very broad area, till in Rome and Ancon. The operative committee of the Civil Protection Department immediately gathered and a first operating group was despatched in the epicentre; the voluntary association of civil protection were in a pre-alarm situation and then were activated. This work want describe all the activities from 6th April 2009 till 31th August 2009, giving too a synthesis of the normative lines in case of catastrophic events typology C, otherwise all that events impossible to manage without national intervention.

Interaction between vision and neck proprioception in the control of stance

Balance control depends on the interaction of multiple inputs originating from different sensory systems. Here, we investigated the effect on quiet human stance of changing the visual condition prior to a proprioceptive perturbation produced by vibration of dorsal neck muscles. In complete absence of visual references, the amplitude of the postural responses to neck vibration (forward shift of the centre of foot pressure) was the largest and became progressively larger as a function of the repetition of administered stimuli. The posture-destabilizing effect of vibration eyes-closed (EC) and the build-up effect were reduced if vibration was preceded by a period during which vision was allowed (EO). Similarly, the small destabilizing effect of vibration EO was increased if vibration was preceded by an EC period. The fore-period must last more than 3 s in order to affect the response to neck muscle vibration. The responsiveness to a proprioceptive disturbing input does not immediately change on adding or subtracting vision, but a finite time period must elapse before the postural "set" defined by vision is fully established. The findings underline the importance of time when vision is used in re-weighting the excitability of the postural control mechanisms.

The pharyngeal mucosa is not involved in eosinophilic oesophagitis

BACKGROUND

Eosinophilic oesophagitis is thought to be an isolated oesophageal disease associated with biopsy-verified eosinophilia of the squamous cell epithelium of the oesophagus. Food- or aeroallergens have been suggested to be the cause of eosinophilic oesophagitis; however, as these allergens pass through the pharynx sharing the same squamous cell epithelium, eosinophilic infiltration could be expected also here. Whether this is true or not has hitherto not been clarified.

AIM

To find out whether eosinophilia is present also within the pharyngeal epithelium in patients with eosinophilic oesophagitis.

METHODS

In all, 10 patients (median age 34, range 15-70) with biopsy-verified eosinophilic oesophagitis [peak count >20 eosinophils per high power field (hpf)] were biopsied also in the pharynx. The biopsies underwent histopathological examination and at each level, the peak number of eosinophils per hpf was counted.

RESULTS

None of the patients examined was found to have eosinophilia within the squamous cell epithelium of the pharynx (median peak count 0, range 0-1).

CONCLUSIONS

The pronounced eosinophilic infiltration in eosinophilic oesophagitis appears to be an isolated oesophageal phenomenon not shared by the adjoining organ sites and in particular, not by the pharynx. This may have implications for future research.