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Background:Gout is the most common form of inflammatory arthritis and its economic burden is substantial, with estimates for the overall cost exceeding $20 billion (US) annually. Contributing to the economic burden are hospital admissions and iatrogenic events associated with pharmacotherapy. Identification of modifiable risk factors would be an important contribution to clinical practice.Objectives:The aim of this study was to identify opportunities for enhancing gout care in patients presenting to the Emergency Department (ED) with gout flares.Methods:This retrospective cohort study used data from electronic medical records (EMR) at a large community hospital. All consecutive patients visiting the medical center ED with a primary diagnosis of gout from 1/1/2016 to 7/1/2019 were included. Patients were then followed for 90 days to determine whether they were readmitted to the ED for any reason. A chart review identified whether they were on appropriate medications in terms of gout flare management. All data were summarized using descriptive statistics. A multiple logistic regression was constructed to identify risk factors for ED utilization within 90 days of the index visit.Results:A total of 214 patients were included in the analysis. Most patients were male (79%), mean age was 59.4 ± 15.6 years, and mean Charlson comorbidity index was 0.5 ± 1.14. The most common medications prescribed during the ED visit included NSAIDs (41.6%), opioids (28%), corticosteroids (26.6%), and colchicine (21%). Allopurinol and febuxostat were initiated in the ED in 4.7% and 0.9%, respectively. Discharge medications for the management of gout included NSAIDs (37%), corticosteroids (34.6%), opioids (23.8%), colchicine (14%), febuxostat (7%), and allopurinol (6.5%). Of the patients sent home with an opioid, 40% were newly prescribed. An anti-inflammatory medication was not prescribed in 29.6% of patients discharged from the ED. Readmission within 90 days was recorded in 16.8% of patients. Of these readmissions, 33.3% were gout-related and 11.1% were cardiac related.After adjusting for age and comorbidity index, patients receiving colchicine were 2.8 times more likely (OR, 2.81; 95% CI, 1.12 to 7.02; p=0.027) to return to the ED within 90 days. The most common cause of readmission in this subset was gout-related (54.5%).Conclusion:Nearly 30% of patients were discharged from the ED without an anti-inflammatory medication, whereas initiation of urate lowering therapy was rare. Opiates were used frequently, but the indication was uncertain. Only 5.6% of subjects revisited the ED for gout-related diagnoses in the subsequent 3 months. Colchicine prescription was associated with an increased risk of gout-related ED utilization within 90 days. Treatment of gout in the ED is sub-optimal and often does not follow established guidelines.Disclosure of Interests: :Luigi Brunetti Grant/research support from: Astellas Pharma, CSL Behring, Consultant of: Horizon Foundation of New Jersey, Janaki Vekaria: None declared, Peter Lipsky Consultant of: Horizon Therapeutics, Naomi Schlesinger Grant/research support from: Pfizer, AMGEN, Consultant of: Novartis, Horizon Pharma, Selecta Biosciences, Olatec, IFM Therapeutics, Mallinckrodt Pharmaceuticals, Speakers bureau: Takeda, Horizon

Introduction and Purpose. Diffusion weighted imaging (DWI) has been proven to be valuable in the diagnosis of middle ear cholesteatoma. The aims of our study were to evaluate the advantage of multi-shot turbo spin echo (MSh TSE) DWI compared to single-shot echo-planar (SSh EPI) DWI for the diagnosis of cholesteatoma. Material and Methods. Thirty-two patients with clinical suspicion of unilateral cholesteatoma underwent preoperative MRI (1.5T) with SSh EPI and MSh TSE. Images were separately analyzed by 4 readers with different expertise to confirm the presence of cholesteatoma. Sensitivity, specificity, diagnostic accuracy, and positive (PPV) and negative predictive values (NPV) were assessed for each observer and interrater agreement was assessed using kappa statistics. Diagnosis was obtained at surgery. Results. Overall MSh TSE showed higher diagnostic accuracy and lower negative predictive value (NPV) compared to conventional SSh EPI. Interreader agreement between the observers revealed the superiority of MSh TSE compared to SSh EPI. Interrater agreement among all the four observers was higher by using MSh TSE compared to SSh EPI. Conclusion. Our findings suggest that MSh TSE DWI has higher sensitivity for detection of cholesteatoma and lower probability of misdiagnosis. MSh TSE DWI is useful in guiding less experienced observers to the diagnosis.

Background During recent years, interest on Sleep Disordered Breathing (SDB) in pediatric age has increased, due to the impact on quality of life, psycho-physical attitude and other serious morbidities if undiagnosed and untreated. Methods Italian Pediatric Respiratory Diseases Society (SIMRI) SDB-Working Group carried out an exploratory survey in Italy, from January to December 2016, to assess the diagnostic and therapeutic pathways, perception and relevance of SDB in Italian Hospitals. Results A questionnaire was sent to 180 Pediatric Units (PUs) distributed throughout the Italy; 102 Pediatric Units (PUs; 56.6%) answered and among them 57% dealt with SDB, and 94% recognized SDB as a major problem. Instrumental tests performed by the PUs were saturimetry (66%), nocturnal polygraphy with complete cardio-respiratory monitoring (46%) and full polysomnography (23%). In addition, hospital pediatricians reported that 54% of parents were unaware of the SDB and 84% did not know their complications. In the Northern Italy, the diagnosis was frequently performed with instrumental tools and the treatment was often surgical. In the Southern Italy the diagnosis was clinical, and the treatment was usually with drugs. Conclusions The results of our study showed a heterogeneity in the diagnosis and treatment of SDB throughout Italy. Parents know little about SDB and their complications. The operator satisfaction was associated with the availability of tools for diagnosing SDB.

Cyanobacteria are commonly found in drinking water supplies, and are responsible by numerous cases of humans’ intoxications. Geitlerinema is a genus described as unable to form blooms, however, it is very frequent in Sao Paulo’s reservoirs, the most densely populated area in Brazil. During the search for bioactive substances from strains maintained in the Cyanobacteria Culture Collection of the Institute of Botany, Sao Paulo, Brazil, three strains of Geitlerinema spp. (CCIBt920, CCIBt1044—G. amphibium; CCIBt939—G. splendidum) showed toxicity in mouse bioassay (i.p.). The symptoms observed in this bioassay were very distinct from those presented by animals poisoned with the already known cyanotoxins. In such cases, histological analysis of vital organs is very important to determine the cause of deaths and intoxication. Histological analyses were performed in mice administrated with CCIBt920 and CCIBt1044 methanol extract (ME), and CCIBt939 0.1 M acetic acid extract (AE). All extracts caused very similar histopathological features: hemorrhagic focuses, edema, alveolar collapse and hyperplasia in the lungs, due to an increase in the number of immune system cells (macrophages); disorganization of the hepatic parenchyma, necrosis, loss of vein endothelium, presence of polymorphonuclear cells in the liver; alterations in the convoluted tubules and necrotic areas in the kidneys of mice intoxicated with CCIBt939 AE, while the other G. amphibium extracts had no major effects in this organ. The histopathological findings indicate the occurrence of inflammatory processes in the mice treated with these cyanobacteria extracts. Taken together, our results suggest the presence of new cyanotoxins(s), different from the known cyanotoxins. The isolation and characterization of this toxin(s) are in progress in our laboratories.

Thyroid hormones (TH) are the primary endocrine stimulators of non-shivering thermogenesis and are known to stimulate lactation. Triiodothyronine (T3) is the bioactive form, mainly derived by deiodination of thyroxine (T4), and the free quote (unbound to plasma proteins) is immediately bioavailable. This study aimed to evaluate potential relationships among TH in the blood, triiodothyronine in the milk (T3M), milk yield and environmental temperature in March to July for 8 lactating donkeys. Milk yield and blood TH concentrations changed significantly over time, whereas T3M was rather stable among individuals and not affected by time of sampling. Free T3 was not correlated with free T4 or with total TH in the blood, but it was weakly correlated with T3M. No relationship was found between blood TH and milk yield, which was negatively correlated with T3M. Thus, the absolute quantity of bioactive hormone in milk secretion is maintained. Milk yield was positively correlated with the free/total T3 and free T3/free T4 ratios, thus in turn with the relative quote of the circulating bioactive hormone. Circulating T3/T4 ratios were negatively correlated with environmental temperature. It is concluded that environmental temperature, in the range of the present study (-2 to 35°C), does not significantly entrain thyroid gland activity, which is affected more by other factors, such as inter-individual variations and physiological status (i.e., stage of lactation). However, increases in environmental temperature most likely induce decreases in deiodinase activity at the peripheral tissue level, as indicated by the decrease in the T3/T4 ratios in the blood.

We investigated the toxic effects on Prototheca zopfii of indole-3-acetic acid (IAA) and 2,4-pentanedione (PD) combined with horseradish peroxidase (HRP) alongside the oxidation products of 3-methyl-2-oxindole (MOI) and indole-3-carbinol (I3C) from the IAA/HRP system and methylglyoxal (MGO) from the PD/HRP system. The microorganism was incubated in the absence (control) or presence of IAA, PD, IAA/HRP, PD/HRP, MOI, I3C and MGO and determined: (1) cytotoxicity by MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium) assay; (2) growth inhibitory concentration by resazurin assay and (3) antioxidant enzymes activities of: catalase (CAT), glutathione reductase (GR) and superoxide dismutase (SOD). P. zopfii was more susceptible to IAA at 40 mM than PD at the same concentration, which seems to indicate that IAA was more effective at initiating cell death. These data corroborate results from the resazurin assay. Concentrations of 40 mM of IAA, IAA/HRP and PD/HRP, 20 mM of PD/HRP, 10 mM of MOI, 2 mM of I3C and 8 mM of MGO inhibited the growth of P. zopfii . With sub-inhibitory concentrations of IAA and IAA/HRP at 30 mM, MOI at 8 mM and I3C at 1 mM, the activities of CAT and GR increased, whereas no statistical difference was observed for CAT activity with IAA/HRP. Thus, PD at 30 mM and MGO at 6 mM increased the activities of CAT and GR, whereas PD/HRP system at 15 mM decreased CAT activity and PD/HRP and MGO showed no statistical difference for SOD activity. In conclusion, IAA/HRP or PD/HRP systems and their oxidation products exert cytotoxic effects on P. zopffi ; however, I3C and MGO appear to exert greater microbicidal effect on P. zopfii .

Type 2 diabetes mellitus is a widespread disease, affecting millions of people globally. Although genetics and environmental factors seem to have a role, the cause of this metabolic disorder is largely unknown. Here we report a genetic flaw that markedly reduced the intracellular expression of the high mobility group A1 (HMGA1) protein, and adversely affected insulin receptor expression in cells and tissues from four subjects with insulin resistance and type 2 diabetes. Restoration of HMGA1 protein expression in subjects' cells enhanced INSR gene transcription, and restored cell-surface insulin receptor protein expression and insulin-binding capacity. Loss of Hmga1 expression, induced in mice by disrupting the Hmga1 gene, considerably decreased insulin receptor expression in the major targets of insulin action, largely impaired insulin signaling and severely reduced insulin secretion, causing a phenotype characteristic of human type 2 diabetes.

Besides its role as key regulator in gonadotropin releasing hormone secretion, reproductive function, and puberty onset, kisspeptin has been proposed to act as a bridge between energy homeostasis and reproduction. In the present study, to characterize the role of hypothalamic kisspeptin as metabolic regulator, we evaluated the effects of kisspeptin-10 on neuropeptide Y (NPY) and brain-derived neurotrophic factor (BDNF) gene expression and the extracellular dopamine (DA), norepinephrine (NE), serotonin (5-hydroxytriptamine, 5-HT), dihydroxyphenylacetic acid (DOPAC), and 5-hydroxyindoleacetic acid (5-HIIA) concentrations in rat hypothalamic (Hypo-E22) cells. Our study showed that kisspeptin-10 in the concentration range 1 nM–10 μM was well tolerated by the Hypo-E22 cell line. Moreover, kisspeptin-10 (100 nM–10 μM) concentration independently increased the gene expression of NPY while BDNF was inhibited only at the concentration of 10 μM. Finally, kisspeptin-10 decreased 5-HT and DA, leaving unaffected NE levels. The inhibitory effect on DA and 5-HT is consistent with the increased peptide-induced DOPAC/DA and 5-HIIA/5-HT ratios. In conclusion, our current findings suggesting the increased NPY together with decreased BDNF and 5-HT activity following kisspeptin-10 would be consistent with a possible orexigenic effect induced by the peptide.